- Miscellaneous Codes
- Ambulation Devices - General Use
- Bath and Bathroom Equipment - General Use
- Bed and Bedroom Equipment - General Use
- Repairs/Labor
- Chairs, Wheelchairs and Accessories - General Use
- Cochlear Equipment and Supplies
- Diabetic Monitoring Equipment and Supplies
- Disposable Supplies - General Use
- Elastic Supports and Stockings - General Use
- Heat and Cold Application Equipment - General Use
- Monitoring Equipment and Supplies- General Use
- Phototherapy - General Use
- Oxygen and Respiratory Care - General Use
- Nebulizers, Vaporizers and Suction
- Respiratory Care, Accessories, Supplies and Related Services
- TENS or NMES (Transcutaneous or Neuromuscular Electrical Nerve Stimulator) Equipment and Supplies - General Use
- Trapeze, Traction and Fracture Frames - General Use
- Lymphedema Pumps and Compressors - Specialized Use
- Wound Therapy Equipment
- Rehabilitation Equipment - Specialized Use
- Oral and Enteral Nutrition, Formulas, Equipment and Supplies - Specialized Use
- Home IV Therapy - Specialized Use
- Prosthetics and Orthotics
- Diabetic Shoes - Fitting and Modifications
- Orthotic Devices - Spinal
- Orthotic Devices - Lower Limb
- Hip Orthosis (HO) - Flexible
- Legg Perthes
- Knee Orthosis (KO)
- Ankle-Foot Orthosis (AFO)
- Knee-Ankle-Foot Orthosis (KAFO) - or Any Combination
- Torsion Control: Hip-Knee-Ankle-Foot Orthosis (HKAFO)
- Fracture Orthosis (Lower Body)
- Additions to Fracture Orthosis
- Additions to Lower Extremity Orthosis: Shoe-Ankle-Shin-Knee
- Additions to Straight Knee or Offset Knee Joints
- Additions: Thigh/Weight Bearing - Gluteal/Ischial Weight Bearing
- Additions: Pelvic and Thoracic Control
- Additions: General
- Orthopedic Shoes
- Orthotic Devices - Upper Limbs
- Shoulder Orthosis (SO)
- Elbow Orthosis
- Wrist-Hand Orthosis
- Elbow-Wrist-Hand Orthosis
- Elbow-Wrist-Hand-Finger Orthosis
- Wrist-Hand-Finger Orthosis (WHFO)
- Additions - General
- Dynamic Flexor Hinge, Reciprocal Wrist Extension/Flexion, Finger Flexion/Extension
- External Power
- Other WHFOs - Custom Fitted
- Shoulder-Elbow-Wrist-Hand Orthosis (SEWHO)
- Fracture Orthosis (Upper Extremity)
- Specific Repairs
- Repairs
- Prosthetic Procedures L5000-L9999
- Lower Limb
- Partial Foot
- Ankle
- Below Knee
- Knee Disarticulation
- Above Knee
- Hip Disarticulation
- Hemipelvectomy
- Immediate Post-Surgical or Early Fitting Procedures
- Initial Prosthesis
- Preparatory Prosthesis
- Additions: Lower Extremity
- Additions: Test Sockets
- Additions: Socket Variations
- Replacements
- Additions: Exoskeletal Knee-Shin System
- Component Modification
- Additions: Endoskeletal Knee-Shin System
- Upper Limb
- Partial Hand
- Wrist Disarticulation
- Below Elbow
- Elbow Disarticulation
- Above Elbow
- Shoulder Disarticulation
- Interscapular Thoracic
- Immediate and Early Post-Surgical Procedures
- Endoskeletal: Below Elbow
- Endoskeletal: Elbow Disarticulation
- Endoskeletal: Above Elbow
- Endoskeletal: Shoulder Disarticulation
- Endoskeletal: Interscapular Thoracic
- Additions: Upper Limb
- Terminal Devices
- Replacement Sockets
- Gloves for Above Hands
- Hand Restoration
- External Power Base Devices
- Electronic Elbow
- Battery Components
- Addition to Upper Extremity Prosthesis
- Repairs
- Prostheses
- Trusses
- Prosthetic Socks
- Prosthetic Implants
- Lower Limb
HCPCS Code Table
The following listing is divided into sections to assist providers who bill for specific types of service.
Miscellaneous Codes
| Code | Description | PAR | Unit Limits | Comments |
|---|---|---|---|---|
| A4266 | Diaphragm for contraceptive use | None | ||
| A4459 | Manual pump-operated enema system, includes balloon, catheter and all accessories, reusable any type | Yes | To be used for the first month, includes 15 catheters. See A4453 if additional catheters are needed. | |
| A4453 | Rectal catheter for use with the manual pump-operated enema system, replacement only | Yes | 31/month | 1 unit = 1 catheter. 15 units for every other day use, up to 31 units for everyday use. |
| A4457 | Enema tube, with or without adapter, any type, replacement only, each | Yes | Code opened 01-01-2024. | |
| A4468 | Exsufflation belt, includes all supplies and accessories | Yes | Code opened 01-01-2024. | |
| A7023 | Mechanical allergen particle barrier/inhalation filter, cream, nasal, topical | No | Code opened 01-01-2024. | |
| A7048 | Vacuum drainage collection unit and tubing kit, including all supplies needed for collection unit change, for use with implanted catheter, each | None | SEE NCCI MUE LIMIT | NCCI MUE - cannot be overridden with a PAR. |
| A7049 | Expiratory positive airway pressure intranasal resistance valve | Yes | Code opened 04-01-2023. | |
| A9999 | Miscellaneous DME supply or accessory, not otherwise specified | Yes | Use for accessories or parts for DME other than wheelchairs. | |
| B9998 | (NOC) For enteral supplies | Yes | Include description and quantities on PAR. For rental, must submit manufacturer's invoice with PAR. Rental based on percentage of invoice and rate will be determined at the time of PAR approval. PAR copy must be submitted with claim. Do not use for items included in supply kits. | |
| B9999 | For parenteral supplies | Yes | Include description and quantity on par. Do not use for items included in kits. Submit paper claim with manufactures invoice attached. | |
| E1399 | Durable medical equipment, miscellaneous | Yes | Use for durable reusable equipment other than wheelchairs. | |
| E1905 | Virtual reality cognitive behavioral therapy device (CBT), including pre-programmed therapy software | Yes | Rental only, PARs limited to three (3) months at a time. Code opened 04-01-2023. | |
| K0108 | Wheelchair component or accessory, not otherwise specified | Yes | Use for wheelchair parts and accessories only when an appropriate code is not available. | |
| K1037 | Docking station for use with oral device/appliance used to reduce upper airway collapsibility | Yes | Code opened 04-01-2024. | |
| L7259 | Electronic wrist rotator, any type | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L7700 | Gasket or seal, for use with prosthetic socket insert, any type, each | New code effective 01/01/2018. | ||
| L8696 | Antenna (external) for use with implantable diaphragmatic/phrenic nerve stimulation device, replacement, each | Yes | *Effective April 1, 2019, a prior authorization is required. | |
| S8189 | Tracheostomy supply, not otherwise classified | Yes | Use for tracheostomy supplies when an appropriate code is not available. | |
| S8301 | Infection control supplies, not otherwise specified | Yes | Use for masks, disposable gowns, etc. | |
| T5999 | Supply, not otherwise specified | Yes | As of November 1, 2017, this code requires PAR. | |
| Q0477 | Power module patient cable for use with electric or electric/pneumatic ventricular assist device, replacement only | None | ||
| Q0478 | Power adapter for use with electric or electric/pneumatic ventricular assist device, vehicle type | None | ||
| Q0479 | Power module for use with electric or electric/pneumatic ventricular assist device, replacement only | None | ||
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Ambulation Devices - General Use
| Code | Description | PAR | Unit Limits | Comments |
|---|---|---|---|---|
| Canes | ||||
| E0100 | Cane, all materials, adjustable or fixed with tip | No | *Code is subject to the 2019 DME UPL | |
| E0105 | Cane, quad or three (3) prong, all materials, adjustable or fixed with tips | No | *Code is subject to the 2019 DME UPL | |
| Crutches | ||||
| E0110 | Crutches, forearm, all materials, adjustable or fixed, complete with tips and handgrips, pair | No | 1 unit = 1 pair *Code is subject to the 2019 DME UPL | |
| E0111 | Crutches, forearm, all materials, adjustable or fixed, with tip and handgrip, each | No | 1 unit = 1 crutch *Code is subject to the 2019 DME UPL | |
| E0112 | Crutches, underarm, wood, adjustable or fixed, with pads, tips and handgrips, pair | No | 1 unit = 1 pair *Code is subject to the 2019 DME UPL | |
| E0113 | Crutches, underarm, wood, adjustable or fixed, with pad, tip and handgrip, each | No | 1 unit= 1 crutch *Code is subject to the 2019 DME UPL | |
| E0114 | Crutches, underarm, other than wood, adjustable or fixed, pair with pads, tips and handgrips | No | 1 unit= 1 pair *Code is subject to the 2019 DME UPL | |
| E0116 | Crutch, underarm, other than wood, adjustable or fixed, with pat, tip, handgrip, with or without shock absorber, each | No | 1 unit= 1 crutch *Code is subject to the 2019 DME UPL | |
| E0117 | Crutch, underarm, articulating, spring assisted, each | Yes | 1 unit= 1 crutch | |
| E0118 | Crutch substitute, lower leg platform, with or without wheels, each | No | ||
| Walkers | ||||
| E0130 | Walker, rigid (pickup), adjustable or fixed height, each | No | *Code is subject to the 2019 DME UPL | |
| E0135 | Walker, folding (pickup), adjustable or fixed height, each | No | *Code is subject to the 2019 DME UPL | |
| E0140 | Walker, with trunk support, adjustable or fixed height, any type | Yes | *Code is subject to the 2019 DME UPL | |
| E0141 | Walker, rigid, wheeled, adjustable or fixed height | No | *Code is subject to the 2019 DME UPL | |
| E0143 | Walker, folding, wheeled, adjustable or fixed height | No | *Code is subject to the 2019 DME UPL | |
| E0144 | Walker, enclosed, four (4) sided framed, rigid or folding, wheeled with posterior seat | Yes | *Code is subject to the 2019 DME UPL | |
| E0147 | Walker, heavy duty, multiple braking system, variable wheel resistance | Yes | *Code is subject to the 2019 DME UPL | |
| E0148 | Heavy duty walker, without wheels, rigid or folding, any type, each | Yes | *Code is subject to the 2019 DME UPL | |
| E0149 | Walker, heavy duty, wheeled, rigid or folding, any type | Yes | *Code is subject to the 2019 DME UPL | |
| Accessories for Ambulation Devices | ||||
| A4635 | Underarm pad replacement, crutch, each | No | ||
| A4636 | Handgrip replacement, cane, crutch or walker, each | No | ||
| A4637 | Tip replacement, cane, crutch or walker, each | No | ||
| E0152 | Walker, battery powered, wheeled, folding, adjustable or fixed height | Yes | Code opened 04-01-2024. | |
| E0153 | Platform attachment, forearm crutch, each | No | ||
| E0154 | Platform attachment, walker, each | No | ||
| E0155 | Wheel attachment, rigid pick-up walker, per pair | No | 1 unit = 1 pair | |
| E0156 | Seat attachment, walker, each | No | ||
| E0157 | Crutch attachment, walker, each | No | ||
| E0158 | Leg extensions for walker, per set of four (4) | No | 1 unit = 1 set of four (4) | |
| E0159 | Brake attachment for wheeled walker, replacement, each | No | ||
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Bath and Bathroom Equipment - General Use
| Code | Description | PAR | Unit Limits | Comments |
|---|---|---|---|---|
| Bath Equipment | ||||
| E0160 | Sitz type bath, portable, fits over commode seat, each | Yes | Limited to EPSDT program, up to age 20. *Code is subject to the 2019 DME UPL | |
| E0163 | Commode chair, mobile or stationary, with fixed arms | No | *Code is subject to the 2019 DME UPL | |
| E0165 | Commode chair, mobile or stationary, with detachable arms | Yes | *Code is subject to the 2019 DME UPL | |
| E0167 | Pail or pan for use with commode chair, replacement only | No | Purchase for member owned equipment only. *Code is subject to the 2019 DME UPL | |
| E0168 | Extra wide and/or heavy duty commode chair, stationary or mobile, with or without arms, any type, each | Yes | *Code is subject to the 2019 DME UPL | |
| E0170 | Commode chair with integrated seat lift mechanism, electric, any type | Yes | *Code is subject to the 2019 DME UPL | |
| E0171 | Commode chair with integrated seat lift mechanism, non-electric, any type | Yes | *Code is subject to the 2019 DME UPL | |
| E0172 | Seat lift mechanism placed over or on top of toilet, any type | Yes | ||
| E0175 | Foot rest, for use with commode chair, each | No | Purchase for member owned equipment only. | |
| E0240 | Bath/shower chair, with or without wheels, any size | Yes | ||
| E0241 | Bathtub wall rail, each | Yes | ||
| E0242 | Bathtub rail, floor base, each | Yes | SEE NCCI MUE LIMIT | |
| E0243 | Toilet rail, each | Yes | ||
| E0244 | Toilet seat, raised, each | Yes | ||
| E0245 | Tub stool or bench, each | Yes | ||
| E0246 | Transfer tub rail attachment, each | Yes | ||
| E0247 | Transfer bench for tub or toilet with or without commode opening | Yes | ||
| E0248 | Transfer bench, heavy duty, for tub or toilet with or without commode opening | Yes | ||
| E1399 | Durable medical equipment, miscellaneous | Yes | Use for hand held shower, and other miscellaneous bath equipment. Clearly identify on PAR and on claim the particular item being requested or billed. | |
| Whirlpool Equipment | ||||
| E1300 | Whirlpool, portable (over tub type) | Yes | ||
| E1310 | Whirlpool, non-portable (built-in type) | Yes | Required: F2F | |
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Bed and Bedroom Equipment - General Use
| Code | Description | PAR | Unit Limits | Comments |
|---|---|---|---|---|
| Beds | ||||
| E0194 | Bed, powered air flotation (low air loss therapy), per day | Yes | 1 unit = 1 day rental. Includes necessary disposable supplies. Bill with RR modifier. Required: F2F, Q1, Q2 *Code is subject to the 2019 DME UPL | |
| E0250 | Hospital bed, fixed height, with any type side rails, with mattress | Yes | Required: F2F, Q1 *Code is subject to the 2019 DME UPL | |
| E0255 | Hospital bed, variable height, Hi-Lo, with any type side rails, with mattress | Yes | Required: F2F, Q1 *Code is subject to the 2019 DME UPL | |
| E0256 | Hospital bed, variable height, hi-lo, with any type side rails, without mattress | Yes | Required: F2F, Q1 *Code is subject to the 2019 DME UPL | |
| E0260 | Hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress | Yes | Required: F2F, Q1 *Code is subject to the 2019 DME UPL | |
| E0261 | Hospital bed, semi-electric (head and foot adjustment), with any type side rails, without mattress | Yes | Required: F2F, Q1 *Code is subject to the 2019 DME UPL | |
| E0265 | Hospital bed, total electric (head, foot and height adjustments) with any type side rails, with mattress | Yes | Required: F2F, Q1 *Code is subject to the 2019 DME UPL | |
| E0266 | Hospital bed, total electric (head, foot, and height adjustments), with any type side rails, without mattress | Yes | Required: F2F, Q1 *Code is subject to the 2019 DME UPL | |
| E0270 | Hospital bed, institutional type includes: oscillating, circulating and Stryker frame, with mattress | Yes | Required: Q1 | |
| E0280 | Bed, cradle, any type | Yes | ||
| E0290 | Hospital bed, fixed height, without side rails, with mattress | Yes | Required: F2F, Q1 *Code is subject to the 2019 DME UPL | |
| E0291 | Hospital bed, fixed height, without side rails, without mattress | Yes | Required: F2F, Q1 *Code is subject to the 2019 DME UPL | |
| E0292 | Hospital bed, variable height, hi-lo, without side rails, with mattress | Yes | Required: F2F, Q1 *Code is subject to the 2019 DME UPL | |
| E0293 | Hospital bed, variable height, hi-lo, without side rails, without mattress | Yes | Required: F2F, Q1 *Code is subject to the 2019 DME UPL | |
| E0294 | Hospital bed, semi-electric (head and foot adjustment), without side rails, with mattress | Yes | Required: F2F, Q1 *Code is subject to the 2019 DME UPL | |
| E0295 | Hospital bed, semi-electric (head and foot adjustment), without side rails, without mattress | Yes | Required: F2F, Q1 *Code is subject to the 2019 DME UPL | |
| E0296 | Hospital bed, total electric (head, foot, and height adjustments), without side rails, with mattress | Yes | Required: F2F, Q1 *Code is subject to the 2019 DME UPL | |
| E0297 | Hospital bed, total electric (head, foot, and height adjustments), without side rails, without mattress | Yes | Required: F2F, Q1 | |
| E0300 | Pediatric crib, hospital grade, fully enclosed, with or without top enclosure | Yes | Required: F2F, Q1 *Code is subject to the 2019 DME UPL | |
| E0301 | Hospital bed, heavy duty, extra wide, with weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, without mattress | Yes | Required: F2F, Q1 *Code is subject to the 2019 DME UPL | |
| E0302 | Hospital bed, extra heavy duty, extra wide, with weight capacity greater than 600 pounds, with any type side rails, without mattress | Yes | Required: F2F, Q1 *Code is subject to the 2019 DME UPL | |
| E0303 | Hospital bed, heavy duty, extra wide, with weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, with mattress | Yes | Required: F2F, Q1 *Code is subject to the 2019 DME UPL | |
| E0304 | Hospital bed, extra heavy duty, extra wide, with weight capacity greater than 600 pounds, with any type side rails, with mattress | Yes | Required: F2F, Q1 *Code is subject to the 2019 DME UPL | |
| E0328 | Hospital bed, pediatric, manual, 360 degree side enclosures, top of headboard, footboard and side rails up to 24 inches above the spring, includes mattress | Yes | Required: Q1 | |
| E0329 | Hospital bed, pediatric, electric or semi- electric, 360 degree side enclosures, top of headboard, footboard and side rails up to 24 inches above the spring, includes mattress | Yes | Required: Q1 | |
| E0462-KR | Rocking bed with or without side rails, per day | Yes | 1 unit= 1 day rental. Required: F2F, Q1 | |
| E1399 | Durable medical equipment miscellaneous | Yes | If MSRP or actual acquisition cost is $2,700 or greater, rental is required for 6 - 9 months before purchase will be considered. 1 unit = 1 month rental months require PAR. New PAR is required for purchase. Required: F2F, Q1 | |
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| Mattresses and Pads | ||||
| A4640 | Replacement pad for use with medically necessary alternating pressure pad owned by patient | Yes | Purchase for member owned equipment only. | |
| E0181 | Powered pressure reducing mattress overlay/pad, alternating, with pump, includes heavy duty | Yes | Required: Q2 *Code is subject to the 2019 DME UPL | |
| E0182 | Pump for alternating pressure pad, for replacement only | Yes | ||
| E0184 | Mattress, dry flotation | Yes | Purchase for member owned hospital bed only. Required: Q2 *Code is subject to the 2019 DME UPL | |
| E0185 | Gel or gel-like pressure pad for mattress, standard mattress length and width | Yes | Required: F2F, Q2 *Code is subject to the 2019 DME UPL | |
| E0186 | Mattress, air pressure | Yes | Purchase for member owned bed only. Required: Q2 *Code is subject to the 2019 DME UPL | |
| E0187 | Mattress, water pressure | Yes | Purchase for member owned bed only. Required: Q2 | |
| E0188 | Sheepskin pad, synthetic | Yes | Required: F2F *Code is subject to the 2019 DME UPL | |
| E0189 | Sheepskin pad, lamb's wool, any size | Yes | Required: F2F *Code is subject to the 2019 DME UPL | |
| E0190 | Positioning cushion/pillow/wedge, any shape or size, includes all components and accessories | Yes | ||
| E0191 | Heel or elbow protector, each | Yes | ||
| E0193 | Air fluidized bed, per day | Yes | Air loss bed. 1 unit = 1 day rental. Bill with RR modifier. *Code is subject to the 2019 DME UPL | |
| E0196 | Mattress, Gel pressure | Yes | Purchase for member owned bed only. Required: Q2 *Code is subject to the 2019 DME UPL | |
| E0197 | Air pressure pad for mattress, standard mattress length and width | Yes | Required: F2F, Q2 *Code is subject to the 2019 DME UPL | |
| E0198 | Water pressure pad for mattress, standard mattress length and width | Yes | Required: F2F | |
| E0199 | Dry pressure pad for mattress, standard mattress length and width | No | Egg crate for bed or wheelchair. Required: F2F *Code is subject to the 2019 DME UPL | |
| E0271 | Mattress, innerspring | Yes | Purchase for member owned hospital bed only. | |
| E0272 | Mattress, foam rubber | Yes | Purchase for member owned hospital bed only. | |
| E0277 | Powered pressure-reducing air mattress | Yes | Identify brand. Required: Q2 *Code is subject to the 2019 DME UPL | |
| E0370 | Air pressure elevator for heel | Yes | Required: Q2 | |
| E0371 | Non-powered advanced pressure reducing overlay for mattress, standard mattress length and width | Yes | Required: Q2 *Code is subject to the 2019 DME UPL | |
| E0372 | Powered air overlay for mattress, standard mattress length and width | Yes | Required: Q2 *Code is subject to the 2019 DME UPL | |
| E0373 | Non-powered advanced pressure reducing mattress | Yes | Required: Q2 *Code is subject to the 2019 DME UPL | |
| E1399 | Durable medical equipment miscellaneous | Yes | If MSRP or actual acquisition cost is $6,500 or greater, rental is required for 6 - 9 months before purchase will be considered. 1 unit = 1 month All rental months require PAR. New PAR is required for purchase. Required: Q2 | |
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| Accessories/Safety Equipment | ||||
| A9281 | Reaching/grabbing device, any type, any length, each | Yes | ||
| E0273 | Bed board | Yes | ||
| E0274 | Over-bed table | Yes | ||
| E0275 | Bedpan, standard, metal or plastic | No | ||
| E0276 | Bedpan, fracture, metal or plastic | No | ||
| E0305 | Bed side rails, half length, pair | Yes | ||
| E0310 | Bed side rails, full length, pair | Yes | ||
| E0316 | Safety enclosure frame/canopy for use with hospital bed, any type | Yes | ||
| E0325 | Urinal, male, jug-type, any material, each | No | ||
| E0326 | Urinal, female, jug-type, any material, each | No | ||
| E0700 | Safety equipment, device or accessory, any type | Yes | Includes gait belt. Not for use as wheelchair accessory. See E0960, E0978 and E0980 for wheelchairs. | |
| E0710 | Restraints, any type (body, chest, wrist or ankle) | Yes | Hip belt. Not for use as wheelchair accessory. | |
| E0711 | Upper extremity medical tubing/lines enclosure or covering device, restricts elbow range of motion | Yes | Code opened 04-01-2023. | |
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| Lifts | ||||
| E0621 | Sling or seat, patient lift, canvas or nylon | Yes | ||
| E0625 | Patient lift, bathroom or toilet, not otherwise classified | Yes | Lift for bathtub, includes seat. | |
| E0627 | Seat lift mechanism, electric, any type | Yes | Required: F2F, Q4 *Code is subject to the 2019 DME UPL | |
| E0629 | Seat lift mechanism, non-electric, any type | Yes | Required: F2F, Q4 *Code is subject to the 2019 DME UPL | |
| E0630 | Patient lift, hydraulic or mechanical, includes any seat, sling, strap(s) or pad(s) | Yes | Required: Q3 *Code is subject to the 2019 DME UPL | |
| E0635 | Patient lift, electric, with seat or sling | Yes | Required: Q3 *Code is subject to the 2019 DME UPL | |
| E0636 | Multipositional patient support system, with integrated lift, patient accessible controls | Yes | Required: F2F, Q3 *Code is subject to the 2019 DME UPL | |
| E0639 | Patient lift, moveable from room to room with disassembly and reassembly, includes all components/accessories | Yes | Includes sling and chains. Required: Q3 *Code is subject to the 2019 DME UPL | |
| E1035 | Multi-positional patient transfer system, with integrated seat operated by caregiver, patient weight capacity up to and including 300 lbs. | Yes | Required: F2F, Q3 *Code is subject to the 2019 DME UPL | |
| E1036 | Multi-positional patient transfer system, extra-wide, with integrated seat, operated by caregiver, patient weight capacity greater than 300 lbs. | Yes | Required: F2F, Q3 *Code is subject to the 2019 DME UPL | |
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Repairs/Labor
| Code | Description | PAR | Unit Limits | Comments |
|---|---|---|---|---|
| A9900 | Miscellaneous DME supply, accessory, and/or service component of another HCPCS code | Yes | Labor and Dealer preparation. Limited to specialized, detailed or complex work in the initial preparation of a product. 1 unit = 15 mins | |
| A9901 | DME delivery, set up, and/or dispensing service component of another HCPCS code | No | ||
| K0739 | Repair or non-routine service for durable medical equipment other than oxygen requiring the skill of a technician, labor component, per 15 minutes | Con | 480/Y | Cost of repair cannot exceed cost to purchase replacement equipment. Serial number of the equipment being repaired must be identified in field 12 of the PAR. Paper claims must include serial number. If codes are available to identify specific components, they must be used (e.g., tires, upholstery, batteries, etc.). 1 unit = 15 minutes. Annual maximum 480 units or 120 hours of service. (Average 40 units or 10 hours of service per month.) Request PA for more than 5 units. See also K0739-MS. |
| K0739-MS | Repair or non-routine service for durable medical equipment other than oxygen requiring the skill of a technician, labor component | No | 1 per 6 M | Quick minor repairs to DME products. In addition to labor, the costs of minor parts may be included under this code. Claims must include the serial number. |
| K0740 | Repair or non-routine service for oxygen equipment requiring the skill of a technician, labor component, per 15 minutes | Yes | Cost of repair cannot exceed cost to purchase replacement equipment. Serial number of the equipment being repaired must be identified in field 12 of the PAR. Paper claims must include serial number. If codes are available to identify specific components, they must be used. 1 unit = 15 minutes. Annual maximum 480 units or 120 hours of service. (Average 40 units or 10 hours of service per month.) See also K0740-MS. | |
| K0740-MS | Repair or non-routine service for oxygen equipment requiring the skill of a technician, labor component | No | 1 per 6 M | Quick minor repairs to oxygen equipment. In addition to labor, the costs of minor parts may be included under this code. Claims must include the serial number. |
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Chairs, Wheelchairs and Accessories - General Use
Providers are instructed to submit the Healthcare Common Procedure Coding System (HCPCS) code most closely describing the wheelchair or related equipment being requested on the Prior Authorization Request (PAR) form. Visit the PDAC website for the most updated and complete information for product classification for wheelchairs, wheelchair accessories, etc. Use Medicare procedures regarding weight and measurements to code appropriately.
| Code | Description | PAR | Unit Limits | Comments |
|---|---|---|---|---|
| Chairs | ||||
| E1031 | Rollabout chair, any and all types with castors 5 in or greater | Yes | Required: F2F *Code is subject to the 2019 DME UPL | |
| E1038 | Transport chair, adult size, patient weight capacity up to and including 300 pounds | Yes | Required: F2F *Code is subject to the 2019 DME UPL | |
| E1039 | Transport chair, adult size, heavy duty, patient weight capacity greater than 300 pounds | Yes | Required: F2F *Code is subject to the 2019 DME UPL | |
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| Wheelchairs - Motorized/Powered Vehicles | ||||
| E1230 | Power operated vehicle, three (3) or four (4) wheel non-highway | Yes | Must indicate brand name and model number on PAR. | |
| K0010 | Standard - weight frame motorized/power wheelchair | Yes | *Code is subject to the 2019 DME UPL | |
| K0011 | Standard - weight frame motorized/power wheelchair with programmable control parameters for speed adjustment, tremor dampening, acceleration control and braking | Yes | *Code is subject to the 2019 DME UPL | |
| K0012 | Lightweight portable motorized/power wheelchair | Yes | *Code is subject to the 2019 DME UPL | |
| K0014 | Other motorized/power wheelchair base | Yes | ||
| K0800 | Power operated vehicle, group 1 standard, patient weight capacity up to and including 300 pounds | Yes | *Code is subject to the 2019 DME UPL | |
| K0801 | Power operated vehicle, group 1 heavy duty, patient weight capacity 301 to 450 pounds | Yes | *Code is subject to the 2019 DME UPL | |
| K0802 | Power operated vehicle, group 1 very heavy duty, patient weight capacity 451 to 600 pounds | Yes | *Code is subject to the 2019 DME UPL | |
| K0806 | Power operated vehicle, group 2 standard, patient weight capacity up to and including 300 pounds | Yes | *Code is subject to the 2019 DME UPL | |
| K0807 | Power operated vehicle, group 2 heavy duty, patient weight capacity 301 to 450 pounds | Yes | *Code is subject to the 2019 DME UPL | |
| K0808 | Power operated vehicle, group 2 very heavy duty, patient weight capacity 451 to 600 pounds | Yes | ||
| K0812 | Power operated vehicle, not otherwise classified | Yes | ||
| K0813 | Power wheelchair, group 1 standard, portable, sling/solid seat and back, patient weight capacity up to and including 300 pounds | Yes | *Code is subject to the 2019 DME UPL | |
| K0814 | Power wheelchair, group 1 standard, portable, captain's chair, patient weight capacity up to and including 300 pounds | Yes | *Code is subject to the 2019 DME UPL | |
| K0815 | Power wheelchair, group 1 standard, sling/solid seat and back, patient weight capacity up to and including 300 pounds | Yes | *Code is subject to the 2019 DME UPL | |
| K0816 | Power wheelchair, group 1 standard, captain's chair, patient weight capacity up to and including 300 pounds | Yes | *Code is subject to the 2019 DME UPL | |
| K0820 | Power wheelchair, group 2 standard, portable, sling/solid seat/back, patient weight capacity up to and including 300 pounds | Yes | *Code is subject to the 2019 DME UPL | |
| K0821 | Power wheelchair, group 2 standard, portable, captain's chair, patient weight capacity up to and including 300 pounds | Yes | *Code is subject to the 2019 DME UPL | |
| K0822 | Power wheelchair, group 2 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds | Yes | *Code is subject to the 2019 DME UPL | |
| K0823 | Power wheelchair, group 2 standard, captain's chair, patient weight capacity up to and including 300 pounds | Yes | *Code is subject to the 2019 DME UPL | |
| K0824 | Power wheelchair, group 2 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds | Yes | *Code is subject to the 2019 DME UPL | |
| K0825 | Power wheelchair, group 2 heavy duty, captain's chair, patient weight capacity 301 to 450 pounds | Yes | *Code is subject to the 2019 DME UPL | |
| K0826 | Power wheelchair, group 2 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds | Yes | *Code is subject to the 2019 DME UPL | |
| K0827 | Power wheelchair, group 2 very heavy duty, captain's chair, patient weight capacity 451 to 600 pounds | Yes | *Code is subject to the 2019 DME UPL | |
| K0828 | Power wheelchair, group 2 extra heavy duty, sling/solid seat/back, patient weight capacity 601 pounds or more | Yes | *Code is subject to the 2019 DME UPL | |
| K0829 | Power wheelchair, group 2 extra heavy duty, captain's chair, patient weight 601 pounds or more | Yes | *Code is subject to the 2019 DME UPL | |
| K0830 | Power wheelchair, group 2 standard, seat elevator, sling/solid seat/back, patient weight capacity up to and including 300 pounds | Yes | ||
| K0831 | Power wheelchair, group 2 standard, seat elevator, captain's chair, patient weight capacity up to and including 300 pounds | Yes | ||
| K0899 | Power mobility device, not coded by DME PDAC or does not meet criteria | Yes | ||
| Back to Top | Back to DMEPOS Manual | |||
| Manual Wheelchair Codes Providers are instructed to submit the HCPCS code on the PAR form that most closely describes the requested wheelchair or related equipment. Health First Colorado reserves the right to amend the coding for any approved item. | ||||
| E1050 | Fully-reclining wheelchair, fixed full- length arms, swing-away detachable elevating leg rests | Yes | ||
| E1060 | Fully-reclining wheelchair, detachable arms, desk or full-length, swing-away detachable elevating leg rests | Yes | ||
| E1070 | Fully-reclining wheelchair, detachable arms (desk or full-length) swing-away detachable footrest | Yes | ||
| E1083 | Hemi-wheelchair, fixed full-length arms, swing-away, detachable, elevating leg rests | Yes | ||
| E1084 | Hemi-wheelchair, detachable arms desk or full-length arms, swing-away detachable elevating leg rests | Yes | ||
| E1085 | Hemi-wheelchair, fixed full-length arms, swing-away detachable footrests | Yes | ||
| E1086 | Hemi-wheelchair, detachable arms, desk or full-length, swing-away detachable footrests | Yes | ||
| E1087 | High strength lightweight wheelchair, fixed full-length arms, swing-away detachable elevating leg rests | Yes | ||
| E1088 | High strength lightweight wheelchair, detachable arms desk or full-length, swing-away detachable elevating leg rests | Yes | *Code is subject to the 2019 DME UPL | |
| E1089 | High-strength lightweight wheelchair, fixed-length arms, swing-away detachable footrest | Yes | ||
| E1090 | High-strength lightweight wheelchair, detachable arms, desk or full-length, swing-away detachable footrests | Yes | ||
| E1092 | Wide heavy-duty wheelchair, detachable arms (desk or full-length), swing-away detachable elevating leg rests | Yes | ||
| E1093 | Wide heavy-duty wheelchair, detachable arms, desk or full-length, swing-away detachable footrests | Yes | *Code is subject to the 2019 DME UPL | |
| E1100 | Semi-reclining wheelchair, fixed full- length arms, swing-away detachable elevating leg rests | Yes | ||
| E1110 | Semi-reclining wheelchair, detachable arms (desk or full-length) elevating leg rest | Yes | ||
| E1130 | Standard wheelchair, fixed full-length arms, fixed or swing-away detachable footrests | Yes | ||
| E1140 | Wheelchair, detachable arms, desk or full-length, swing-away detachable footrests | Yes | ||
| E1150 | Wheelchair, detachable arms, desk or full-length swing-away detachable elevating leg rests | Yes | *Code is subject to the 2019 DME UPL | |
| E1160 | Wheelchair, fixed full-length arms, swing-away detachable elevating leg rests | Yes | *Code is subject to the 2019 DME UPL | |
| E1170 | Amputee wheelchair, fixed full-length arms, swing-away detachable elevating leg rests | Yes | ||
| E1171 | Amputee wheelchair, fixed full-length arms, without footrests or leg rest | Yes | ||
| E1172 | Amputee wheelchair, detachable arms (desk or full-length) without footrests or leg rest | Yes | ||
| E1180 | Amputee wheelchair, detachable arms (desk or full-length) swing-away detachable footrests | Yes | ||
| E1190 | Amputee wheelchair, detachable arms (desk or full-length) swing-away detachable elevating leg rests | Yes | ||
| E1195 | Heavy-duty wheelchair, fixed full-length arms, swing-away detachable elevating leg rests | Yes | ||
| E1200 | Amputee wheelchair, fixed full-length arms, swing-away detachable footrest | Yes | ||
| E1221 | Wheelchair with fixed arm, footrests | Yes | ||
| E1222 | Wheelchair with fixed arm, elevating leg rests | Yes | ||
| E1223 | Wheelchair with detachable arms, footrests | Yes | ||
| E1224 | Wheelchair with detachable arms, elevating leg rests | Yes | ||
| E1240 | Lightweight wheelchair, detachable arms, (desk or full-length) swing-away detachable, elevating leg rest | Yes | ||
| E1250 | Lightweight wheelchair, fixed full-length arms, swing-away detachable footrest | Yes | ||
| E1260 | Lightweight wheelchair, detachable arms (desk or full-length) swing-away detachable footrest | Yes | ||
| E1270 | Lightweight wheelchair, fixed full-length arms, swing-away detachable elevating leg rests | Yes | ||
| E1280 | Heavy-duty wheelchair, detachable arms (desk or full-length) elevating leg rests | Yes | ||
| E1285 | Heavy-duty wheelchair, fixed full-length arms, swing-away detachable footrest | Yes | ||
| E1290 | Heavy-duty wheelchair, detachable arms (desk or full-length) swing-away detachable footrest | Yes | ||
| E1295 | Heavy-duty wheelchair, fixed full-length arms, elevating leg rest | Yes | ||
| K0001 | Standard wheelchair | Yes | Required: F2F *Code is subject to the 2019 DME UPL | |
| K0002 | Standard Hemi (low seat) wheelchair | Yes | Required: F2F *Code is subject to the 2019 DME UPL | |
| K0003 | Lightweight wheelchair | Yes | Required: F2F *Code is subject to the 2019 DME UPL | |
| K0004 | High strength, lightweight wheelchair | Yes | Required: F2F *Code is subject to the 2019 DME UPL | |
| K0006 | Heavy duty wheelchair | Yes | Member greater than 250 lbs. Required: F2F *Code is subject to the 2019 DME UPL | |
| K0007 | Extra heavy-duty wheelchair | Yes | Member greater than 300 lbs. Required: F2F *Code is subject to the 2019 DME UPL | |
| Back to Top | Back to DMEPOS Manual | |||
| Wheelchair Accessories | ||||
| A9900 | Miscellaneous DME supply, accessory, and/or service component of another HCPCS code | Yes | Labor, dealer preparation. Limited to specialized, detailed or complex work in the initial preparation of a product. 1 unit = 15 mins. | |
| A9999 | Miscellaneous DME supply or accessory, not otherwise specified | Yes | Use for accessories or parts for DME other than wheelchairs. | |
| E0181 | Powered pressure reducing mattress overlay/pad, alternating, with pump, includes heavy duty | Yes | Required: Q2 *Code is subject to the 2019 DME UPL | |
| E0182 | Pump for alternating pressure pad, for replacement only | Yes | ||
| E0188 | Sheepskin pad, synthetic | Yes | *Code is subject to the 2019 DME UPL | |
| E0189 | Sheepskin pad, lamb's wool, any size | Yes | *Code is subject to the 2019 DME UPL | |
| E0705 | Transfer device, any type, each | Yes | ||
| E0710 | Restraints, any type (body, chest, wrist, ankle) | Yes | ||
| E0950 | Wheelchair accessory, tray, each | Yes | Upper extremity support surface. | |
| E0951 | Heel loop/holder, any type, with or without ankle strap, each | Con | 2/Y | 1 unit = 1 heel loop Over 2 require PAR |
| E0952 | Toe loop/holder, any type, each | Con | 2/Y | 1 unit = 1 toe loop/holder. Over 2 require PAR |
| E0953 | Wheelchair accessory, lateral thigh or knee support, any type including fixed mounting hardware, each | Yes | New code effective 01/01/2018. | |
| E0954 | Wheelchair accessory, foot box, any type, includes attachment and mounting hardware, each foot | Yes | New code effective 01/01/2018. | |
| E0955 | Wheelchair accessory, headrest, cushioned, any type, including fixed mounting hardware, each | Yes | ||
| E0958 | Manual wheelchair accessory, one-arm drive attachment, each | Yes | 1 unit = 1 attachment Required: F2F | |
| E0959 | Manual wheelchair accessory, adapter for amputee, each | Yes | Required: F2F | |
| E0960 | Wheelchair accessory, shoulder harness/straps or chest strap, including any type mounting hardware | Con | 1/Y | Over 1 requires PAR. Required: F2F |
| E0961 | Manual wheelchair accessory, wheel lock brake extension (handle), each | Con | 2/Y | Over 2 requires PAR. Required: F2F |
| E0966 | Manual wheelchair accessory, headrest extension, each | Yes | Required: F2F | |
| E0968 | Commode seat, wheelchair | Yes | Required: F2F | |
| E0969 | Narrowing device, wheelchair | Yes | For positioning. Required: F2F | |
| E0970 | No. 2 footplates, except for elevating leg rest | Yes | ||
| E0971 | Manual wheelchair accessory, anti- tipping device, each | Con | 2/Y | 1 unit =1 device Over 2 requires PAR. Required: F2F |
| E0974 | Manual wheelchair accessory, anti- rollback device, each | Con | 2/Y | Over 2 requires PAR. Required: F2F |
| E0978 | Wheelchair accessory, positioning belt/safety belt/pelvic strap, each | Con | 1/Y | Over 1 requires PAR. Required: F2F |
| E0980 | Safety vest, wheelchair | Yes | Shoulder harness Required: F2F | |
| E0983 | Manual wheelchair accessory, power add-on to convert manual wheelchair to motorized wheelchair, joystick control | Yes | Required: F2F | |
| E0984 | Manual wheelchair accessory, power add-on to convert manual wheelchair to motorized wheelchair, tiller control | Yes | Required: F2F | |
| E0985 | Wheelchair accessory, seat lift mechanism | Yes | Required: F2F, Q4 | |
| E0988-RR | Manual wheelchair accessory, lever- activated, wheel drive, pair | Yes | ||
| E0992 | Manual wheelchair accessory, solid seat insert | Yes | Required: F2F | |
| E1020 | Residual limb support system for wheelchair, any type | Yes | Required: F2F | |
| E1028 | Wheelchair accessory, manual swing away, retractable or removable mounting hardware for joystick, other control interface or positioning accessory | Yes | 4 | Required: F2F |
| E1029 | Wheelchair accessory, ventilator tray, fixed | Yes | Required: F2F | |
| E1030 | Wheelchair accessory, ventilator tray, gimbaled | Yes | Required: F2F | |
| E1225 | Wheelchair accessory, manual semi- reclining back, (recline greater than 15 degrees but less than 80 degrees | Yes | ||
| E1226 | Manual wheelchair accessory, manual fully reclining back, (recline greater than 80 degrees), each | Yes | ||
| E1227 | Special height arms for wheelchair | Yes | Required: F2F | |
| E1296 | Special wheelchair seat height from floor | Yes | Required: F2F | |
| E1297 | Special wheelchair seat depth, by upholstery | Yes | Required: F2F | |
| E1298 | Special wheelchair seat depth and/or width, by construction | Yes | Required: F2F | |
| E1399 | Miscellaneous durable medical equipment | Yes | Important, please note: Use for durable medical equipment other than wheelchairs. | |
| E2201 | Manual wheelchair accessory, nonstandard seat frame, width greater than or equal to 20 inches and less than 24 inches | Yes | ||
| E2202 | Manual wheelchair accessory, nonstandard seat frame width, 24-27 inches | Yes | ||
| E2203 | Manual wheelchair accessory, nonstandard seat frame depth, 20 to less than 22 inches | Yes | ||
| E2204 | Manual wheelchair accessory, nonstandard seat frame depth, 22 to 25 inches | Yes | ||
| E2207 | Wheelchair accessory, crutch and cane holder, each | Yes | 1 unit = 1 crutch and cane holder | |
| E2208 | Wheelchair accessory, cylinder tank carrier, each | Yes | 1 unit = 1 carrier | |
| E2340 | Power wheelchair accessory, nonstandard seat frame width, 20-30 inches | Yes | ||
| E2341 | Power wheelchair accessory, nonstandard seat frame width 24-27 inches | Yes | ||
| E2342 | Power wheelchair accessory, nonstandard seat frame depth, 20 or 21 inches | Yes | ||
| E2343 | Power wheelchair accessory, nonstandard seat frame depth, 22-25 inches | Yes | ||
| E2601 | General use wheelchair seat cushion, width less than 22 inches, any depth | Yes | Identify specific brand/name of cushion requested on prior authorization request. | |
| E2602 | General use wheelchair seat cushion, width 22 inches or greater, any depth | Yes | Identify specific brand/name of cushion requested on prior authorization request. | |
| E2603 | Skin protection wheelchair seat cushion, width less than 22 inches, any depth | Yes | Identify specific brand/name of cushion requested on prior authorization request. | |
| E2604 | Skin protection wheelchair seat cushion, width 22 inches or greater, any depth | Yes | Identify specific brand/name of cushion requested on prior authorization request. | |
| E2605 | Positioning wheelchair seat cushion, width less than 22 inches, any depth | Yes | Identify specific brand/name of cushion requested on prior authorization request. | |
| E2606 | Positioning wheelchair seat cushion, width 22 inches or greater, any depth | Yes | Identify specific brand/name of cushion requested on prior authorization request. | |
| E2607 | Skin protection and positioning wheelchair seat cushion, width less than 22 inches, any depth | Yes | Identify specific brand/name of cushion requested on prior authorization request. | |
| E2608 | Skin protection and positioning wheelchair seat cushion, width 22 inches or greater, any depth | Yes | Identify specific brand/name of cushion requested on prior authorization request. | |
| E2611 | General use wheelchair back cushion, width less than 22 inches, any height, including any type mounting hardware | Yes | Identify specific brand/name of cushion requested on prior authorization request. | |
| E2612 | General use wheelchair back cushion, width 22 inches or greater, any height, including any type mounting hardware | Yes | Identify specific brand/name of cushion requested on prior authorization request. | |
| E2613 | Positioning wheelchair back cushion, posterior, width less than 22 inches, any height, including any type mounting hardware | Yes | Identify specific brand/name of cushion requested on prior authorization request. | |
| E2614 | Positioning wheelchair back cushion, posterior, width 22 inches or greater, any height, including any type mounting hardware | Yes | Identify specific brand/name of cushion requested on prior authorization request. | |
| E2615 | Positioning wheelchair back cushion, posterior-lateral, width less than 22 inches, any height, including any type mounting hardware | Yes | Identify specific brand/name of cushion requested on prior authorization request. | |
| E2616 | Positioning wheelchair back cushion, posterior-lateral, width 22 inches or greater, any height, including any type mounting hardware | Yes | Identify specific brand/name of cushion requested on prior authorization request. | |
| E2619 | Replacement cover for wheelchair seat cushion or back cushion, each | Yes | Identify specific brand/name of cushion requested on prior authorization request. | |
| E2622 | Skin protection wheelchair seat cushion, adjustable, width less than 22 inches, any depth | Yes | Identify specific brand/name of cushion requested on prior authorization request. | |
| E2623 | Skin protection wheelchair seat cushion, adjustable, width 22 inches or greater, any depth | Yes | Identify specific brand/name of cushion requested on prior authorization request. | |
| E2624 | Skin protection and positioning wheelchair seat cushion, adjustable, width less than 22 inches, any depth | Yes | Identify specific brand/name of cushion requested on prior authorization request. | |
| E2625 | Skin protection and positioning wheelchair seat cushion, adjustable, width 22 inches or greater, any depth | Yes | Identify specific brand/name of cushion requested on prior authorization request. | |
| K0038 | Leg strap, each | Con | 1/Y | 1 unit = 1 leg strap Over 1 requires PAR. |
| K0039 | Leg strap, H style, each | Con | 1/Y | 1 unit = 1 leg strap Over 1 requires PAR. |
| K0056 | Seat height <, 17" or equal to or greater than 21" for a high strength, lightweight, or ultra-lightweight wheelchair | Yes | ||
| K0105 | IV hanger, each | Yes | 1 unit = 1 IV hanger | |
| K0108 | Wheelchair component or accessory, not otherwise specified | Yes | Specific accessory must be identified on PAR. Use for wheelchair parts and accessories only when an appropriate code is not available. | |
| Back to Top | Back to DMEPOS Manual | |||
| Wheelchair Replacement Parts and Attachments | ||||
| E0967 | Manual wheelchair accessory, hand rim with projections, any type, replacement only, each | Yes | Use for repair only. | |
| E0971 | Anti-tipping device, wheelchair | Con | 2/Y | 1 unit = 1 device |
| E0973 | Wheelchair accessory, adjustable height, detachable armrest, complete assembly, each | Yes | 1 unit = 1 armrest | |
| E0981 | Wheelchair accessory, seat upholstery, replacement only, each | Con | 1/Y | For repair only. Over 1 requires PAR. |
| E0982 | Wheelchair accessory, back upholstery replacement only, each | Con | 1/Y | For repair only. Over 1 requires PAR. |
| E0990 | Wheelchair accessory, elevating leg rest, complete assembly, each | Yes | Articulating Required: F2F | |
| E0994 | Armrest, each | Yes | Required: F2F | |
| E0995 | Wheelchair accessory, calf rest/pad, replacement only, each | Con | 2/Y | For repair only. Over 2 requires PAR. |
| E1011 | Modification to pediatric size wheelchair, width adjustment package (not to be dispensed with initial chair) | Yes | For modification of an existing wheelchair only. | |
| E1015 | Shock absorber for manual wheelchair, each | Yes | 1 unit = 1 shock absorber Required: F2F | |
| E1016 | Shock absorber for power wheelchair, each | Yes | 1 unit = 1 shock absorber | |
| E1017 | Heavy duty shock absorber for heavy duty or extra heavy-duty manual wheelchair, each | Yes | 1 unit = 1 shock absorber | |
| E1018 | Heavy duty shock absorber for heavy duty or extra heavy-duty power wheelchair, each | Yes | 1 unit = 1 shock absorber | |
| E2205 | Manual wheelchair accessory, hand rim without projections (includes ergonomic or contoured), any type, replacement only, each | Yes | Use for repair only. | |
| E2206 | Manual wheelchair accessory, wheel lock assembly, complete, replacement only, each | Yes | Wheel locks | |
| E2210 | Wheelchair accessory, bearings, any type, replacement only, each | Con | SEE NCCI MUE LIMIT | Over 16 units requires PAR. NCCI MUE - Do not provide more than 12 per DOS. |
| E2211 | Manual wheelchair accessory, pneumatic propulsion tire, any size, each | Con | 2/Y | 1 unit = 1 tire. Over two (2) units requires PAR. |
| E2212 | Manual wheelchair accessory, tube for pneumatic propulsion tire, any size, each | Con | 2/Y | 1 unit = 1 tire tube. Over two (2) units requires PAR. |
| E2213 | Manual wheelchair accessory, insert for pneumatic propulsion tire (removable), any type, any size, each | Con | 2/Y | 1 unit = 1 tire insert. Over two (2) units requires PAR. |
| E2214 | Manual wheelchair accessory, pneumatic caster tire, any size, each | Con | 2/Y | 1 unit = 1 tire. Over two (2) units requires PAR. |
| E2215 | Manual wheelchair accessory, tube for pneumatic caster tire, any size, each | Con | 2/Y | 1 unit = 1 tire tube. Over two (2) units requires PAR. |
| E2216 | Manual wheelchair accessory, foam filled propulsion tire, any size, each | Con | 2/Y | 1 unit = 1 tire. Over two (2) units requires PAR. |
| E2217 | Manual wheelchair accessory, foam filled caster tire, any size, each | Con | 2/Y | 1 unit = 1 tire. Over two (2) units requires PAR. |
| E2218 | Manual wheelchair accessory, foam propulsion tire, any size, each | Con | 2/Y | 1 unit = 1 tire. Over two (2) units requires PAR. |
| E2219 | Manual wheelchair accessory, foam caster tire, any size, each | Con | 2/Y | 1 unit = 1 tire. Over two (2) units requires PAR. |
| E2220 | Manual wheelchair accessory, solid (rubber/plastic) propulsion tire, any size, replacement only, each | Con | 2/Y | 1 unit = 1 tire. Over two (2) units requires PAR. |
| E2221 | Manual wheelchair accessory, solid (rubber/plastic) caster tire (removable), any size, replacement only, each | Con | 2/Y | 1 unit = 1 tire. Over two (2) units requires PAR. |
| E2222 | Manual wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel, any size, replacement only, each | Con | 2/Y | PAR required for purchase but not required for repair. 1 unit = 1 tire with wheel Over two (2) units requires PAR. |
| E2224 | Manual wheelchair accessory, propulsion wheel excludes tire, any size, replacement only, each | Con | 2/Y | PAR required for purchase but not required for repair. 1 unit = 1 wheel Over two (2) units requires PAR. |
| E2225 | Manual wheelchair accessory, caster wheel excludes tire, any size, replacement only, each | Con | 2/Y | PAR required for purchase but not required for repair. 1 unit = 1 caster wheel Over two (2) units requires PAR. |
| E2226 | Manual wheelchair accessory, caster fork, any size, replacement only, each | Con | 2/Y | 1 unit = 1 caster fork Over two (2) units requires PAR. |
| E2227 | Manual wheelchair accessory, gear reduction drive wheel, each | Con | 1 unit = 1 gear reduction drive wheel. Required: F2F | |
| E2228 | Manual wheelchair accessory, wheel braking system and lock, complete, each | Con | 1 unit = 1 wheel braking system and lock | |
| E2230 | Manual wheelchair accessory, manual standing system | Yes | ||
| E2231 | Manual wheelchair accessory, solid seat support base (replaces sling seat), includes any type mounting hardware | Yes | ||
| E2358 | Power wheelchair accessory, group 34 non-sealed lead acid battery, each | Con | 2/Y | PAR required for purchase but not for repair. |
| E2359 | Power wheelchair accessory, group 34 sealed lead acid battery, each (e.g., gel cell, absorbed glass mat) | Con | 2/Y | PAR required for purchase but not for repair. |
| E2360 | Power wheelchair accessory, 22 NF non- sealed lead acid battery, each | Con | 2/Y | PAR required for purchase but not for repair. |
| E2361 | Power wheelchair accessory, 22 NF sealed lead acid battery, each (e.g. Gel cell, absorbed glassmat) | Con | 2/Y | PAR required for purchase but not for repair. |
| E2362 | Power wheelchair accessory, group 24 non-sealed lead acid battery, each | Con | 2/Y | PAR required for purchase but not for repair. |
| E2363 | Power wheelchair accessory, group 24 sealed lead acid battery, each (e.g. gel cell, absorbed glassmat) | Con | 2/Y | PAR required for purchase but not for repair. |
| E2364 | Power wheelchair accessory, U-1 non- sealed lead acid battery, each | Con | 2/Y | PAR required for purchase but not for repair. |
| E2365 | Power wheelchair accessory, U-1 sealed lead acid battery, each (e.g. gel cell, absorbed glassmat) | Con | 2/Y | PAR required for purchase but not for repair. |
| E2366 | Power wheelchair accessory, battery charger, single mode, for use with only one (1) battery type, sealed or non- sealed, each | Con | 2/Y | NCCI MUE - Do not provide more than one (1) per DOS. Effective 5-1-21: Over two (2) units requires a PAR. |
| E2367 | Power wheelchair accessory, battery charger, dual mode, for use with either battery type, sealed or non-sealed, each | Con | 1/Y | |
| E2368 | Power wheelchair component, drive wheel motor, replacement only | Con | 2 per 3 Y | PAR required for more than two (2) per three (3) fiscal years. |
| E2369 | Power wheelchair component, drive wheel gear box, replacement only | Con | 2 per 3 Y | PAR required for more than two (2) per three (3) fiscal years. |
| E2370 | Power wheelchair component, integrated drive wheel motor and gear box combination, replacement only | Con | 2 per 3 Y | PAR required for more than two (2) per three (3) fiscal years. |
| E2371 | Power wheelchair accessory, group 27 sealed lead acid battery, (e.g. gel cell, absorbed glassmat), each | Con | 2/Y | Effective 5-1-21: Over two (2) unites requires a PAR. |
| E2372 | Power wheelchair accessory, group 27 non-sealed lead acid battery, each | Con | 2/Y | Effective 5-1-21: Over two (2) unites requires a PAR. |
| E2375 | Power wheelchair accessory, non- expandable controller, including all related electronics and mounting hardware, replacement only | Con | 1/Y | Over one (1) unit requires PAR. |
| E2378 | Power wheelchair component, actuator, replacement only | Yes | 3/Y | One (1) per feature (Left Pwr ELR, Right Pwr ELR, Recline) 1 unit per month may be approved for rental. |
| E2381 | Power wheelchair accessory, pneumatic drive wheel tire, any size, replacement only, each | Con | 2/Y | Over two (2) units requires PAR. |
| E2382 | Power wheelchair accessory, tube for pneumatic drive wheel tire, any size, replacement only, each | Con | 2/Y | Over two (2) units requires PAR. |
| E2383 | Power wheelchair accessory, insert for pneumatic drive wheel tire (removable), any type, any size, replacement only, each | Con | 2/Y | Over two (2) units requires PAR. |
| E2384 | Power wheelchair accessory, pneumatic caster tire, any size, replacement only, each | Con | 2/Y | Over two (2) units requires PAR. |
| E2385 | Power wheelchair accessory, tube for pneumatic caster tire, any size, replacement only, each | Con | 2/Y | Over two (2) units requires PAR. |
| E2386 | Power wheelchair accessory, foam filled drive wheel tire, any size, replacement only, each | Con | 2/Y | Over two (2) units requires PAR. |
| E2387 | Power wheelchair accessory, foam filled caster tire, any size, replacement only, each | Con | 2/Y | Over two (2) units requires PAR. |
| E2388 | Power wheelchair accessory, foam drive wheel tire, any size, replacement only, each | Con | 2/Y | Over two (2) units requires PAR. |
| E2389 | Power wheelchair accessory, foam caster tire, any size, replacement only, each | Con | 2/Y | Over two (2) units requires PAR. |
| E2390 | Power wheelchair accessory, solid (rubber/plastic) drive wheel tire, any size, replacement only, each | Con | 2/Y | Over two (2) units requires PAR. |
| E2391 | Power wheelchair accessory, solid (rubber/plastic) caster tire (removable), any size, replacement only, each | Con | 2/Y | Over two (2) units requires PAR |
| E2392 | Power wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel, any size, replacement only, each | Con | 2/Y | Over two (2) units requires PAR. |
| E2394 | Power wheelchair accessory, drive wheel excludes tire, any size, replacement only, each | Con | 2/Y | Over two (2) units requires PAR. |
| E2395 | Power wheelchair accessory, caster wheel excludes tire, any size, replacement only, each | Con | 2/Y | Over two (2) units requires PAR. |
| E2396 | Power wheelchair accessory, caster fork, any size, replacement only, each | Con | 2/Y | Over two (2) units requires PAR. |
| E2397 | Power wheelchair accessory, lithium-based battery, each | Con | ||
| K0015 | Detachable, non-adjustable height armrest, each | Yes | 1 unit = 1 armrest | |
| K0017 | Detachable, adjustable height armrest, base, replacement only, each | Yes | 1 unit = 1 armrest | |
| K0018 | Detachable, adjustable height armrest, upper portion, replacement only, each | Yes | 1 unit = 1 armrest | |
| K0019 | Arm pad, replacement only, each | Con | 2/Y | For repair only. 1 unit = 1 arm pad Over two (2) units requires PAR. |
| K0020 | Fixed, adjustable height armrest, pair | Yes | 1 unit = 1 pair | |
| K0037 | High mount flip-up footrest, replacement only, each | Yes | 1 unit = 1 leg strap | |
| K0040 | Adjustable angle footplate, each | Con | 2/Y | 1 unit = 1 footplate Over two (2) units requires PAR. |
| K0041 | Large size footplate, each | Con | 2/Y | 1 unit = 1 footplate Over two (2) units requires PAR. |
| K0042 | Standard size footplate, replacement only, each | Con | 2/Y | 1 unit = 1 footplate Over two (2) units requires PAR. |
| K0043 | Footrest, lower extension tube, replacement only, each | Con | 2/Y | For repair only, slider extension tubes Over two (2) units requires PAR. |
| K0044 | Footrest, upper hanger bracket, replacement only, each | Con | 2/Y | For repair only. Over two (2) units requires PAR. |
| K0045 | Footrest, complete assembly, replacement only, each | Con | 2/Y | Swing away Over two (2) units requires PAR. |
| K0046 | Elevating leg rest, lower extension tube, replacement only, each | Con | 2/Y | For repair only. PAR required for more than two (2) per fiscal year. |
| K0047 | Elevating leg rest, upper hanger bracket, replacement only, each | Con | 2/Y | For repair only. PAR required for more than two (2) per fiscal year. |
| K0050 | Ratchet assembly, replacement only | Yes | For repair only. | |
| K0051 | Cam release assembly, footrest or leg rest, replacement only, each | Yes | For repair only. | |
| K0052 | Swingaway, detachable footrests, replacement only, each | Con | 2/Y | New or repair. Over two (2) units requires PAR. |
| K0053 | Elevating footrests, articulating (telescoping), each | Yes | ||
| K0065 | Spoke protectors, each | Yes | 1 unit = 1 spoke protector | |
| K0069 | Rear wheel assembly, complete, with solid tire, spokes or molded, replacement only, each | Con | 2/Y | Effective 5-1-21: Over two (2) unites requires a PAR. |
| K0070 | Rear wheel assembly, complete, with pneumatic tire, spokes or molded, each | Con | 2/Y | 1 unit = 1 assembly. Over two (2) units requires PAR. |
| K0071 | Front caster assembly, complete, with pneumatic tire, replacement only, each | Con | 2 per 3/Y | 1 unit = 1 assembly. PAR required for more than two (2) per three (3) fiscal years. |
| K0072 | Front caster assembly, complete, with semi-pneumatic tire, replacement only, each | Con | 2 per 3 Y | 1 unit = 1 assembly. PAR required for more than two (2) per three (3) fiscal years. |
| K0073 | Caster pin lock, each | No | 1 unit = 1 pin. | |
| K0077 | Front caster assembly, complete, with solid tire, replacement only, each | Con | 2 per 3 Y | PAR required for more than two (2) per three (3) fiscal years. |
| K0098 | Drive belt for power wheelchair, replacement only | Yes | For repair only. | |
| K0195 | Elevating leg rest, pair (for use with capped rental wheelchair base) | Yes | ||
| K0462-RR | Temporary replacement for patient owned equipment being repaired, any type | Yes | Do not use when there is an appropriate code available for the rental equipment being provided. | |
| K0733 | Power wheelchair accessory, 12 to 24 AMP hour sealed lead acid battery, each (e.g., gel cell, absorbed glassmat) | Con | 2/Y | Effective 5-1-21: Over two (2) unites requires a PAR. |
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| Support Systems | ||||
| E0956 | Wheelchair accessory, lateral trunk or hip support, any type, including fixed mounting hardware, each | Yes | ||
| E0957 | Wheelchair accessory, medial thigh support, any type, including fixed mounting hardware, each | Yes | ||
| E2620 | Positioning wheelchair back cushion, planar back with lateral supports, width less than 22 inches, any height, including any type mounting hardware | Yes | ||
| E2621 | Positioning wheelchair back cushion, planar back with lateral supports, width 22 inches or greater, any height, including any type mounting hardware | Yes | ||
| E2626 | Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, adjustable | Yes | ||
| E2627 | Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, adjustable Rancho type | Yes | ||
| E2628 | Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, reclining | Yes | ||
| E2629 | Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, friction arm support (friction dampening to proximal and distal joints) | Yes | ||
| E2630 | Wheelchair accessory, shoulder elbow, mobile arm support, monosuspension arm and hand support, overhead elbow forearm hand sling support, yoke type suspension support | Yes | ||
| E2631 | Wheelchair accessory, addition to mobile arm support, elevating proximal arm | Yes | ||
| E2632 | Wheelchair accessory, addition to mobile arm support, offset or lateral rocker arm with elastic balance control | Yes | ||
| E2633 | Wheelchair accessory, addition to mobile arm support, supinator | Yes | ||
| T5001 | Positioning seat for persons with special orthopedic needs | Yes | Use this code for custom seating/positioning car seats. | |
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Cochlear Equipment and Supplies
| Code | Description | PAR | Unit Limits | Comments |
|---|---|---|---|---|
| A4638 | Replacement battery for patient -owned ear pulse generator, each | No | ||
| E2120 | Pulse generator system for tympanic treatment of inner ear endolymphatic fluid | Yes | ||
| L8613 | Ossicula implant | None | ||
| L8614 | Cochlear device, includes all internal and external components | Yes | Requires PAR as of December 1, 2022. Refer to the December 2022 Provider Bulletin. | |
| L8615 | Headset/headpiece for use with cochlear implant device, replacement | Refer to the Audiology Billing Manual for coverage information. | ||
| L8616 | Microphone for use with cochlear implant device, replacement | Refer to the Audiology Billing Manual for coverage information. | ||
| L8617 | Transmitting coil for use with cochlear implant device, replacement | Refer to the Audiology Billing Manual for coverage information. | ||
| L8618 | Transmitter cable for use with cochlear implant device or auditory osseointegrated device, replacement | Refer to the Audiology Billing Manual for coverage information. | ||
| L8619 | Cochlear implant external speech processor, replacement | Yes | Refer to the Audiology Billing Manual for coverage information. One (1) per right and left side, every 12 months. *Effective April 1, 2019, a prior authorization is required. | |
| L8621 | Zinc air battery for use with cochlear implant device and auditory osseointegrated sound processors, replacement, each | Refer to the Audiology Billing Manual for coverage information. | ||
| L8622 | Alkaline battery for use with cochlear implant device, any size, replacement, each | Refer to the Audiology Billing Manual for coverage information. | ||
| L8623 | Lithium ion battery for use with cochlear implant device speech processor, other than ear level, replacement, each | Refer to the Audiology Billing Manual for coverage information. | ||
| L8624 | Lithium ion battery for use with cochlear implant or auditory osseointegrated device speech processor, ear level, replacement, each | Refer to the Audiology Billing Manual for coverage information. | ||
| L8625 | External recharging system for battery for use with cochlear implant or auditory osseointegrated device, replacement only, each | New code effective 01/01/2018. Refer to the Audiology Billing Manual for coverage information. NCCI MUE - cannot be overridden with a PAR. | ||
| L8627 | Cochlear implant, external speech processor, component, replacement | Yes | *Effective April 1, 2019, a prior authorization is required | |
| L8628 | Cochlear implant, external controller component, replacement | Yes | *Effective April 1, 2019, a prior authorization is required | |
| L8629 | Transmitting coil and cable, integrated, for use with cochlear implant device, replacement | Yes | *Effective April 1, 2019, a prior authorization is required | |
| L8691 | Auditory osseointegrated device, external sound processor, excludes transducer/actuator, replacement only, each | Yes | ||
| L8692 | Auditory osseointegrated device, used without osseointegration, body worn, includes headband or other means of external attachment | Yes | ||
| L8693 | Auditory osseointegrated device abutment, any length, replacement only | None | ||
| L8694 | Auditory osseointegrated device, transducer/actuator, replacement only, each | Yes | SEE NCCI MUE LIMIT | New code effective 01/01/2018. NCCI MUE - cannot be overridden with a PAR. |
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Diabetic Monitoring Equipment and Supplies
| Code | Description | PAR | Unit Limits | Comments |
|---|---|---|---|---|
| A4206 | Syringe with needle, sterile, 1 cc or less, each | No | 120/M | Use for diabetic syringes. All syringes must be billed on the supply claim form. 1 unit = 1 syringe |
| A4211 | Supplies for self-administered injection | No | ||
| A4215 | Needle, sterile, any size, each | No | Use for diabetic pen needles. Indicate frequency of administration. | |
| A4230 | Infusion set for external insulin pump, non-needle cannula type | Yes | ||
| A4231 | Infusion set for external insulin pump, needle type | Yes | ||
| A4232 | Syringe with needle for external insulin pump, sterile, 3cc | Yes | ||
| A4233 | Replacement battery, alkaline (other than J cell), for use with medically necessary home blood glucose monitor owned by patient, each | No | ||
| A4234 | Replacement battery, alkaline, J cell, for use with medically necessary home blood glucose monitor owned by patient, each | No | ||
| A4235 | Replacement battery, lithium, for use with medically necessary home blood glucose monitor owned by patient, each | No | ||
| A4236 | Replacement battery, silver oxide, for use with medically necessary home blood glucose monitor owned by patient, each | No | ||
| A4238 | Supply allowance for adjunctive, nonimplanted continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service | Yes | PARs for this item are limited to six (6)-month spans at a time. Code opened 05-01-2023. | |
| A4239 | Supply allowance for non-adjunctive, non-implanted continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service | Yes | PARs for this item are limited to dix (6)-month spans at a time. Code opened 01-01-2023. | |
| A4250 | Urine test or reagent strips or tablets (100 tablets or strips) | No | 1 unit = 100 strips/tablets Albustix | |
| A4252 | Blood ketone test or reagent strip, each | No | ||
| A4253 | Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips | No | SEE NCCI MUE LIMIT | 1 unit = 50 strips NCCI MUE - cannot be overridden with a PAR. |
| A4255 | Platforms for home blood glucose monitor, 50 per box | No | 1 unit = 50 per box | |
| A4258 | Spring-powered device for lancet, each | No | 1 unit = 1 device | |
| A4259 | Lancets, per box of 100 | No | SEE NCCI MUE LIMIT | 1 unit = box of 100 NCCI MUE - cannot be overridden with a PAR. |
| A4271 | Integrated lancing and blood sample testing cartridges for home blood glucose monitor, per month | Yes | Code opened 04-01-2024. | |
| A4772 | Blood glucose test strips, for dialysis, per 50 | No | 1 unit = per 50 Also for diabetic use. | |
| A9274 | External ambulatory insulin delivery system, disposable, each, includes all supplies and accessories | Yes | ||
| A9276 | Sensor, invasive (e.g. subcutaneous), disposable, for use with interstitial continuous glucose monitoring system | Yes | 1 unit = 1 day supply | |
| A9277 | Transmitter; external, for use with interstitial continuous glucose monitoring system | Yes | ||
| A9278 | Receiver (monitor); external, for use with interstitial continuous glucose monitoring system | Yes | ||
| E0607 | Home blood glucose monitor | No | 2/Y | Required: F2F *Code is subject to the 2019 DME UPL. |
| E0784 | External ambulatory infusion pump, insulin | Yes | 1 unit = 1 system Required: F2F *Code is subject to the 2019 DME UPL. | |
| E2100 | Blood glucose monitor with integrated voice synthesizer | Yes | Medical justification needed for upgrade. *Code is subject to the 2019 DME UPL. | |
| E2101 | Blood glucose monitor with integrated lancing/blood sample | Yes | Medical justification needed for upgrade. *Code is subject to the 2019 DME UPL. | |
| K0553 | Supply allowance for therapeutic continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service | Yes | PARs for this item are limited to six (6)-month spans at a time. Code closed 12-31-2022. See replacement code A4239 for 1-1-2023 onwards. | |
| K0554 | Receiver (monitor), dedicated, for use with therapeutic glucose continuous monitor system | Yes | PARs for this item are limited to six (6)-month spans at a time. Code closed 12-31-2022. See replacement code E2103 for 1-1-2023 onwards. | |
| E2102 | Adjunctive, nonimplanted continuous glucose monitor (CGM) or receiver | Yes | PARs for this item are limited to six (6)-month spans at a time. Code opened 05-01-2023. | |
| E2103 | Non-adjunctive, non-implanted continuous glucose monitor (CGM) or receiver | Yes | PARs for this item are limited to six (6)-month spans at a time. Code opened 01-01-2023. | |
| E2104 | Home blood glucose monitor for use with integrated lancing/blood sample testing cartridge | Yes | Code opened 04-01-2024. | |
| S5565 | Insulin cartridge for use in insulin delivery device other than pump; 150 units | None | ||
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Disposable Supplies - General Use
| Code | Description | PAR | Unit Limits | Comments |
|---|---|---|---|---|
| Antiseptics/Solutions | ||||
| A4216 | Sterile water, saline and/or dextrose, diluent/flush, 10 ml | Yes | 93/M | NDC required on claim |
| A4217 | Sterile water/saline, 500 ml | Yes | 30/M | NDC required on claim |
| A4218 | Sterile saline or water, metered dose dispenser, 10 ml | Yes | 20/M | NDC required on claim |
| A4244 | Alcohol or peroxide, per pint | Yes | 1 unit = 1 pint | |
| A4245 | Alcohol wipes, each | No | Not allowable for incontinence/baby wipes use. 1 unit = 1 wipe | |
| A4246 | Betadine, per pint | Yes | 1 unit = 1 pint | |
| A4247 | Betadine or Iodine swabs/wipes, each | Yes | 1 unit = 1 swab/wipe | |
| A6250 | Skin sealants, protectants, moisturizers, ointment, any type, any size | No | Do not bill in combination with E2404. E2404 is inclusive of this supply. | |
| S8301 | Infection control supplies, not otherwise specified | Yes | Use for masks, disposable gowns, etc. | |
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| First Aid/Dressings | ||||
| A4450 | Tape, non-waterproof, per 18 square inches | Yes | 1 unit = 18 square inches. If the requested product is not measured in inches, please provide the conversion on the PAR to confirm the units requested are correct. | |
| A4452 | Tape, waterproof, per 18 square inches | Yes | 120/M | |
| A4455 | Adhesive remover or solvent, each | No | ||
| A4456 | Adhesive remover, wipes, any type, each | No | ||
| A4461 | Surgical dressing holder, non-reusable, each | No | ||
| A4463 | Surgical dressing holder, reusable, each | No | ||
| A4561 | Pessary, reusable, rubber, any type | No | ||
| A4562 | Pessary, reusable, non-rubber, any type | No | ||
| A4564 | Pessary, disposable, any type | Yes | Code opened 04-01-2024. | |
| A4565 | Sling, each | No | ||
| A4566 | Shoulder sling or vest design, abduction restrainer, with or without swathe control, prefabricated, includes fitting and adjustment | No | ||
| A4570 | Splint | No | ||
| Effective November 1, 2017, this code is not billable by Provider Types Supply or Pharmacy w/DME. | ||||
| A4927 | Gloves, non-sterile, per 100 | No | 5/M | 1 unit = 100 gloves Over 5 boxes requires PAR. |
| A4930 | Gloves, sterile, per pair | No | 5/D | 1 unit = 1 pair Limit five (5) pair per day. |
| A6010 | Collagen based wound filler, dry form, sterile, per gram of collagen | Yes | 100/M | |
| A6011 | Collagen based wound filler, gel/paste, per gram of collagen | Yes | 60/M | |
| A6021 | Collagen dressing, sterile, size 16 sq. in. or less, each | Yes | 120/M | |
| A6022 | Collagen dressing, sterile, size more than 16 sq. in. but less than or equal to 48 sq. in., each | Yes | 120/M | |
| A6023 | Collagen dressing, sterile, size more than 48 sq. in., each | Yes | 60/M | |
| A6024 | Collagen dressing wound filler, sterile, per 6 inches | Yes | ||
| A6025 | Gel sheet for dermal or epidermal application, (e.g., silicone, hydrogel, other), each | Yes | 1 unit = 1 sheet | |
| A6154 | Wound pouch, each | Yes | 1 unit = 1 pouch | |
| A6196 | Alginate or other fiber gelling dressing, wound cover, sterile, pad size 16 sq. in. or less, each dressing | Yes | ||
| A6197 | Alginate or other fiber gelling dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., each dressing | Yes | ||
| A6198 | Alginate or other fiber gelling dressing, wound cover, sterile, pad size more than 48 sq. in., each dressing | Yes | ||
| A6199 | Alginate or other fiber gelling dressing, wound filler, sterile, per 6 inches | Yes | ||
| A6203 | Composite dressing, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing | Yes | ||
| A6204 | Composite dressing, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in. with any size adhesive border, each dressing | Yes | ||
| A6205 | Composite dressing, sterile, pad size more than 48 sq. in., with any size adhesive border, each dressing | Yes | ||
| A6206 | Contact layer, sterile, 16 sq. in. or less, each dressing | Yes | ||
| A6207 | Contact layer, sterile, more than 16 sq. in. but less than or equal to 48 sq. in., each dressing | Yes | ||
| A6208 | Contact layer, sterile, more than 48 sq. in., each dressing | Yes | ||
| A6209 | Foam dressing, wound cover, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing | Yes | ||
| A6210 | Foam dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing | Yes | ||
| A6211 | Foam dressing, wound cover, sterile, pad size more than 48 sq. in., without adhesive border, each dressing | Yes | ||
| A6212 | Foam dressing, wound cover, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing | Yes | ||
| A6213 | Foam dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing | Yes | ||
| A6214 | Foam dressing, wound cover, sterile, pad size more than 48 sq. in., with any size adhesive border, each dressing | Yes | ||
| A6215 | Foam dressing, wound filler, sterile, per gram | Yes | ||
| A6216 | Gauze, non-impregnated, non-sterile, pad size 16 sq. in. or less, without adhesive border, each dressing | Yes | ||
| A6217 | Gauze, non-impregnated, non-sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing | Yes | ||
| A6218 | Gauze, non-impregnated, non-sterile, pad size more than 48 sq. in., without adhesive border, each dressing | Yes | ||
| A6219 | Gauze, non-impregnated, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing | Yes | ||
| A6220 | Gauze, non-impregnated, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing | Yes | ||
| A6221 | Gauze, non-impregnated, sterile, pad size more than 48 sq. in., with any size adhesive border, each dressing | Yes | ||
| A6222 | Gauze, impregnated with other than water, normal saline, or hydrogel, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing | Yes | 200/M | |
| A6223 | Gauze, impregnated with other than water, normal saline, or hydrogel, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing | Yes | 150/M | |
| A6224 | Gauze, impregnated with other than water, normal saline, or hydrogel, sterile, pad size more than 48 sq. in., without adhesive border, each dressing | Yes | 150/M | |
| A6228 | Gauze, impregnated, water or normal saline, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing | Yes | ||
| A6229 | Gauze, impregnated, water or normal saline, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing | Yes | ||
| A6230 | Gauze, impregnated, water or normal saline, sterile, pad size more than 48 sq. in., without adhesive border, each dressing | Yes | ||
| A6231 | Gauze, impregnated, hydrogel, for direct wound contact, sterile, pad size 16 sq. in. or less, each dressing | Yes | 120/M | |
| A6232 | Gauze, impregnated, hydrogel, for direct wound contact, sterile, pad size greater than 16 sq. in. but less than or equal to 48 sq. in., each dressing | Yes | 120/M | |
| A6233 | Gauze, impregnated, hydrogel, for direct wound contact, sterile, pad size more than 48 sq. in., each dressing | Yes | 60/M | |
| A6234 | Hydrocolloid dressing, wound cover, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing | Yes | ||
| A6235 | Hydrocolloid dressing, wound cover, sterile, pad size more than 16 sq. in but less than or equal to 48 sq. in., without adhesive border, each dressing | Yes | ||
| A6236 | Hydrocolloid dressing, wound cover, sterile, pad size more than 48 sq. in., without adhesive border, each dressing | Yes | ||
| A6237 | Hydrocolloid dressing, wound cover, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing | Yes | ||
| A6238 | Hydrocolloid dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing | Yes | ||
| A6239 | Hydrocolloid dressing, wound cover, sterile, pad size more than 48 sq. in., with any size adhesive border, each dressing | Yes | ||
| A6240 | Hydrocolloid dressing, wound filler, paste, sterile, per fluid ounce | Yes | ||
| A6241 | Hydrocolloid dressing, wound filler, dry form, sterile, per gram | Yes | ||
| A6242 | Hydrogel dressing, wound cover, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing | Yes | ||
| A6243 | Hydrogel dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing | Yes | ||
| A6244 | Hydrogel dressing, wound cover, sterile, pad size more than 48 sq. in., without adhesive border, each dressing | Yes | ||
| A6245 | Hydrogel dressing, wound cover, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing | Yes | ||
| A6246 | Hydrogel dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing | Yes | ||
| A6247 | Hydrogel dressing, wound cover, sterile, pad size more than 48 sq. in., with any size adhesive border, each dressing | Yes | ||
| A6248 | Hydrogel dressing, wound filler, gel, per fluid ounce | Yes | ||
| A6251 | Specialty absorptive dressing, wound cover, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing | Yes | ||
| A6252 | Specialty absorptive dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing | Yes | ||
| A6253 | Specialty absorptive dressing, wound cover, sterile, pad size more than 48 sq. in., without adhesive border, each dressing | Yes | ||
| A6254 | Specialty absorptive dressing, wound cover, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing | Yes | ||
| A6255 | Specialty absorptive dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing | Yes | ||
| A6256 | Specialty absorptive dressing, wound cover, sterile, pad size more than 48 sq. in., with any size adhesive border, each dressing | Yes | ||
| A6257 | Transparent film, sterile, 16 sq. in. or less, each dressing | Yes | ||
| A6258 | Transparent film, sterile, more than 16 sq. in. but less than or equal to 48 sq. in., each dressing | Yes | ||
| A6259 | Transparent film, sterile, more than 48 sq. in., each dressing | Yes | ||
| A6260 | Wound cleansers, any type, any size | Yes | 2/M | |
| A6261 | Wound filler, gel/paste, per fluid ounce, not otherwise specified | Yes | ||
| A6262 | Wound filler, dry form, per gram, not otherwise specified | Yes | ||
| A6266 | Gauze, impregnated, other than water, normal saline, or zinc paste, sterile, any width, per linear yard | Yes | ||
| A6402 | Gauze, non-impregnated, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing | Yes | ||
| A6403 | Gauze, non-impregnated, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing | Yes | ||
| A6404 | Gauze, non-impregnated, sterile, pad size more than 48 sq. in., without adhesive border, each dressing | Yes | ||
| A6407 | Packing strips, non-impregnated, sterile, up to 2 inches in width, per linear yard | Yes | ||
| A6441 | Padding bandage, non-elastic, non- woven/non-knitted, width greater than or equal to three (3) inches and less than five (5) inches, per yard | Yes | 62/M | 1 unit = one yard |
| A6442 | Conforming bandage, non-elastic, knitted/woven, non-sterile, width less than three (3) inches, per yard | Yes | 62/M | 1 unit = one yard |
| A6443 | Conforming bandage, non-elastic, knitted/woven, non-sterile, width greater than or equal to three (3) inches and less than five (5) inches, per yard | Yes | 62/M | 1 unit = one yard |
| A6444 | Conforming bandage, non-elastic, knitted/woven, non-sterile, width greater than or equal to five (5) inches, per yard | Yes | 62/M | 1 unit = one yard |
| A6445 | Conforming bandage, non-elastic, knitted/woven, sterile, width less than three (3) inches, per yard | Yes | 62/M | 1 unit = one yard |
| A6446 | Conforming bandage, non-elastic, knitted/woven, sterile, width greater than or equal to three (3) inches and less than five (5) inches, per yard | Yes | 62/M | 1 unit = one yard |
| A6447 | Conforming bandage, non-elastic, knitted/woven, sterile, width greater than or equal to five (5) inches, per yard | Yes | 62/M | 1 unit = one yard |
| A6448 | Light compression bandage, elastic, knitted/woven, width less than three (3) inches, per yard | Yes | 62/M | 1 unit = one yard |
| A6449 | Light compression bandage, elastic, knitted/woven, width greater than or equal to three (3) inches and less than five (5) inches, per yard | Yes | 62/M | 1 unit = one yard |
| A6450 | Light compression bandage, elastic, knitted/woven, width greater than or equal to five (5) inches, per yard | Yes | 62/M | 1 unit = one yard |
| A6451 | Moderate compression bandage, elastic, knitted/woven, load resistance of 1.25 to 1.34 foot pounds at 50% maximum stretch, width greater than or equal to three (3) inches and less than five (5) inches, per yard | Yes | 62/M | 1 unit = one yard |
| A6452 | High compression bandage, elastic, knitted/woven, load resistance greater than or equal to 1.35 foot pounds at 50% maximum stretch, width greater than or equal to three (3) inches and less than (5) five (5) inches, per yard | Yes | 62/M | 1 unit = one yard |
| A6453 | Self-adherent bandage, elastic, non- knitted/non-woven, width less than three (3) inches, per yard | Yes | 62/M | 1 unit = one yard |
| A6454 | Self-adherent bandage, elastic, non- knitted/non-woven, width greater than or equal to three (3) inches and less than five (5) inches, per yard | Yes | 62/M | 1 unit = one yard |
| A6455 | Self-adherent bandage, elastic, non- knitted/non-woven, width greater than or equal to five (5) inches, per yard | Yes | 62/M | 1 unit = one yard |
| A6456 | Zinc paste impregnated bandage, non- elastic, knitted/non-woven, width greater than or equal to three (3) inches and less than five (5) inches, per yard | Yes | 62/M | 1 unit = one yard |
| A6457 | Tubular dressing with or without elastic, any width, per linear yard | Yes | 100/M | |
| A9285 | Inversion/eversion correction device | Yes | New code effective 01/01/2017. | |
| S8450 | Splint, prefabricated, digit (specify digit by use of modifier) | No | ||
| S8451 | Splint, prefabricated, wrist or ankle | No | ||
| S8452 | Splint, prefabricated, elbow | No | ||
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| Compression Burn Garments | ||||
| A6501 | Compression burn garment, bodysuit (head to foot), custom fabricated | Yes | ||
| A6502 | Compression burn garment, chin strap, custom fabricated | Yes | ||
| A6503 | Compression burn garment, facial hood, custom fabricated | Yes | ||
| A6504 | Compression burn garment, glove to wrist, custom fabricated | Yes | ||
| A6505 | Compression burn garment, glove to elbow, custom fabricated | Yes | ||
| A6506 | Compression burn garment, glove to axilla, custom fabricated | Yes | ||
| A6507 | Compression burn garment, foot to knee length, custom fabricated | Yes | ||
| A6508 | Compression burn garment, foot to thigh length, custom fabricated | Yes | ||
| A6509 | Compression burn garment, upper trunk to waist including arm openings (vest), custom fabricated | Yes | ||
| A6510 | Compression burn garment, trunk, including arms down to leg openings (leotard), custom fabricated | Yes | ||
| A6511 | Compression burn garment, lower trunk including leg openings (panty), custom fabricated | Yes | ||
| A6512 | Compression burn garment, not otherwise classified | Yes | ||
| A6513 | Compression burn mask, face and/or neck, plastic or equal, custom fabricated | Yes | ||
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| Ostomy Care | ||||
| A4361 | Ostomy face plate, all sizes, each | No | 1 unit = 1 faceplate | |
| A4362 | Skin barrier, solid, 4x4 or equivalent, each | No | ||
| A4363 | Ostomy clamp, any type, replacement only, each | No | ||
| A4364 | Adhesive for ostomy or catheter, liquid (spray, brush, etc.), cement, powder or paste, any composition, per ounce | No | 1 unit = 1 ounce Silicone, latex. | |
| A4366 | Ostomy vent, any type, each | No | ||
| A4367 | Ostomy belt, each | No | 1 unit = 1 belt | |
| A4368 | Ostomy filter, any type, each | No | 1 unit = 1 filter | |
| A4369 | Ostomy skin barrier, liquid (spray, brush, etc.), per ounce | No | 1 unit = 1 ounce | |
| A4371 | Ostomy skin barrier, powder, per ounce | No | 1 unit = 1 ounce | |
| A4372 | Ostomy skin barrier, solid 4x4 or equivalent, standard wear, with built-in convexity, each | No | 1 unit = 1 skin barrier | |
| A4373 | Ostomy skin barrier, with flange (solid, flexible or accordion), with built-in convexity, any size, each | No | 1 unit = 1 skin barrier | |
| A4375 | Ostomy pouch, drainable, with faceplate attached, plastic, each | No | 1 unit = 1 pouch | |
| A4376 | Ostomy pouch, drainable, with faceplate attached, rubber, each | No | 1 unit = 1 pouch | |
| A4377 | Ostomy pouch drainable, for use on faceplate, plastic, each | No | 1 unit = 1 pouch | |
| A4378 | Ostomy pouch, drainable, for use on faceplate, rubber, each | No | 1 unit = 1 pouch | |
| A4379 | Ostomy pouch, urinary, with faceplate attached, plastic, each | No | 1 unit = 1 pouch | |
| A4380 | Ostomy pouch, urinary, with faceplate attached, rubber, each | No | 1 unit = 1 pouch | |
| A4381 | Ostomy pouch, urinary, for use on faceplate, plastic, each | No | 1 unit = 1 pouch | |
| A4382 | Ostomy pouch, urinary, for use on faceplate, heavy plastic, each | No | 1 unit = 1 pouch | |
| A4383 | Ostomy pouch, urinary, for use on faceplate, rubber, each | No | 1 unit = 1 pouch | |
| A4384 | Ostomy faceplate equivalent, silicone ring, each | No | 1 unit = 1 faceplate, silicone ring | |
| A4385 | Ostomy skin barrier, solid 4x4 or equivalent, extended wear, without built-in convexity, each | No | 1 unit = 1 skin barrier | |
| A4387 | Ostomy pouch, closed, with barrier attached, with built-in convexity (1 piece), each | No | 1 unit = 1 pouch | |
| A4388 | Ostomy pouch, drainable, with extended wear barrier attached, (1 piece), each | No | 1 unit = 1 pouch | |
| A4389 | Ostomy pouch, drainable, with barrier attached, with built-in convexity (1 piece), each | No | 1 unit = 1 pouch | |
| A4390 | Ostomy pouch, drainable, with extended wear barrier attached, with built-in convexity (1 piece), each | No | 1 unit = 1 pouch | |
| A4391 | Ostomy pouch, urinary, with extended wear barrier attached (1 piece), each | No | 1 unit = 1 pouch | |
| A4392 | Ostomy pouch, urinary, with standard wear barrier attached, with built-in convexity (1 piece), each | No | 1 unit = 1 pouch | |
| A4393 | Ostomy pouch, urinary, with extended wear barrier attached, with built-in convexity (1 piece), each | No | 1 unit = 1 pouch | |
| A4394 | Ostomy deodorant, with or without lubricant, for use in ostomy pouch, per fluid ounce | No | ||
| A4395 | Ostomy deodorant for use in ostomy pouch, solid, per tablet | No | 1 unit = 1 tablet | |
| A4396 | Ostomy belt with peristomal hernia support | No | 1 unit = 1 belt | |
| A4398 | Ostomy irrigation supply, bag, each | No | 1 unit = 1 bag | |
| A4399 | Ostomy irrigation supply, cone/catheter, with or without brush | No | 1 unit = cone/catheter and brush | |
| A4400 | Ostomy irrigation set, each | No | 1 unit = 1 set | |
| A4402 | Lubricant, per ounce | No | 1 unit = 1 ounce | |
| A4404 | Adhesive rings (washers, wafers, discs, etc.), each | No | 1 unit = 1 ring | |
| A4405 | Ostomy skin barrier, non-pectin based, paste, per ounce | No | 6/M | 1 unit = 1 ounce |
| A4406 | Ostomy skin barrier, pectin based, paste, per ounce | No | 6/M | 1 unit =1 ounce |
| A4407 | Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, with built-in convexity, 4 X 4 inches or smaller, each | No | 31/M | 1 unit = 1 skin barrier |
| A4408 | Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, with built-in convexity, larger than 4 X 4 inches, each | No | 31/M | 1 unit = 1 skin barrier |
| A4409 | Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, without built-in convexity, 4 X 4 inches or smaller, each | No | 31/M | 1 unit = 1 skin barrier |
| A4410 | Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, without built-in convexity, larger than 4 X 4 inches, each | No | 60/M | 1 unit = 1 skin barrier |
| A4411 | Ostomy skin barrier, solid 4X4 or equivalent, extended wear, with built-in convexity, each | No | 60/M | |
| A4412 | Ostomy pouch, drainable, high output, for use on a barrier with flange (2 piece system), without filter, each | No | 31/M | |
| A4413 | Ostomy pouch, drainable, high output, for use on a barrier with flange (2 piece system), with filter, each | No | 31/M | 1 unit = 1 pouch |
| A4414 | Ostomy skin barrier, with flange (solid, flexible or accordion), without built-in convexity, 4 X 4 inches or smaller, each | No | 31/M | 1 unit = 1 skin barrier |
| A4415 | Ostomy skin barrier, with flange (solid, flexible or accordion), without built-in convexity, larger than 4 X 4 inches, each | No | 31/M | 1 unit = 1 skin barrier |
| A4416 | Ostomy pouch, closed, with barrier attached, with filter (1 piece), each | No | 50/M | 1 unit = 1 pouch |
| A4417 | Ostomy pouch, closed, with barrier attached, with built-in convexity, with filter (1 piece), each | No | 50/M | 1 unit = 1 pouch |
| A4418 | Ostomy pouch, closed, without barrier attached, with filter (1 piece), each | No | 50/M | 1 unit = 1 pouch |
| A4419 | Ostomy pouch, closed, for use on barrier with non-locking flange, with filter (2 piece), each | No | 60/M | 1 unit = 1 pouch |
| A4420 | Ostomy pouch, closed, for use on barrier with locking flange, (2 piece), each | No | 50/M | 1 unit = 1 pouch |
| A4421 | Miscellaneous ostomy supply not otherwise classified | No | ||
| A4422 | Ostomy absorbent material (sheet/pad/crystal packet) for use in ostomy pouch to thicken liquid stomal output, each | No | 1 unit = 1 packet | |
| A4423 | Ostomy pouch, closed, for use on barrier with locking flange, with filter (2 piece), each | No | 50/M | 1 unit = 1 pouch |
| A4424 | Ostomy pouch, drainable, with barrier attached, with filter (1 piece), each | No | 50/M | 1 unit = 1 pouch |
| A4425 | Ostomy pouch, drainable, for use on barrier with non-locking flange, with filter (two (2) piece system), each | No | 50/M | 1 unit = 1 pouch |
| A4426 | Ostomy pouch, drainable, for use on barrier with locking flange (2 piece system), each | No | 50/M | 1 unit = 1 pouch |
| A4427 | Ostomy pouch, drainable, for use on barrier with locking flange with filter (2 piece system), each | No | 50/M | 1 unit = 1 pouch |
| A4428 | Ostomy pouch, urinary, with extended wear barrier attached, with faucet-type tap with valve (1 piece), each | No | 50/M | 1 unit = 1 pouch |
| A4429 | Ostomy pouch, urinary, with barrier attached, with built-in convexity, with faucet-type tap with valve (1 piece), each | No | 50/M | 1 unit = 1 pouch |
| A4430 | Ostomy pouch, urinary, with extended wear barrier attached, with built-in convexity, with faucet-type tap with valve (1 piece), each | No | 50/M | 1 unit = 1 pouch |
| A4431 | Ostomy pouch, urinary, with barrier attached, with faucet-type tap with valve (1 piece), each | No | 50/M | 1 unit = 1 pouch |
| A4432 | Ostomy pouch, urinary, for use on barrier with non-locking flange, with faucet-type tap with valve (2 piece), each | No | 50/M | 1 unit = 1 pouch |
| A4433 | Ostomy pouch, urinary, for use on barrier with locking flange (2 piece), each | No | 50/M | 1 unit = 1 pouch |
| A4434 | Ostomy pouch, urinary, for use on barrier with locking flange, with faucet- type tap with valve (2 piece), each | No | 50/M | 1 unit = 1 pouch |
| A4435 | Ostomy pouch, drainable, high output, with extended wear barrier (one-piece system), with or without filter, each | No | 31/M | 1 unit per one (1) to two (2) days per site. This item should not be billed with barriers. |
| A4436 | Irritation supply; sleeve, reusable, per month | Yes | ||
| A4437 | Irritation supply; sleeve, disposable, per month | Yes | ||
| A4438 | Adhesive clip applied to the skin to secure external electrical nerve stimulator controller, each | Yes | Code opened 04-01-2024. | |
| A5051 | Pouch, closed, with barrier attached (1 piece), each | No | 1 unit = 1 pouch | |
| A5052 | Ostomy pouch, closed, without barrier attached (1 piece), each | No | 1 unit = 1 pouch | |
| A5053 | Ostomy pouch, closed, for use on faceplate, each | No | 1 unit = 1 pouch | |
| A5054 | Ostomy pouch, closed, for use on barrier with flange, (2 piece) each | No | 1 unit = 1 pouch (2 piece system) each | |
| A5055 | Stoma cap, each | No | 1 unit = 1 cap | |
| A5056 | Ostomy pouch, drainable, with extended wear barrier attached, with filter, (1 piece), each | No | SEE NCCI MUE LIMIT | NCCI MUE - cannot be overridden with a PAR. |
| A5057 | Ostomy pouch, drainable, with extended wear barrier attached, with built in convexity, with filter, (1 piece), each | No | ||
| A5061 | Ostomy pouch, drainable, with barrier attached (1 piece), each | No | 1 unit = 1 pouch | |
| A5062 | Ostomy pouch, drainable, without barrier attached (1 piece), each | No | 1 unit = 1 pouch | |
| A5063 | Ostomy pouch, drainable, for use on barrier with flange, (2 piece system), each | No | 1 unit = 1 pouch (2 piece system) each | |
| A5071 | Ostomy pouch, urinary, with barrier attached (1 piece), each | No | 1 unit = 1 pouch | |
| A5072 | Ostomy pouch, urinary, without barrier attached (1 piece), each | No | 1 unit = 1 pouch | |
| A5073 | Ostomy pouch, urinary, for use on barrier with flange, per (2 piece), each | No | 1 unit = 1 pouch | |
| A5081 | Stoma plug or seal, any type | No | 1 unit = 1 device | |
| A5082 | Continent device, catheter for continent stoma, each | No | 1 unit = 1 catheter | |
| A5083 | Continent device, stoma absorptive cover for continent stoma | No | 1 unit = 1 cover | |
| A5093 | Ostomy accessory, convex insert, each | No | 1 unit = 1 insert | |
| A5102 | Bedside drainage bottle, with or without tubing rigid or expandable, each | No | 1 unit = 1 bottle | |
| A5105 | Urinary suspensory with leg bag, with or without tube, each | No | 1 unit = 1 suspensory | |
| A5112 | Urinary drainage bag, leg or abdomen, latex, with or without tube, with straps, each | No | 1 unit = 1 bag | |
| A5113 | Leg strap, latex, replacement only, per set | No | 1 unit = 1 pair | |
| A5114 | Leg strap, foam or fabric, replacement only, per set | No | 1 unit = 1 set | |
| A5120 | Skin barrier, wipes or swabs, each | No | SEE NCCI MUE LIMIT | NCCI MUE - cannot be overridden with a PAR. |
| A5121 | Skin barrier, solid, 6x6 or equivalent, each | No | 1 unit = 1 skin barrier | |
| A5122 | Skin barrier, solid, 8x8 or equivalent, each | No | 1 unit = 1 skin barrier | |
| A5126 | Adhesive or non-adhesive disc or foam pad | No | 1 unit = 1 pad | |
| A5131 | Appliance cleaner, incontinence or ostomy appliance, per 16 ounces | No | SEE NCCI MUE LIMIT | 1 unit = 16 ounces. NCCI MUE - cannot be overridden with a PAR |
| A6250 | Skin sealants, protectants, moisturizers, ointments, any type, any size | No | Do not bill in combination with E2404. E2404 is inclusive of this supply. | |
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Incontinence Products or Briefs Combination Limit: Products are limited to 360 per calendar month in any combination of diapers, liners and undergarments. Combined quantities above 360 require a Prior Authorization Request (PAR). | ||||
| T4521 | Adult sized disposable incontinence product, brief/diaper, small, each | Con | 360/M | Diaper. COMBINATION LIMIT |
| T4522 | Adult sized disposable incontinence product, brief/diaper, medium, each | Con | 360/M | Diaper. COMBINATION LIMIT |
| T4523 | Adult sized disposable incontinence product, brief/diaper, large, each | Con | 360/M | Diaper. COMBINATION LIMIT |
| T4524 | Adult sized disposable incontinence product, brief/diaper, extra-large, each | Con | 360/M | Diaper. COMBINATION LIMIT |
| T4525 | Adult sized disposable incontinence product, protective underwear/pull-on, small size, each | Con | 360/M | Pull-up. COMBINATION LIMIT |
| T4526 | Adult sized disposable incontinence product, protective underwear/pull-on, medium size, each | Con | 360/M | Pull-up. COMBINATION LIMIT |
| T4527 | Adult sized disposable incontinence product, protective underwear/pull-on, large size, each | Con | 360/M | Pull-up. COMBINATION LIMIT |
| T4528 | Adult sized disposable incontinence product, protective underwear/pull-on, extra-large size, each | Con | 360/M | Pull-up. COMBINATION LIMIT |
| T4529 | Pediatric sized disposable incontinence product, brief/diaper, small/medium size, each | Con | 360/M | Diaper. COMBINATION LIMIT |
| T4530 | Pediatric size disposable incontinence product brief/diaper, large size, each | Con | 360/M | Diaper. COMBINATION LIMIT |
| T4531 | Pediatric size disposable incontinence product, protective underwear/pull-on, small/medium size, each | Con | 360/M | Pull-up. COMBINATION LIMIT |
| T4532 | Pediatric sized disposable incontinence product, protective underwear/pull-on, large size, each | Con | 360/M | Pull-up. COMBINATION LIMIT |
| T4533 | Youth sized disposable incontinence product, brief/diaper, each | Con | 360/M | Diaper. COMBINATION LIMIT |
| T4534 | Youth sized disposable incontinence product, protective underwear/pull-on, each | Con | 360/M | Pull-up. COMBINATION LIMIT |
| T4535 | Disposable liner/shield/guard/pad/undergarment, for incontinence, each | Con | 360/M | Liner. COMBINATION LIMIT |
| T4543 | Adult sized disposable incontinence product, protective brief/diaper, above extra-large, each | Con | 360/M | Brief. COMBINATION LIMIT |
| T4544 | Adult sized disposable incontinence product, protective underwear/pull-on, above extra-large, each | Con | 360/M | Pull-Up. COMBINATION LIMIT |
| A4553 | Non-disposable underpads, all sizes | No | 16/Y | New code effective 01/01/2017. Covered for age 4 and over. 1 unit = 1 pad. |
| A4554 | Underpads, disposable, each | Con | 150/M | Chux. 1 unit = 1 pad. Above 150 per month requires a PAR. Not included in Combination Limit. |
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| Syringes, Needles and Infusion Supplies | ||||
| A4206 | Syringe with needle, sterile, 1 cc, each | No | 120/M | Use for diabetic syringes. 1 unit = 1 syringe. |
| A4207 | Syringe with needle, sterile, 2 cc, each | Yes | 240/M | 1 unit = 1 syringe. Indicate medication administered, route of administration, dosage, frequency, and length of necessity on each prior authorization request. |
| A4208 | Syringe with needle, sterile, 3 cc, each | Yes | 1 unit = 1 syringe. Indicate medication administered, route of administration, dosage, frequency, and length of necessity on each prior authorization request. | |
| A4209 | Syringe with needle, sterile, 5 cc up to 20 cc, each | Yes | 1 unit = 1 syringe. Indicate medication administered, route of administration, dosage, frequency, and length of necessity on each prior authorization request. | |
| A4210 | Needle-Free Injection Device | No | 2/D 15/Y | Use for nasal atomizers only. May only be provided with the rescue medications Naloxone or Midazolam. 1 unit = 1 nasal atomizer |
| A4212 | Noncoring needle or stylet with or without catheter | No | 1 unit = 1 stylet. | |
| A4213 | Syringe, sterile, 20 cc or greater, each | Yes | 1 unit = 1 syringe. Indicate medication administered, route of administration, dosage, frequency, and length of necessity on each prior authorization request. | |
| A4215 | Needle (only), sterile, any size, each | No | 1 unit = 1 needle. Use for diabetic pen needles. Indicate frequency of administration. Do not use with B4220, A4206-A4209. | |
| A4220 | Refill kit for implantable infusion pump | No | 31/M | |
| A4221 | Supplies for maintenance of non-insulin drug infusion catheter, per week (list drugs separately) | No | SEE NCCI MUE LIMIT | 1 unit = 1 week's supplies. NCCI MUE - cannot be overridden with a PAR. |
| A4222 | Infusion supplies for external drug infusion pump, per cassette or bag (list drugs separately) | No | 31/M | |
| A4224 | Supplies for maintenance of insulin infusion catheter, per week | No | 4/M | New code effective 01/01/2017. 1 unit = 1 week's supply. |
| A4225 | Supplies for external insulin infusion pump, syringe type cartridge, sterile, each | No | 31/M | New code effective 01/01/2017. 1 unit = 1 item. |
| A4232 | Syringe with needle for external insulin pump, sterile, 3cc | Yes | ||
| S8490 | Insulin syringes (100 syringes, any size) | No | 3/M | 1 unit = 100 syringes |
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| Urinary Care | ||||
| A4310 | Insertion tray without drainage bag and without catheter (accessories only), each | No | SEE NCCI MUE LIMIT | Includes underpad/drape, povidone iodine, 10cc syringe, specimen container, sterile gloves, lubricant, and graduated collection basin. Do not bill included items separately. NCCI MUE - cannot be overridden with a PAR. |
| A4311 | Insertion tray without drainage bag, with indwelling catheter, Foley type, two-way latex with coating (Teflon, silicone, silicone elastomer or hydrophilic, etc.), per set | No | SEE NCCI MUE LIMIT | 1 unit = 1 set. NCCI MUE - cannot be overridden with a PAR. |
| A4312 | Insertion tray without drainage bag with indwelling catheter, Foley type, two- way, all silicone, per set | No | SEE NCCI MUE LIMIT | 1 unit = 1 set. NCCI MUE - cannot be overridden with a PAR. |
| A4314 | Insertion tray with drainage bag with indwelling catheter, Foley type, two-way latex with coating (Teflon, silicone, silicone elastomer or hydrophilic, etc.), per set | No | SEE NCCI MUE LIMIT | 1 unit = 1 set. NCCI MUE - cannot be overridden with a PAR. |
| A4315 | Insertion tray with drainage bag with indwelling catheter, Foley type, two- way, all silicone, per set | No | SEE NCCI MUE LIMIT | 1 unit = 1 set. NCCI MUE - cannot be overridden with a PAR. |
| A4320 | Irrigation tray with bulb or piston syringe, each | No | 1 unit = 1 set | |
| A4322 | Irrigation syringe, bulb or piston, each | No | 1 unit = 1 syringe | |
| A4326 | Male external catheter with integral collection chamber, any type, each | No | 35/M | Inflatable, faceplate, etc. 1 unit = 1 catheter |
| A4327 | Female external urinary collection device, metal cup, each | No | 1 unit = 1 cup | |
| A4328 | Female external urinary collection device, pouch, each | No | 1 unit = 1 pouch | |
| A4330 | Perianal fecal collection pouch with adhesive, each | No | 1 unit = 1 pouch | |
| A4331 | Extension drainage tubing, any type, any length, with connector/adapter, for use with urinary leg bag or urostomy pouch, each | No | SEE NCCI MUE LIMIT | 1 unit = 1 extension drainage tubing. NCCI MUE - cannot be overridden with a PAR. |
| A4332 | Lubricant, individual sterile packet, each | No | SEE NCCI MUE LIMIT | 1 unit = 1 packet *NCCI MUE - cannot be overridden with a PAR. |
| A4333 | Urinary catheter anchoring device, adhesive skin attachment, each | No | 30/M | 1 unit = 1 device |
| A4334 | Urinary catheter anchoring device, leg strap, each | No | SEE NCCI MUE LIMIT | 1 unit = 1 device. NCCI MUE - cannot be overridden with a PAR. |
| A4335 | Miscellaneous incontinence supply not otherwise classified | Yes | Use for urinary tubing, clamps, connectors, hand adapters, etc. Billing must include description of urinary item. | |
| A4336 | Incontinence supply, urethral insert, any type, each | No | 30/M | 1 unit = 1 insert |
| A4338 | Indwelling catheter, Foley type, two-way latex with coating (Teflon, silicone, silicone elastomer or hydrophilic, etc.), each | No | SEE NCCI MUE LIMIT | 1 unit = 1 catheter. NCCI MUE - cannot be overridden with a PAR. |
| A4340 | Indwelling catheter, specialty type (coude, mushroom, wing, etc.), each | No | SEE NCCI MUE LIMIT | 1 unit = 1 catheter. NCCI MUE - cannot be overridden with a PAR. |
| A4341 | Indwelling intraurethral drainage device with valve, patient inserted, replacement only, each | Yes | Code opened 04-01-23 | |
| A4342 | Accessories for patient inserted indwelling intraurethral draining device with valve, replacement only, each | Yes | Code opened 04-01-23 | |
| A4344 | Indwelling catheter, Foley type, two- way, all silicone, each | No | SEE NCCI MUE LIMIT | 1 unit = 1 catheter. NCCI MUE - cannot be overridden with a PAR. |
| A4349 | Male external catheter, with or without adhesive, disposable, each | No | 35/M | |
| A4351 | Intermittent urinary catheter, straight tip, with or without coating (Teflon, silicone, silicone elastomer, or hydrophilic, etc.), each | No | 120/M | 1 unit = 1 catheter |
| A4352 | Intermittent urinary catheter, Coude (curved) tip, with or without coating (Teflon, silicone, silicone elastomer, or hydrophilic, etc.), each | No | 1 unit = 1 catheter | |
| A4353 | Intermittent urinary catheter, with insertion supplies | Yes | 240/M | |
| A4354 | Insertion tray with drainage bag, without catheter, each | No | SEE NCCI MUE LIMIT | 1 unit = 1 tray and bag. NCCI MUE - cannot be overridden with a PAR. |
| A4356 | External urethral clamp or compression device (not to be used for catheter clamp), each | No | SEE NCCI MUE LIMIT | 1 unit = 1 clamp. NCCI MUE - cannot be overridden with a PAR. |
| A4357 | Bedside drainage bag, day or night, with or without anti-reflux device, with or without tube, per set | No | SEE NCCI MUE LIMIT | 1 unit = 1 set. NCCI MUE - cannot be overridden with a PAR. |
| A4358 | Urinary drainage bag, leg or abdomen, vinyl, with or without tube, with straps, each | No | SEE NCCI MUE LIMIT | 1 unit = 1 bag. NCCI MUE - cannot be overridden with a PAR. |
| A4360 | Disposable external urethral clamp or compression device, with pad and/or pouch, each | No | 31/M | |
| A6590 | External urinary catheters; disposable, with wicking material, for use with suction pump, per month | Yes | Code opened 04-01-2023. | |
| A6591 | External urinary catheter; non-disposable, for use with suction pump, per month | Yes | Code opened 04-01-2023. | |
| L8603 | Injectable bulking agent, collagen implant, urinary tract, 2.5ml syringe, includes shipping and necessary supplies | No | ||
| L8606 | Injectable bulking agent, synthetic implant, urinary tract, 1ml syringe, includes shipping and necessary supplies | No | ||
| S4988 | Penile contracture device, manual, greater than 3 lbs. traction force | Yes | Code opened 04-01-2024. | |
| S9002 | Intra-vaginal motion sensor system, provides biofeedback for pelvic floor muscle rehabilitation device | Yes | Code opened 04-01-2024. | |
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| Miscellaneous | ||||
| A4265 | Paraffin, per pound | Yes | 1 unit = 1 pound | |
| A6410 | Eye Pad, sterile, each | No | 90/M | 1 unit = 1 eye pad |
| A6411 | Eye Pad, non-sterile, each | No | 180/M | 1 unit = 1 eye pad |
| A6412 | Eye patch, occlusive, each | No | 1 unit = 1 eye patch | |
| A9286 | Hygienic item or device, disposable or non-disposable, any type, each | No | Effective 7-1-2021: used exclusively for wipes under EPSDT. 1 unit = 1 individual wipe. PAR requirement removed effective 12-1-2021. | |
| E0235 | Paraffin bath unit, portable each | Yes | 1 unit = 1 unit *Code is subject to the 2019 DME UPL | |
| L8670 | Vascular graft material, synthetic, implant | |||
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Elastic Supports and Stockings - General Use
| Code | Description | PAR | Unit Limits | Comments |
|---|---|---|---|---|
| A4465 | Non-elastic binder for extremity | No | SEE NCCI MUE LIMIT | NCCI MUE - cannot be overridden with a PAR. |
| A4467 | Belt, strap, sleeve, garment, or covering, any type | No | 4/Y | New code effective 01/01/2017. |
| A4490 | Surgical stocking, above knee length, each | No | 1 unit = 1 stocking | |
| A4495 | Surgical stocking, thigh length, each | No | 1 unit = 1 stocking | |
| A4500 | Surgical stocking, below knee length, each | No | 1 unit = 1 stocking | |
| A4510 | Surgical stocking, full length, each | No | 1 unit = 1 stocking | |
| A6520 | Gradient compression garment, glove, padded, for nighttime use, each | No | Code opened 01-01-2024. | |
| A6521 | Gradient compression garment, glove, padded, for nighttime use, custom, each | No | Code opened 01-01-2024. | |
| A6522 | Gradient compression garment, arm, padded, for nighttime use, each | No | Code opened 01-01-2024. | |
| A6523 | Gradient compression garment, arm, padded, for nighttime use, custom, each | No | Code opened 01-01-2024. | |
| A6524 | Gradient compression garment, lower leg and foot, padded, for nighttime use, each | No | Code opened 01-01-2024. | |
| A6525 | Gradient compression garment, lower leg and foot, padded, for nighttime use, custom, each | No | Code opened 01-01-2024. | |
| A6526 | Gradient compression garment, full leg and foot, padded, for nighttime use, each | No | Code opened 01-01-2024. | |
| A6527 | Gradient compression garment, full leg and foot, padded, for nighttime use, custom, each | No | Code opened 01-01-2024. | |
| A6528 | Gradient compression garment, bra, for nighttime use, each | No | Code opened 01-01-2024. | |
| A6529 | Gradient compression garment, bra, for nighttime use, custom, each | No | Code opened 01-01-2024. | |
| A6530 | Gradient compression stocking, below knee, 18-30 mm hg, each | No | ||
| A6531 | Gradient compression stocking, below knee, 30-40 mm hg, each | No | ||
| A6532 | Gradient compression stocking, below knee, 40-50 mm hg, each | No | ||
| A6533 | Gradient compression stocking, thigh length, 18-30 mm hg, each | No | ||
| A6534 | Gradient compression stocking, thigh length, 30-40 mm hg, each | No | ||
| A6535 | Gradient compression stocking, thigh length, 40-50 mm hg, each | No | ||
| A6536 | Gradient compression stocking, full length/chap style, 18-30 mm hg, each | No | ||
| A6537 | Gradient compression stocking, full length/chap style, 30-40 mm hg, each | No | ||
| A6538 | Gradient compression stocking, full length/chap style, 40-50 mm hg, each | No | ||
| A6539 | Gradient compression stocking, waist length, 18-30 mm hg, each | No | ||
| A6540 | Gradient compression stocking, waist length, 30-40 mm hg, each | No | ||
| A6541 | Gradient compression stocking, waist length 40-50 mm hg, each | No | ||
| A6544 | Gradient compression stocking, garter belt | No | ||
| A6545 | Gradient compression wrap, non-elastic, below knee, 30-50 mm hg, each | No | ||
| A6549 | Gradient compression stocking/sleeve, not otherwise specified | No | ||
| A6552 | Gradient compression stocking, below knee, 30-40 mmhg, each | No | Code opened 01-01-2024. | |
| A6553 | Gradient compression stocking, below knee, 30-40 mmhg, custom, each | No | Code opened 01-01-2024. | |
| A6554 | Gradient compression stocking, below knee, 40 mmhg or greater, each | No | Code opened 01-01-2024. | |
| A6555 | Gradient compression stocking, below knee, 40 mmhg or greater, custom, each | No | Code opened 01-01-2024. | |
| A6556 | Gradient compression stocking, thigh length, 18-30 mmhg, custom, each | No | Code opened 01-01-2024. | |
| A6557 | Gradient compression stocking, thigh length, 30-40 mmhg, custom, each | No | Code opened 01-01-2024. | |
| A6558 | Gradient compression stocking, thigh length, 40 mmhg or greater, custom, each | No | Code opened 01-01-2024. | |
| A6559 | Gradient compression stocking, full length/chap style, 18-30 mmhg, custom, each | No | Code opened 01-01-2024. | |
| A6560 | Gradient compression stocking, full length/chap style, 30-40 mmhg, custom, each | No | Code opened 01-01-2024. | |
| A6561 | Gradient compression stocking, full length/chap style, 40 mmhg or greater, custom, each | No | Code opened 01-01-2024. | |
| A6562 | Gradient compression stocking, waist length, 18-30 mmhg, custom, each | No | Code opened 01-01-2024. | |
| A6563 | Gradient compression stocking, waist length, 30-40 mmhg, custom, each | No | Code opened 01-01-2024. | |
| A6564 | Gradient compression stocking, waist length, 40 mmhg or greater, custom, each | No | Code opened 01-01-2024. | |
| A6565 | Gradient compression gauntlet, custom, each | No | Code opened 01-01-2024. | |
| A6566 | Gradient compression garment, neck/head, each | No | Code opened 01-01-2024. | |
| A6567 | Gradient compression garment, neck/head, custom, each | No | Code opened 01-01-2024. | |
| A6568 | Gradient compression garment, torso and shoulder, each | No | Code opened 01-01-2024. | |
| A6569 | Gradient compression garment, torso/shoulder, custom, each | No | Code opened 01-01-2024. | |
| A6570 | Gradient compression garment, genital region, each | No | Code opened 01-01-2024. | |
| A6571 | Gradient compression garment, genital region, custom, each | No | Code opened 01-01-2024. | |
| A6572 | Gradient compression garment, toe caps, each | No | Code opened 01-01-2024. | |
| A6573 | Gradient compression garment, toe caps, custom, each | No | Code opened 01-01-2024. | |
| A6574 | Gradient compression arm sleeve and glove combination, custom, each | No | Code opened 01-01-2024. | |
| A6575 | Gradient compression arm sleeve and glove combination, each | No | Code opened 01-01-2024. | |
| A6576 | Gradient compression arm sleeve, custom, medium weight, each | No | Code opened 01-01-2024. | |
| A6577 | Gradient compression arm sleeve, custom, heavy weight, each | No | Code opened 01-01-2024. | |
| A6578 | Gradient compression arm sleeve, each | No | Code opened 01-01-2024. | |
| A6579 | Gradient compression glove, custom, medium weight, each | No | Code opened 01-01-2024. | |
| A6580 | Gradient compression glove, custom, heavy weight, each | No | Code opened 01-01-2024. | |
| A6581 | Gradient compression glove, each | No | Code opened 01-01-2024. | |
| A6582 | Gradient compression gauntlet, each | No | Code opened 01-01-2024. | |
| A6583 | Gradient compression wrap with adjustable straps, below knee, 30-50 mmhg, each | No | Code opened 01-01-2024. | |
| A6584 | Gradient compression wrap with adjustable straps, not otherwise specified | No | Code opened 01-01-2024. | |
| A6585 | Gradient pressure wrap with adjustable straps, above knee, each | No | Code opened 01-01-2024. | |
| A6586 | Gradient pressure wrap with adjustable straps, full leg, each | No | Code opened 01-01-2024. | |
| A6587 | Gradient pressure wrap with adjustable straps, foot, each | No | Code opened 01-01-2024. | |
| A6588 | Gradient pressure wrap with adjustable straps, arm, each | No | Code opened 01-01-2024. | |
| A6589 | Gradient pressure wrap with adjustable straps, bra, each | No | Code opened 01-01-2024. | |
| A6593 | Accessory for gradient compression garment or wrap with adjustable straps, non-otherwise specified | No | Code opened 01-01-2024. | |
| A6594 | Gradient compression bandaging supply, bandage liner, lower extremity, any size or length, each | No | Code opened 01-01-2024. | |
| A6595 | Gradient compression bandaging supply, bandage liner, upper extremity, any size or length, each | No | Code opened 01-01-2024. | |
| A6596 | Gradient compression bandaging supply, conforming gauze, per linear yard, any width, each | No | Code opened 01-01-2024. | |
| A6597 | Gradient compression bandage roll, elastic long stretch, linear yard, any width, each | No | Code opened 01-01-2024. | |
| A6598 | Gradient compression bandage roll, elastic medium stretch, per linear yard, any width, each | No | Code opened 01-01-2024. | |
| A6599 | Gradient compression bandage roll, inelastic short stretch, per linear yard, any width, each | No | Code opened 01-01-2024. | |
| A6600 | Gradient compression bandaging supply, high density foam sheet, per 250 square centimeters, each | No | Code opened 01-01-2024. | |
| A6601 | Gradient compression bandaging supply, high density foam pad, any size or shape, each | No | Code opened 01-01-2024. | |
| A6602 | Gradient compression bandaging supply, high density foam roll for bandage, per linear yard, any width, each | No | Code opened 01-01-2024. | |
| A6603 | Gradient compression bandaging supply, low density channel foam sheet, per 250 square centimeters, each | No | Code opened 01-01-2024. | |
| A6604 | Gradient compression bandaging supply, low density flat foam sheet, per 250 square centimeters, each | No | Code opened 01-01-2024. | |
| A6605 | Gradient compression bandaging supply, padded foam, per linear yard, any width, each | No | Code opened 01-01-2024. | |
| A6606 | Gradient compression bandaging supply, padded textile, per linear yard, any width, each | No | Code opened 01-01-2024. | |
| A6607 | Gradient compression bandaging supply, tubular protective absorption layer, per linear yard, any width, each | No | Code opened 01-01-2024. | |
| A6608 | Gradient compression bandaging supply, tubular protective absorption padded layer, per linear yard, any width, each | No | Code opened 01-01-2024. | |
| A6609 | Gradient compression bandaging supply, not otherwise specified | No | Code opened 01-01-2024. | |
| A6610 | Gradient compression stocking, below knee, 18-30 mmhg, custom, each | No | Code opened 01-01-2024. | |
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Heat and Cold Application Equipment - General Use
| Code | Description | PAR | Unit Limits | Comments |
|---|---|---|---|---|
| A9273 | Hot water bottle, ice cap or collar, heat and/or cold wrap, any type | Yes | ||
| E0200 | Heat lamp, without stand (table model), includes bulb or infrared element, each | Yes | ||
| E0215 | Electric heat pad, moist | Yes | Benefit under very limited circumstances. | |
| E0217 | Water circulating heat pad with pump | Yes | ||
| E0218 | Water circulating cold pad with pump | Yes | ||
| E0221 | Infrared heating pad system | Yes | ||
| E0236 | Pump for water circulating pad, each | Yes | ||
| E0249 | Pad for water circulating heat unit, for replacement only | Yes | Purchase for member owned equipment only. | |
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Monitoring Equipment and Supplies - General Use
| Code | Description | PAR | Unit Limits | Comments |
|---|---|---|---|---|
| A4556 | Electrodes (e.g., apnea monitor), per pair | No | 1 unit = 1 pair. Note: Purchase for member owned equipment only. Must be provided by supplier for rented equipment. | |
| A4557 | Lead wires or cables, per pair | No | SEE NCCI MUE LIMIT | 1 unit = 1 pair. Note: Purchase for member owned equipment only. Must be provided by supplier for rented equipment. NCCI MUE - cannot be overridden with a PAR. |
| A4558 | Conductive gel or paste, for use with electrical device (e.g., TENS, NMES), per oz | No | 1 unit = 1 tube of gel | |
| A4560 | Neuromuscular electrical stimulator (NMES), disposable, replacement only | Yes | Code opened 04-01-2023. | |
| A4660 | Sphygmomanometer/blood pressure apparatus with cuff and stethoscope | Yes | ||
| A4663 | Blood pressure cuff only | Yes | 1 unit = 1 cuff only | |
| A4670 | Automatic blood pressure monitor | Yes | Digital | |
| E0607 | Home blood glucose monitor, each | No | Required: F2F *Code is subject to the 2019 DME UPL | |
| E0619-RR | Apnea monitor, with recording feature | Yes | SEE NCCI MUE LIMIT | Includes cardiac monitoring (belts included). 1 unit = 1 month Beyond 6 months requires Questionnaire #7. NCCI MUE - cannot be overridden with a PAR. |
| E0445 | Oximeter device for measuring blood oxygen levels non-invasively | Yes | Use modifier U1 for fingertip pulse oximeters and U2 for tabletop pulse oximeters effective January 1, 2023. Required: Q6 Rental:
| |
| E0610 | Pacemaker monitor, self-contained (checks battery depletion, includes audible and visual check systems), each | Yes | ||
| E0615 | Pacemaker monitor, self-contained, checks battery depletion and other pacemaker components, includes digital/visual check systems, each | Yes | ||
| E0618 | Apnea monitor, without recording feature | None | ||
| K0606 | Automatic external defibrillator, with integrated electrocardiogram analysis, garment type | Yes | Required: F2F | |
| K0607 | Replacement battery for automated external defibrillator, garment type only, each | Yes | ||
| K0608 | Replacement garment for use with automated external defibrillator, each | Yes | ||
| K0609 | Replacement electrodes for use with automated external defibrillator, garment type only, each | Yes | ||
| S8270 | Enuresis alarm, using auditory buzzer and/or vibration device | Yes | ||
| S9001-KR | Home uterine monitor with or without associated nursing services | Yes | 31/M | Equipment only. Limited to 1 unit per day- no more than 31 days at a time. NAB without essential nursing services. Telephonic transmission and interpretation are not benefits. |
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Phototherapy - General Use
| Code | Description | PAR | Unit Limits | Comments |
|---|---|---|---|---|
| E0202-KR | Phototherapy (bilirubin) light with photometer, per day | No | 31/M | 1 unit = 1 day rental. Claims may be date spanned using the KR modifier for the rental period. |
| E0691 | Ultraviolet light therapy system, includes bulbs/lamps, timer and eye protection, treatment area 2 square feet or less | Yes | For rental, bill with RR and a date span. NCCI MUE - cannot be overridden with a PAR. *Code is subject to the 2019 DME UPL | |
| E0692 | Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, 4-foot panel | Yes | For rental, bill with RR and a date span. NCCI MUE - cannot be overridden with a PAR. Required: F2F *Code is subject to the 2019 DME UPL | |
| E0693 | Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, 6-foot panel | Yes | For rental, bill with RR and a date span. NCCI MUE - cannot be overridden with a PAR. Required: F2F *Code is subject to the 2019 DME UPL | |
| E0694 | Ultraviolet multidirectional light therapy system in 6-foot cabinet, includes bulbs/lamps, timer and eye protection | Yes | For rental, bill with RR and a date span. NCCI MUE - cannot be overridden with a PAR. Required: F2F *Code is subject to the 2019 DME UPL | |
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Oxygen and Respiratory Care - General Use
Respiratory care equipment requires a physician's prescription. The supplier must maintain a copy of the prescription and questionnaire #17 on file at all times.
| Code | Description | PAR | Unit Limits | Comments |
|---|---|---|---|---|
| Humidifiers | ||||
| A4483 | Moisture exchanger, disposable, for use with invasive mechanical ventilation | Yes | 31/M | |
| A7046 | Water chamber for humidifier, used with positive airway pressure device, replacement, each | Yes | 1 unit = 1 bottle | |
| E0500 | IPPB machine(s), all types, with built in nebulization, manual or automatic valves, internal or external power source (Manual valves external power source includes cylinder regulator built-in nebulization) | No | *Code is subject to the 2019 DME UPL | |
| E0550 | Humidifier, durable, for extensive supplemental humidification during IPPB treatment or oxygen delivery (e.g., Cascade) | No | ||
| E0555 | Humidifier, durable, glass or autoclavable plastic bottle type, for use with regulator or flowmeter | No | ||
| E0560 | Humidifier, durable for supplemental humidification during IPPB treatment or oxygen delivery (e.g., Cascade Jr.) | No | ||
| E0561 | Humidifier, non-heated, used with positive airway pressure device | Yes | Purchase for member owned equipment only. | |
| E0562 | Humidifier, heated, used with positive airway pressure device | Yes | One-time purchase per provider per member. | |
| E1405 | Oxygen and water vapor enriching system with heated delivery | Yes | ||
| E1406 | Oxygen and water vapor enriching system without heated delivery | Yes | ||
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| Intermittent Positive Pressure Breathing (IPPB) Machines | ||||
| Oxygen Contents | ||||
| E0441 | Stationary oxygen contents, gaseous, 1 month's supply = 1 unit | No | 1/M | Bill with RR modifier and QE for <,2 LPM no modifier for 2-4 LPM QF for >,4 to 6 LPM QG for >, 6 LPM *Code is subject to the 2019 DME UPL |
| E0442 | Stationary oxygen contents, liquid, 1 month's supply = 1 unit | No | 1/M | Bill with RR modifier and QE for <,2 LPM no modifier for 2-4 LPM QF for >,4 to 6 LPM QG for >, 6 LPM *Code is subject to the 2019 DME UPL |
| E0443 | Portable oxygen contents, gaseous, 1 month's supply = 1 unit | No | Available only for Medicare crossover claims. *Code is subject to the 2019 DME UPL Bill with RR modifier. | |
| E0444 | Portable oxygen contents, liquid, 1 month's supply = 1 unit | No | Available only for Medicare crossover claims. *Code is subject to the 2019 DME UPL Bill with RR modifier. | |
| S8120 | Oxygen contents, gaseous, 1 unit equals 1 cubic foot | No | Available for ventilator members. Use Modifier TG Available for use with members receiving more than 6LPM when approved by HCPF. | |
| S8121 | Oxygen contents, liquid, 1 unit equals 1 pound | No | Available only for ventilator members. Use Modifier TG Available for use with members receiving more than 6LPM when approved by HCPF. | |
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| Oxygen Systems | ||||
| E0424 | Stationary compressed gaseous oxygen system, rental, includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing | No | Bill with RR modifier *Code is subject to the 2019 DME UPL | |
| E0425 | Stationary compressed gas system, purchase: includes regulator, flow meter, humidifier, cannula or mask, and tubing | No | Bill with RR modifier | |
| E0430 | Portable gaseous oxygen system, purchase: includes regulator, flowmeter, humidifier, cannula or mask, and tubing | No | Bill with RR modifier | |
| E0431 | Portable gaseous oxygen system, rental, includes portable container, regulator, flow meter, humidifier, cannula or mask, and tubing | No | Bill with RR modifier *Code is subject to the 2019 DME UPL | |
| E0433 | Portable liquid oxygen system, rental, home liquefier used to fill portable liquid oxygen containers, includes portable containers, regulator, flowmeter, humidifier, cannula or mask and tubing, with or without supply reservoir and contents gauge | No | Bill with RR modifier *Code is subject to the 2019 DME UPL | |
| E0434 | Portable liquid oxygen system, rental, includes portable container, supply reservoir, humidifier, flow meter, refill adapter, contents gauge, cannula or mask, and tubing | No | Bill with RR modifier Also use for monthly rental of a portable liquid oxygen system to be filled through a centrally located/shared stationary reservoir, includes portable container, flow humidifier, cannula or mask, tubing and refill adaptor. *Code is subject to the 2019 DME UPL | |
| E0435 | Portable liquid oxygen system, purchase, includes portable container, supply reservoir, flowmeter, humidifier, contents gauge, cannula or mask, tubing, and refill adapter | No | Bill with RR modifier Also use for monthly rental of a portable liquid oxygen system to be filled through a centrally located/shared stationary reservoir, includes portable container, flow humidifier, cannula or mask, tubing and refill adaptor. | |
| E0439 | Stationary liquid oxygen system, rental, includes container, contents, regulator, flow meter, humidifier, nebulizer, cannula or mask, and tubing | No | Bill with RR modifier Also use for multiple member use of reservoir. Bill usual and customary charge divided by total number of all members utilizing reservoir. The total, unduplicated count of members (regardless of payment source) using the equipment during the month must be maintained in each member's file. *Code is subject to the 2019 DME UPL | |
| E0440 | Stationary liquid oxygen system, purchase, includes use of reservoir, contents indicator, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing | No | Bill with RR modifier Also use for multiple member use of reservoir. Bill usual and customary charge divided by total number of all members utilizing reservoir. The total, unduplicated count of members (regardless of payment source) using the equipment during the month must be maintained in each member's file. | |
| K0738 | Portable gaseous oxygen system, rental, home compressor used to fill portable oxygen cylinders, includes portable containers, regulator, flowmeter, humidifier, cannula or mask, and tubing | No | Bill with RR modifier 1 unit = 1 month rental *Code is subject to the 2019 DME UPL | |
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| Oxygen Concentrators | ||||
| E1390 | Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate | None | Bill with RR modifier *Code is subject to the 2019 DME UPL | |
| E1391 | Oxygen concentrator, dual delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate, each | None | Bill with RR modifier *Code is subject to the 2019 DME UPL | |
| E1392 | Portable oxygen concentrator, rental | None | Bill with RR modifier *Code is subject to the 2019 DME UPL | |
| E1390-RR | Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate | None | ||
| E1391-RR | Oxygen concentrator, dual delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate, each | None | ||
| E1392-RR | Portable oxygen concentrator, rental | None | ||
| Ventilators, Percussors and Respirators | ||||
| A4604 | Tubing with integrated heating element for use with positive airway pressure device | Yes | ||
| A7020 | Interface for cough stimulating device, includes all components, replacement only | Yes | ||
| A7025 | High frequency chest wall oscillation system vest, replacement for use with patient owned equipment, each | Yes | Required: Q14 | |
| A7026 | High frequency chest wall oscillation system hose, replacement for use with patient owned equipment, each | None | Purchase for member owned equipment only. | |
| A7027 | Combination oral/nasal mask, used with continuous positive airway pressure device, each | Yes | SEE NCCI MUE LIMIT | Purchase for member owned equipment only. NCCI MUE - Do not provide more than one (1) per DOS. |
| A7028 | Oral cushion for combination oral/nasal mask, replacement only, each | Yes | SEE NCCI MUE LIMIT | Purchase for member owned equipment only. NCCI MUE - Do not provide more than two (2) per DOS. |
| A7029 | Nasal pillows for combination oral/nasal mask, replacement only, pair | Yes | SEE NCCI MUE LIMIT | Purchase for member owned equipment only. NCCI MUE - Do not provide more than two (2) per DOS. |
| A7030 | Full face mask used with positive airway pressure device, each | Yes | SEE NCCI MUE LIMIT | Purchase for member owned equipment only. NCCI MUE - Do not provide more than one (1) per DOS. |
| A7031 | Face mask interface, replacement for full face mask, each | Yes | 6/Y | Purchase for member owned equipment only. Do not provide more than three (3) per DOS. |
| A7032 | Cushion for use on nasal mask interface, replacement only, each | Yes | SEE NCCI MUE LIMIT | Purchase for member owned equipment only. NCCI MUE - Do not provide more than two (2) per DOS. |
| A7033 | Pillow for use on nasal cannula type interface, replacement only, pair | Yes | SEE NCCI MUE LIMIT | Purchase for member owned equipment only. NCCI MUE - Do not provide more than two (2) per DOS. |
| A7034 | Nasal interface (mask or cannula type) used with positive airway pressure devise, with or without head strap | Yes | SEE NCCI MUE LIMIT | Purchase for member owned equipment only. NCCI MUE - Do not provide more than one (1) per DOS. |
| A7035 | Headgear used with positive airway pressure device | Yes | SEE NCCI MUE LIMIT | Purchase for member owned equipment only. NCCI MUE - Do not provide more than one (1) per DOS. |
| A7036 | Chinstrap used with positive airway pressure device | Yes | SEE NCCI MUE LIMIT | Purchase for member owned equipment only. NCCI MUE - Do not provide more than one (1) per DOS. |
| A7037 | Tubing used with positive airway pressure device | None | SEE NCCI MUE LIMIT | Purchase for member owned equipment only. NCCI MUE - Do not provide more than one (1) per DOS. |
| A7038 | Filter, disposable, used with positive airway pressure device | Yes | SEE NCCI MUE LIMIT | Purchase for member owned equipment only. NCCI MUE - cannot be overridden with a PAR. |
| A7039 | Filter, non-disposable, used with positive airway pressure device | Yes | 1/Y | Purchase for member owned equipment only. |
| A7044 | Oral interface used with positive airway pressure device, each | Yes | SEE NCCI MUE LIMIT | Purchase for member owned equipment only. NCCI MUE - Do not provide more than one (1) per DOS. |
| A7045 | Exhalation port with or without swivel used with accessories for positive airway devices, replacement only | Yes | SEE NCCI MUE LIMIT | Purchase for member owned equipment only. NCCI MUE - Do not provide more than one (1) per DOS. |
| A9280 | Alert or alarm device, not otherwise classified | Yes | Purchase only for member owned equipment. | |
| E0457 | Chest Shell (cuirass) | Yes | Must be provided if equipment is rented. Purchase for member owned equipment only. | |
| E0459 | Chest wrap | Yes | Must be provided if equipment is rented. Purchase for member owned equipment only. | |
| E0465 | Home ventilator, any type, used with invasive interface, (e.g., tracheostomy tube) | Yes | SEE NCCI MUE LIMIT | Members may receive up to two (2) units per month if a backup ventilator is required. Continuous rental item - Bill with RR modifier. NCCI MUE - Cannot be overridden with a PAR. Required: F2F *Code is subject to the 2019 DME UPL. |
| E0466 | Home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell) | Yes | SEE NCCI MUE LIMIT | Members may receive up to two (2) units per month if a backup ventilator is required. NCCI MUE - cannot be overridden with a PAR. Required: F2F *Code is subject to the 2019 DME UPL |
| E0467 | Home ventilator, multi-function respiratory device, also performs any or all of the additional functions of oxygen concentration, drug nebulization, aspiration, and cough stimulation, includes all accessories, components and supplies for all functions | Yes | SEE NCCI MUE LIMIT | Members may receive up to two (2) units per month if a backup ventilator is required. Continuous rental item – Bill with RR modifier. NCCI MUE - Cannot be overridden with a PAR. Required: F2F. Providers may not separately bill for individual components of this device (unbundle). |
| E0468 | Home ventilator, dual-function respiratory device, also performs additional function of cough stimulation, includes all accessories, components and supplies for all functions | Yes | Code opened 04-01-2024. | |
| E0470 | Respiratory assist device, bi-level pressure capability, without back-up rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device) | Yes | Rental includes all related supplies, including but not limited to the mask and headgear. Use A7030 for mask purchase. Use A7035 for headgear purchase. *Refer to the Continuous and Bilevel Positive Airway Pressure Devices (CPAP/BiPAP) section in the DMEPOS Billing Manual for additional information. Will be considered for continuous rental coverage if used as a ventilator. Required: F2F *Code is subject to the 2019 DME UPL. | |
| E0471 | Respiratory assist device, bi-level pressure capability, with back-up rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device) | Yes | Rental includes all related supplies, including but not limited to the mask and headgear. Use A7030 for mask purchase. Use A7035 for headgear purchase. Between the dates of 7-1-2020 and 6-30-2021 this code was allowed for continuous rental when used as a ventilator. Effective 7-1-2021 this code will no longer be allowed for continuous rental. | |
| E0472 | Respiratory assist device, bi-level pressure capability, with back-up rate feature, used with invasive interface, e.g., tracheostomy tube (intermittent assist device with continuous positive airway pressure device) | Yes | Rental includes all related supplies, including but not limited to the mask and headgear. Use A7030 for mask purchase. Use A7035 for headgear purchase. *Refer to the Continuous and Bilevel Positive Airway Pressure Devices (CPAP/BiPAP) section in the DMEPOS Billing Manual for additional information. Will be considered for continuous rental coverage if used as a ventilator. Required: F2F *Code is subject to the 2019 DME UPL. | |
| E0480 | Percussor, electric or pneumatic, home model | Yes | Required: F2F | |
| E0481 | Intrapulmonary percussive ventilation system and related accessories | Yes | ||
| E0482 | Cough stimulating device, alternating positive and negative airway pressure | Yes | Required: F2F *Code is subject to the 2019 DME UPL. | |
| E0483 | High frequency chest wall oscillation air- pulse generator system, (includes hoses and vest) each. | Yes | Required: F2F, Q14 *Code is subject to the 2019 DME UPL. | |
| E0561 | Humidifier, non-heated, used with positive airway pressure device | Yes | Purchase for member owned equipment only. | |
| E0562 | Humidifier, heated, used with positive airway pressure device | Yes | One-time purchase per provider per member. | |
| E0601 | Continuous positive airway pressure (CPAP) device | Yes | Rental includes all related supplies, including but not limited to the mask and headgear. Use A7030 for mask purchase. Use A7035 for headgear purchase. Required: F2F *Refer to the Continuous and Bilevel Positive Airway Pressure Devices (CPAP/BiPAP) section in the DMEPOS Billing Manual for additional information. *Code is subject to the 2019 DME UPL. | |
| E0606 | Postural drainage board | Yes | ||
| S8185 | Flutter device | Yes | ||
| S8186 | Swivel adapter | Yes | ||
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Nebulizers, Vaporizers and Suction
| Code | Description | PAR | Unit Limits | Comments | |
|---|---|---|---|---|---|
| A7000 | Canister, disposable, used with suction pump | None | 1 unit = 1 canister | ||
| A7001 | Canister, non-disposable, used with suction pump | None | 1 unit = 1 canister | ||
| A7002 | Tubing, used with suction pump | None | 1 unit = 1 tubing | ||
| A7003 | Administration set, with small volume nonfiltered pneumatic nebulizer, disposable | None | |||
| A7004 | Small volume non-filtered pneumatic nebulizer, disposable | None | 1 unit = 1 nebulizer | ||
| A7005 | Administration set, with small volume nonfiltered pneumatic nebulizer, non- disposable | None | |||
| A7006 | Administration set, with small volume filtered pneumatic nebulizer | None | |||
| A7007 | Large volume nebulizer, disposable, unfilled, used with aerosol compressor | None | 1 unit = 1 nebulizer *Code is subject to the 2019 DME UPL | ||
| A7008 | Large volume nebulizer, disposable, pre- filled, used with aerosol compressor | None | 1 unit = 1 nebulizer | ||
| A7009 | Reservoir bottle, non-disposable, used with large volume ultrasonic nebulizer | None | 1 unit = 1 reservoir bottle *Code is subject to the 2019 DME UPL | ||
| A7010 | Corrugated tubing, disposable, used with large volume nebulizer, 100 feet | None | 1 unit = 100 feet | ||
| A7012 | Water collection device, used with large volume nebulizer | None | 1 unit = 1 device | ||
| A7013 | Filter, disposable, used with aerosol compressor or ultrasonic generator | None | 1 unit = 1 filter | ||
| A7014 | Filter, non-disposable, used with aerosol compressor or ultrasonic generator | None | 1 unit = 1 filter | ||
| A7015 | Aerosol mask, used with DME nebulizer | None | 1 unit = 1 mask | ||
| A7016 | Dome and mouthpiece, used with small volume ultrasonic nebulizer | None | 1 unit = dome and mouthpiece | ||
| A7017 | Nebulizer, durable glass, or autoclavable plastic, bottle type, not used with oxygen | None | 1 unit = 1 nebulizer *Code is subject to the 2019 DME UPL | ||
| A7018 | Water, distilled, used with large volume nebulizer, 1000 ml | None | 1 unit = 1,000 ml. | ||
| E0565 | Compressor, air power source for equipment which is not self-contained or cylinder driven | None | |||
| E0570 | Nebulizer with compressor | None | Required: F2F *Code is subject to the 2019 DME UPL | ||
| E0572 | Aerosol compressor, adjustable pressure, light duty for intermittent use | None | *Code is subject to the 2019 DME UPL | ||
| E0574 | Ultrasonic electronic aerosol generator with small volume nebulizer | None | *Code is subject to the 2019 DME UPL | ||
| E0575 | Nebulizer, ultrasonic, large volume | None | Required: F2F | ||
| E0580 | Nebulizer, durable glass or autoclavable plastic bottle type for use with regulator or flowmeter, each | None | Required: F2F | ||
| E0585 | Nebulizer with compressor and heater | None | Required: F2F *Code is subject to the 2019 DME UPL | ||
| E0600 | Respiratory suction pump, home model, portable or stationary, electric | None | SEE NCCI MUE LIMIT | Rental includes suction tubing. Continuous rental is allowed. | |
| E1372 | Immersion external heater for nebulizer | None | |||
| K0730 | Controlled dose inhalation drug delivery system | None | Required: F2F *Code is subject to the 2019 DME UPL | ||
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Respiratory Care, Accessories, Supplies and Related Services
Note: All belts, leads, pads and tubing are included in the rental price. Items may be purchased only for member-owned equipment.
| Code | Description | PAR | Unit Limits | Comments |
|---|---|---|---|---|
| A4481 | Tracheostomy filter, any type, any size, each | None | 1 unit = 1 filter | |
| A4605 | Tracheal suction catheter, closed system, each | None | ||
| A4606 | Oxygen probe for use with oximeter device, replacement | Yes | SEE NCCI MUE LIMIT | 1 unit = 1 probe Non-disposable. NCCI MUE - Do not provide more than 1 per DOS. |
| A4608 | Transtracheal oxygen catheter, each | None | 1 unit = 1 catheter | |
| A4611 | Battery, heavy duty, replacement for patient owned ventilator, each | None | ||
| A4612 | Battery cables, replacement for patient owned ventilator, each | None | ||
| A4613 | Battery charger, replacement for patient owned ventilator, each | None | ||
| A4614 | Peak expiratory flow rate meter, handheld | None | ||
| A4615 | Cannula, nasal, each | None | Must be provided with rental equipment. Purchase for member owned equipment only. | |
| A4616 | Tubing (oxygen), per foot | None | ||
| A4617 | Mouthpiece, each | None | ||
| A4618 | Breathing circuits, each | None | Must be provided with rental equipment. Purchase for member owned equipment only. | |
| A4619 | Face tent, each | None | ||
| A4620 | Variable concentration mask, each | None | ||
| A4623 | Tracheostomy, inner cannula (replacement only), each | None | SEE NCCI MUE LIMIT | NCCI MUE - cannot be overridden with a PAR. |
| A4624 | Tracheal suction catheter, any type other than closed system, each | None | 1 unit = 1 catheter | |
| A4625 | Tracheostomy care kit for new tracheostomy | None | SEE NCCI MUE LIMIT | NCCI MUE - cannot be overridden with a PAR. |
| A4627 | Spacer, bag or reservoir, with or without mask, for use with metered dose inhaler, each | None | Includes aerochamber. | |
| A4628 | Oropharyngeal suction catheter, each | None | 1 unit = 1 catheter | |
| A4629 | Tracheostomy care kit for established tracheostomy | None | 1 unit = 1 kit. Includes: soaking tray, gloves, instrument tray, folded towel, forceps, gauze sponges, cleaning brush, trach dressing, twill tape, pipe cleaners, cotton tip applicators, and hospital wrap. Do not bill included items separately. | |
| A7501 | Tracheostoma valve, including diaphragm, each | None | ||
| A7502 | Replacement diaphragm/faceplate for tracheostoma valve, each | None | ||
| A7503 | Filter holder or filter cap, reusable, for use with tracheostoma heat and moisture exchange system, each | None | ||
| A7504 | Filter for use with tracheostoma heat and moisture exchange system, each | None | SEE NCCI MUE LIMIT | NCCI MUE - cannot be overridden with a PAR. |
| A7505 | Housing, reusable without adhesive, for use in a heat and moisture exchange system and/or with a tracheostoma valve, each | None | ||
| A7506 | Adhesive disc for use in a heat and moisture exchange system and/or with a tracheostoma valve, any type, each | None | SEE NCCI MUE LIMIT | NCCI MUE - cannot be overridden with a PAR. |
| A7507 | Filter holder and integrated filter without adhesive, for use in a tracheostoma heat and moisture exchange system, each | None | SEE NCCI MUE LIMIT | NCCI MUE - cannot be overridden with a PAR. |
| A7508 | Housing and integrated adhesive, for use in a tracheostoma heat and moisture exchange system and/or with a tracheostoma valve, each | None | SEE NCCI MUE LIMIT | NCCI MUE - cannot be overridden with a PAR. |
| A7509 | Filter holder and integrated filter housing, and adhesive, for use as a tracheostoma heat and moisture exchange system, each | None | SEE NCCI MUE LIMIT | NCCI MUE - cannot be overridden with a PAR. |
| A7520 | Tracheostomy/laryngectomy tube, non- cuffed, polyvinylchloride (PVC), silicone or equal, each | None | 1 unit = 1 tube | |
| A7521 | Tracheostomy/laryngectomy tube, cuffed, polyvinylchloride (PVC), silicone or equal, each | None | 1 unit = 1 tube | |
| A7522 | Tracheostomy/laryngectomy tube, stainless steel or equal (sterilizable and reusable), each | None | 1 unit = 1 tube | |
| A7523 | Tracheostomy shower protector, each | None | 31/M | 1 unit = 1 protector |
| A7524 | Tracheostoma stent/stud/button, each | None | 1 unit = 1 stent/stud/button | |
| A7525 | Tracheostomy mask, each | None | ||
| A7526 | Tracheostomy tube collar/holder, each | None | ||
| A7527 | Tracheostomy/laryngectomy tube plug/stop, each | None | ||
| E0455 | Oxygen tent excluding croup or pediatric tents, each | None | ||
| E0755 | Electronic salivary reflex stimulator, intra oral/non-invasive, each | Yes | ||
| E1353 | Regulator, each | None | Purchase for member owned equipment only. | |
| E1354 | Oxygen accessory, wheeled cart for portable cylinder or portable concentrator, any type, replacement only, each | None | Purchase for member owned equipment only. | |
| E1355 | Stand/rack, each | None | Purchase for member owned equipment only. | |
| E1356 | Oxygen accessory, battery pack/cartridge for portable concentrator, any type, replacement only, each | None | Purchase for member owned equipment only. | |
| E1357 | Oxygen accessory, battery charger for portable concentrator, any type, replacement only, each | None | Purchase for member owned equipment only. | |
| E1358 | Oxygen accessory, DC power adapter for portable concentrator, any type, replacement only, each | None | Purchase for member owned equipment only. | |
| L8501 | Tracheostomy, speaking valve, each | None | ||
| S8100 | Holding chamber or spacer for use with an inhaler or nebulizer, without mask | None | ||
| S8101 | Holding chamber or spacer for use with an inhaler or nebulizer, with mask | None | ||
| S8189 | Tracheostomy supply, not otherwise classified | Yes | Use for tracheostomy supplies when an appropriate code is not available. | |
| S8210 | Mucus trap | None | ||
| S8301 | Infection control supplies, not otherwise specified | Yes | Use for cleaning solutions for respiratory equipment. | |
| S8999 | Resuscitation bag (For use by patient on artificial respiration during power failure or other catastrophic event) | None | ||
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TENS or NMES (Transcutaneous or Neuromuscular Electrical Nerve Stimulator) Equipment and Supplies - General Use
Note: Require two (2)-month trial rental before purchase. Requires Questionnaire #9. Refer to the TENS or NMES section of the DMEPOS Billing Manual.
| Code | Description | PAR | Unit Limits | Comments |
|---|---|---|---|---|
| A4540 | Distal transcutaneous electrical nerve stimulator, stimulates peripheral nerves of the upper arm | Yes | Code opened 01-01-2024. | |
| A4541 | Monthly supplies for use of device coded at E0733 | Yes | Code opened 01-01-2024. | |
| A4542 | Supplies and accessories for external upper limb tremor stimulator of the peripheral nerves of the wrist | Yes | Code opened 01-01-2024. | |
| A4593 | Neuromodulation stimulator system, adjunct to rehabilitation therapy regime | Yes | Code opened 04-01-2024. | |
| A4594 | Neuromodulation stimulator system, adjunct to rehabilitation therapy regime, mouthpiece each | Yes | Code opened 04-01-2024. | |
| A4595 | Electrical stimulator supplies, 2 lead, per month, (e.g., TENS, NMES) | None | SEE NCCI MUE LIMIT | Purchase for member owned equipment only. Use for four (4) lead also. NCCI MUE - cannot be overridden with a PAR. |
| A4630 | Replacement batteries, medically necessary, transcutaneous electrical stimulator, owned by patient | None | 4/Y | Purchase for member owned equipment only. |
| E0492 | Power source and control electronics unit for oral device/appliance for neuromuscular electrical stimulation of the tongue muscle, controlled by phone application | Yes | Code opened 01-01-2024. | |
| E0493 | Oral device/appliance for neuromuscular electrical stimulation of the tongue muscle, used in conjunction with the power source and control electronics unit, controlled by phone application, 90-day supply | Yes | Code opened 01-01-2024. | |
| E0530 | Electronic positional obstructive sleep apnea treatment, with sensor, includes all components and accessories, any type | Yes | Code opened 01-01-2024. | |
| E0720 | Transcutaneous Electrical Nerve Stimulation (TENS) device, two (2) lead, localized stimulation | Yes | Required: F2F, Q9 Refer to the TENS or NMES section of the DMEPOS Billing Manual. *Code is subject to the 2019 DME UPL | |
| E0730 | Transcutaneous Electrical Nerve Stimulation (TENS) device, four (4) or more leads, for multiple nerve stimulation | Yes | Required: F2F, Q9 Refer to the TENS or NMES section of the DMEPOS Billing Manual. *Code is subject to the 2019 DME UPL | |
| E0731 | Form fitting conductive garment for delivery of TENS or NMES with conducting fibers separated from the patient's skin by layers of fabric, each | Yes | Required: F2F | |
| E0732 | Cranial Electrotherapy Stimulation (CES) system, any type | Yes | Code opened 01-01-2024. | |
| E0733 | Transcutaneous electrical nerve stimulator for electrical stimulation of the trigeminal nerve | Yes | Code opened 01-01-2024. | |
| E0734 | External upper limb tremor stimulator of the peripheral nerves of the wrist | Yes | Code opened 01-01-2024. | |
| E0735 | Non-invasive vagus nerve stimulator | Yes | Code opened 01-01-2024. | |
| E0736 | Transcutaneous tibial nerve stimulator | Yes | Code opened 04-01-2024. | |
| E0738 | Upper extremity rehabilitation system providing active assistance to facilitate muscle re-education, include microprocessor, all components and accessories | Yes | Code opened 04-01-2024. | |
| E0739 | Rehab system with interactive interface providing active assistance in rehabilitation therapy, includes all components and accessories, motors, microprocessors, sensors | Yes | Code opened 04-01-2024. | |
| E0744 | Neuromuscular stimulator for scoliosis, each | Yes | Required: F2F Required: F2F, Q9 | |
| E0745 | Neuromuscular stimulator electronic shock unit, each | Yes | Required: F2F Refer to the TENS or NMES section of the DMEPOS Billing Manual. | |
| E0746 | Electromyography (EMG), biofeedback device | Yes | ||
| E0747 | Osteogenesis stimulator, electrical noninvasive, other than spinal applications | Yes | Must be FDA classified as a group III devise and billed with the KF modifier. Required: F2F These devices can be re-programmed by the manufacturer for additional treatments. They should not be discarded once initial treatment is complete. *Code is subject to the 2019 DME UPL | |
| E0748 | Osteogenic stimulator, noninvasive, spinal applications | Yes | Must be FDA classified as a group III devise and billed with the KF modifier. Required: F2F These devices can be re-programmed by the manufacturer for additional treatments. They should not be discarded once initial treatment is complete. *Code is subject to the 2019 DME UPL | |
| E0749 | Osteogenesis stimulator, electrical, surgically implanted | None | ||
| E0760 | Osteogenesis stimulator, low intensity ultrasound, non-invasive | Yes | Must be FDA classified as a group III devise and billed with the KF modifier. Required: F2F *Code is subject to the 2019 DME UPL | |
| E0762 | Transcutaneous electrical joint stimulation device system, includes all accessories | Yes | Required: F2F Refer to the TENS or NMES section of the DMEPOS Billing Manual. | |
| E0770 | Functional electrical stimulator, transcutaneous stimulation of nerve and/or muscle groups, any type, complete system, not otherwise specified | Yes | Required: Q9 Refer to the TENS or NMES section of the DMEPOS Billing Manual. | |
| L8678 | Electrical stimulator supplies (external) for use with implantable neurostimulator, per month | Yes | Code opened 04-01-2023. | |
| L8680 | Implantable neurostimulator electrode, each | None | ||
| L8681 | Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only | None | ||
| L8682 | Implantable neurostimulator radiofrequency receiver | None | ||
| L8683 | Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver | None | ||
| L8684 | Radiofrequency transmitter (external) for use with implantable sacral root neurostimulator receiver for bowel and bladder management, replacement | None | ||
| L8685 | Implantable neurostimulator pulse generator, single array, rechargeable, includes extension | None | ||
| L8686 | Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension | None | ||
| L8687 | Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension | None | ||
| L8688 | Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension | None | ||
| L8689 | External recharging system for battery (internal) for use with implantable neurostimulator, replacement only | None | ||
| S8130 | Interferential current stimulator, 2 channel | Yes | ||
| S8131 | Interferential current stimulator, 4 channel | Yes | ||
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Trapeze, Traction and Fracture Frames - General Use
| Code | Description | PAR | Unit Limits | Comments |
|---|---|---|---|---|
| E0830 | Ambulatory traction device, all types, each | Yes | ||
| E0840 | Traction frame, attached to headboard, cervical traction | Yes | Required: F2F *Code is subject to the 2019 DME UPL | |
| E0849 | Traction equipment, cervical, free- standing stand/frame, pneumatic, applying traction force to other than mandible | Yes | Required: F2F *Code is subject to the 2019 DME UPL | |
| E0850 | Traction stand, free standing, cervical traction | Yes | Required: F2F | |
| E0855 | Cervical traction equipment not requiring additional stand or frame | Yes | Required: F2F *Code is subject to the 2019 DME UPL | |
| E0856 | Cervical traction device, cervical collar with inflatable air bladder | Yes | Required: F2F | |
| E0860 | Traction equipment, over door, cervical | Yes | *Code is subject to the 2019 DME UPL | |
| E0870 | Traction frame, attached to footboard, extremity traction | Yes | *Code is subject to the 2019 DME UPL | |
| E0880 | Traction stand, free standing, extremity traction | Yes | *Code is subject to the 2019 DME UPL | |
| E0890 | Traction frame, attached to footboard, pelvic traction | Yes | *Code is subject to the 2019 DME UPL | |
| E0900 | Traction stand, free standing, pelvic traction | Yes | *Code is subject to the 2019 DME UPL | |
| E0910 | Trapeze bars (also known as "patient helper"), attached to bed, with grab bar | Yes | *Code is subject to the 2019 DME UPL | |
| E0911 | Trapeze bar, heavy duty, for patient weight capacity greater than 250 pounds, attached to bed, with grab bar | Yes | *Code is subject to the 2019 DME UPL | |
| E0912 | Trapeze bar, heavy duty, for patient weight capacity greater than 250 pounds, free standing, complete with grab bar | Yes | *Code is subject to the 2019 DME UPL | |
| E0920 | Fracture frame, attached to bed, includes weights | Yes | *Code is subject to the 2019 DME UPL | |
| E0930 | Fracture frame, free standing, includes weights | Yes | ||
| E0935 | Continuous passive motion exercise device for use on knee only | Yes | 7/M | Bill with RR and a date span. First 14 days post-op maximum. *Code is subject to the 2019 DME UPL |
| E0936 | Continuous passive motion exercise device for use other than knee | Yes | 7/M | Bill with RR and a date span. First 14 days post-op maximum. |
| E0940 | Trapeze bar, free standing, complete with grab bar | Yes | *Code is subject to the 2019 DME UPL | |
| E0941 | Traction device, gravity assisted, any type | Yes | *Code is subject to the 2019 DME UPL | |
| E0942 | Cervical head harness or halter, each | Yes | ||
| E0944 | Pelvic belt, harness or boat, each | Yes | ||
| E0945 | Extremity belt or harness, each | Yes | ||
| E0946 | Fracture frame, dual, with cross bars, attached to bed | Yes | Balken, 4-poster *Code is subject to the 2019 DME UPL | |
| E0947 | Fracture frame, attachments for complex pelvic traction | Yes | *Code is subject to the 2019 DME UPL | |
| E0948 | Fracture frame, attachments for complex cervical traction | Yes | *Code is subject to the 2019 DME UPL | |
| E1841 | Static progressive stretch shoulder device, with or without range of motion adjustability, includes all components and accessories | Yes | 1/Y | Rental is per day: Bill with RR and a date span. *Code is subject to the 2019 DME UPL |
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Lymphedema Pumps and Compressors - Specialized Use
| Code | Description | PAR | Unit Limits | Comments |
|---|---|---|---|---|
| A4600 | Sleeve for intermittent limb compression device, replacement only, each | Yes | ||
| E0650 | Pneumatic compressor, non-segmental home model | Yes | *Code is subject to the 2019 DME UPL | |
| E0651 | Pneumatic compressor, segmental home model without calibrated gradient pressure | Yes | *Code is subject to the 2019 DME UPL | |
| E0652 | Pneumatic compressor, segmental home model with calibrated gradient pressure | Yes | *Code is subject to the 2019 DME UPL | |
| E0655 | Non-segmental pneumatic appliance for use with pneumatic compressor, half arm | Yes | ||
| E0656 | Segmental pneumatic appliance for use with pneumatic compressor, trunk | Yes | Required: F2F | |
| E0657 | Segmental pneumatic appliance for use with pneumatic compressor, chest | Yes | Required: F2F | |
| E0660 | Non-segmental pneumatic appliance for use with pneumatic compressor, full leg | Yes | Required: F2F | |
| E0665 | Non-segmental pneumatic appliance for use with pneumatic compressor, full arm | Yes | Required: F2F | |
| E0666 | Non-segmental pneumatic appliance for use with pneumatic compressor, half leg | Yes | Required: F2F | |
| E0667 | Segmental pneumatic appliance for use with pneumatic compressor, full leg | Yes | Required: F2F | |
| E0668 | Segmental pneumatic appliance for use with pneumatic compressor, full arm | Yes | Required: F2F | |
| E0669 | Segmental pneumatic appliance for use with pneumatic compressor, half leg | Yes | Required: F2F | |
| E0670 | Segmental pneumatic appliance for use with pneumatic compressor, integrated, 2 full legs and trunk | Yes | 1/Y | Required: F2F For use with pneumatic compression device only when medical conditions exist that prevent the use of other appliances. |
| E0671 | Segmental gradient pressure pneumatic appliance, full leg | Yes | Required: F2F | |
| E0672 | Segmental gradient pressure pneumatic appliance, full arm | Yes | Required: F2F | |
| E0673 | Segmental gradient pressure pneumatic appliance, half leg | Yes | Required: F2F | |
| E0675 | Pneumatic compression device, high pressure, rapid inflation/deflation cycle, for arterial insufficiency (unilateral or bilateral) | Yes | Required: F2F | |
| E0676 | Intermittent limb compression device (includes all accessories), not otherwise specified | Yes | ||
| E0677 | Non-pneumatic sequential compression garment, trunk | Yes | Code opened 04-01-2023. | |
| E0678 | Non-pneumatic sequential compression garment, full leg | Yes | Code opened 01-01-2024. | |
| E0679 | Non-pneumatic sequential compression garment, half leg | Yes | Code opened 01-01-2024. | |
| E0680 | Non-pneumatic compression controller with sequential calibrated gradient pressure | Yes | Code opened 01-01-2024. | |
| E0681 | Non-pneumatic compression controller without calibrated gradient pressure | Yes | Code opened 01-01-2024. | |
| E0682 | Non-pneumatic sequential compression garment, full arm | Yes | Code opened 01-01-2024. | |
| S8420 | Gradient pressure aid (sleeve and glove combination), custom made | Yes | ||
| S8421 | Gradient pressure aid (sleeve and glove combination), ready made | Yes | ||
| S8422 | Gradient pressure aid (sleeve), custom made, medium weight | Yes | ||
| S8423 | Gradient pressure aid (sleeve), custom made, heavy weight | Yes | ||
| S8424 | Gradient pressure aid (sleeve), ready made | Yes | ||
| S8425 | Gradient pressure aid (glove), custom made, medium weight | Yes | ||
| S8426 | Gradient pressure aid (glove), custom made, heavy weight | Yes | ||
| S8427 | Gradient pressure aid (glove), ready made | Yes | ||
| S8428 | Gradient pressure aid (gauntlet), ready made | Yes | ||
| S8429 | Gradient pressure exterior wrap | Yes | ||
| S8430 | Padding for compression bandage, roll | Yes | ||
| S8431 | Compression bandage, roll | Yes | ||
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Wound Therapy Equipment
| Code | Description | PAR | Unit Limits | Comments |
|---|---|---|---|---|
| E2402 | Negative pressure wound therapy electrical pump, stationary or portable | Yes | For rental, bill with RR and a date span. Price includes equipment and all supplies (including but not limited to A6250). Required: Q12 *Code is subject to the 2019 DME UPL | |
| A9272 | Wound suction, disposable, includes dressing, all accessories and components, any type, each | No | ||
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Rehabilitation Equipment - Specialized Use
| Code | Description | PAR | Unit Limits | Comments |
|---|---|---|---|---|
| A8000 | Helmet, protective, soft, prefabricated, includes all components and accessories | Yes | ||
| A8001 | Helmet, protective, hard, prefabricated, includes all components and accessories | Yes | ||
| A8002 | Helmet, protective, soft, custom fabricated, includes all components and accessories | Yes | ||
| A8003 | Helmet, protective, hard, custom fabricated, includes all components and accessories | Yes | ||
| A8004 | Soft interface for helmet, replacement only | Yes | ||
| E1700 | Jaw motion rehabilitation system | Yes | ||
| E1701 | Replacement cushions for jaw motion rehabilitation system, package of 6 | Yes | ||
| E1702 | Replacement measuring scales for jaw motion rehabilitation system, package of 200 | Yes | ||
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Oral and Enteral Nutrition, Formulas, Equipment and Supplies - Specialized Use
| Code | Description | PAR | Unit Limits | Comments |
|---|---|---|---|---|
| Enteral Formulas | ||||
| B4100 | Food thickener, administered orally, per ounce | Yes | 1 unit = 1 ounce Use modifier BO. | |
| B4102 | Enteral formula, for adults, used to replace fluids and electrolytes (e.g. clear liquids), 500 ml = 1 unit | Yes | ||
| B4103 | Enteral formula, for pediatrics, used to replace fluids and electrolytes (e.g. clear liquids), 500 ml = 1 unit | Yes | ||
| B4104 | Additive for enteral formula (e.g. fiber) | Yes | ||
| B4105 | In-line cartridge containing digestive enzyme(s) for enteral feeding, each | Yes | EPSDT only | |
| B4149 | Enteral formula, manufactured blenderized natural foods with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories=1 unit | Yes | ||
| B4150 | Enteral formula, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit | Yes | For oral administration use modifier -BO. | |
| B4152 | Enteral formula, nutritionally complete, calorically dense (equal to or greater than 1.5 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber administered through an enteral feeding tube, 100 calories = 1 unit | Yes | For oral administration use modifier -BO. | |
| B4153 | Enteral formula, nutritionally complete, hydrolyzed proteins (amino acids and peptide chain), includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit | Yes | For oral administration use modifier -BO. | |
| B4154 | Enteral formula, nutritionally complete, for special metabolic needs, excludes inherited disease of metabolism, includes altered composition of proteins, fats, carbohydrates, vitamins and/or minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit | Yes | For oral administration use modifier -BO. | |
| B4155 | Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (E.G. glucose polymers), proteins/amino acids (e.g. glutamine, arginine), fat (e.g. medium chain triglycerides) or combination, administered through an enteral feeding tube, 100 calories = 1 unit | Yes | For oral administration use modifier -BO. | |
| B4157 | Enteral formula, nutritionally complete, for special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit | Yes | ||
| B4158 | Enteral formula, for pediatrics, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 calories= 1 unit | Yes | ||
| B4159 | Enteral formula, for pediatrics, nutritionally complete soy based with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 calories=1 unit | Yes | ||
| B4160 | Enteral formula, for pediatrics, nutritionally complete calorically dense (equal to or greater than 0.7 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories=1 unit | Yes | ||
| B4161 | Enteral formula, for pediatrics, hydrolyzed/amino acids and peptide chain proteins, includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories=1 unit | Yes | ||
| B4162 | Enteral formula, for pediatrics, special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit | Yes | ||
| B4164 | Parenteral nutrition solution, carbohydrates (dextrose), 50% or less (500 ml = 1 unit) - home mix | Yes | This item must be provided by the pharmacy using a valid NDC. | |
| B4168 | Parenteral nutrition solution, amino acid, 3.5%, (500 ml = 1 unit) - home mix | Yes | This item must be provided by the pharmacy using a valid NDC. | |
| B4172 | Parenteral nutrition solution, amino acid, 5.5% through 7%, (500 ml = 1 unit) - home mix | Yes | This item must be provided by the pharmacy using a valid NDC. | |
| B4176 | Parenteral nutrition solution, amino acid, 7% through 8.5%, (500 ml = 1 unit) - home mix | Yes | This item must be provided by the pharmacy using a valid NDC. | |
| B4178 | Parenteral nutrition solution, amino acid, greater than 8.5% (500 ml = 1 unit) - home mix | Yes | This item must be provided by the pharmacy using a valid NDC. | |
| B4180 | Parenteral nutrition solution, carbohydrates (dextrose), greater than 50% (500 ml = 1 unit) - home mix | Yes | This item must be provided by the pharmacy using a valid NDC. | |
| B4185 | Parenteral nutrition solution, per 10 grams lipids | Yes | This item must be provided by the pharmacy using a valid NDC. | |
| B4189 | Parenteral nutrition solution, compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, 10 to 51 grams of protein - premix | Yes | This item must be provided by the pharmacy using a valid NDC. | |
| B4193 | Parenteral nutrition solution, compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, 52 to 73 grams of protein - premix | Yes | This item must be provided by the pharmacy using a valid NDC. | |
| B4197 | Parenteral nutrition solution, compounded amino acid and carbohydrates with electrolytes, trace elements and vitamins, including preparation, any strength, 74 to 100 grams of protein - premix | Yes | This item must be provided by the pharmacy using a valid NDC. | |
| B4199 | Parenteral nutrition solution, compounded amino acid and carbohydrates with electrolytes, trace elements and vitamins, including preparation, any strength, over 100 grams of protein - premix | Yes | This item must be provided by the pharmacy using a valid NDC. | |
| B4216 | Parenteral nutrition, additives (vitamins, trace elements, heparin, electrolytes) - home mix, per day | Yes | This item must be provided by the pharmacy using a valid NDC. | |
| B5000 | Parenteral nutrition solution: compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, renal - amirosyn rf, nephramine, renamine - premix | Yes | This item must be provided by the pharmacy using a valid NDC. | |
| B5100 | Parenteral nutrition solution: compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, hepatic - freamine hbc, hepatamine - premix | Yes | This item must be provided by the pharmacy using a valid NDC. | |
| B5200 | Parenteral nutrition solution: compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, stress - branch chain amino acids - premix | Yes | This item must be provided by the pharmacy using a valid NDC. | |
| S9432 | Medical foods for non-inborn errors of metabolism | Yes | 1 unit = 1 serving/meal | |
| S9433 | Medical food nutritionally complete, administered orally, providing 100% of nutritional intake | Yes | ||
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| Enteral Equipment and Supplies See the feeding tube/changes and modifications in descriptions, and quantities specific to skin level devices. Quantities exceeding the allowed amount will require additional supporting documentation. | ||||
| A5200 | Percutaneous catheter/tube anchoring device, adhesive skin attachment | None | 1 unit = 1 device | |
| B4034 | Enteral feeding supply kit: Syringe fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape | Yes | ||
| B4035 | Enteral feeding supply kit: Pump fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape | Yes | ||
| B4036 | Enteral feeding supply kit: Gravity fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape | Yes | ||
| B4081 | Nasogastric tubing with stylet, each | Yes | ||
| B4082 | Nasogastric tubing without stylet, each | Yes | ||
| B4083 | Stomach tube, Levine type, each | Yes | ||
| B4087 | Gastrostomy/jejunostomy tube, standard, any material, any type, each | Yes | 2/M | |
| B4088 | Gastrostomy/jejunostomy tube, low- profile, any material, any type, each | Yes | 2/M | |
| B9002-RR | Enteral nutrition infusion pump, any type | Yes | Rental: 1 unit = 1 month. Rent to Own item: After 16 months of rental, the member owns the pump. B4034, B4035, or B4036 may be billed separately during rental period. | |
| E0776 | IV pole | Yes | Total reimbursement, including rental, shall not exceed the purchase price. | |
| E2000 | Gastric suction pump, home model, portable or stationary, electric | Yes | *Code is subject to the 2019 DME UPL | |
| E2001 | Suction pump, home model, portable or stationary, electric, any type, for use with external urine and/or fecal management system | Yes | Code opened 01-01-2024. | |
| S8265 | Haberman feeder for cleft lip/palate | None | Use this code also for glass bottle, nipple, membrane, disc or collar replacements. Must be billed on a paper claim. Bill one (1) line for multiple components. Describe individual components and units of each item in comment section of the claim. | |
| B9998 | Miscellaneous enteral supplies not otherwise classified. (Extension sets [not included in feeding kit code] 24-hour use-one (1) time use only as stated by manufacturer). | Yes | Include description and quantities on PAR. For rental, must submit manufacturer's invoice with PAR. Rental based on percentage of invoice and rate will be determined at the time of PAR approval. PAR copy must be submitted with claim. Do not use for items included in supply kits. Quantity Allowed: 30 per month. | |
| B9998 + U1 | Cholesterol products which otherwise use this code (Effective 7-1-2021) | Yes | Providers of cholesterol products should bill with modifier U1 for fee schedule payment. Modifier U1 is not manually priced and does not require invoicing. | |
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| Breastfeeding Equipment and Supplies | ||||
| A4287 | Disposable collection and storage bag for breast milk, any size, any type, each | None | Code opened 01-01-2024. | |
| E0602 | Breast Pump, manual, any type | None | Includes kit and all supplies. Limited coverage policy ended 6/7/2022. | |
| E0603 | Breast Pump, single user, electric (AC and/or DC), any type | None | Includes breast pump and collection kit supplies. Limited coverage policy ended 6/7/2022. Purchase only. No PAR required as of 6/8/2022. Eligible at the 28th week of pregnancy OR at the time of birth for earlier deliveries. | |
| E0604 | Breast pump, multi-user, electric (AC and/or DC), any type | Yes | Effective January 1, 2023. Continuous rental item, code does not convert to purchase. Rate is inclusive of all accessories, supplies, and servicing. | |
| A4281 | Tubing for breast pump, replacement | None | Purchase for member owned equipment only. | |
| A4282 | Adapter for breast pump, replacement | Yes | Purchase for member owned equipment only. | |
| A4283 | Cap for breast pump bottle, replacement | Yes | Purchase for member owned equipment only. | |
| A4284 | Breast shield and splash protector for use with breast pump, replacement | Yes | Purchase for member owned equipment only. | |
| A4285 | Polycarbonate bottle for use with breast pump, replacement | Yes | Purchase for member owned equipment only. | |
| A4286 | Locking ring for breast pump, replacement | Yes | Purchase for member owned equipment only. | |
| K1005 | Disposable collection and storage bag for breast milk, any size, any type, each | None | Code replaced 01-01-2024. See A4287. | |
| T2101 | Human breast milk processing, storage and distribution only | Yes | ||
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Home IV Therapy - Specialized Use
| Code | Description | PAR | Unit Limits | Comments |
|---|---|---|---|---|
| Enteral Formulas | ||||
| Parenteral Equipment and Supplies | ||||
| A4305 | Disposable Drug Delivery System, flow rate of 50 ml or greater per hour | Yes | 1 unit = 1 system | |
| A4306 | Disposable drug delivery system, flow rate of less than 50 ml per hour | Yes | 1 unit = 1 system | |
| A4602 | Replacement battery for external infusion pump owned by patient, lithium,1.5 volt, each | None | SEE NCCI MUE LIMIT | NCCI MUE - cannot be overridden with a PAR. *Effective January 1, 2019 |
| B4220 | Parenteral nutrition supply kit: Premix, including gloves, wipes, alcohol, acetone, povidone iodine scrub, ointment, swab sticks, sponges, Heparin flush, tape, caps, syringes, needles, ketodiastic and destruclip, per day | Yes | 31/M | 1 unit = 1 day's supplies which includes all or part of the listed items. Do not bill included items separately. May be used utilized for total parenteral nutrition (TPN), the administration of antibiotics, and the maintenance of electrolyte balances or hydration |
| B4224 | Parenteral nutrition administration kit, includes luer lok and microfilter, pump cassettes, clamps, extension sets and connectors, per day | Yes | 1 unit = 1 day's supplies which includes all or part of the listed items. Do not bill included items separately. May be used utilized for total parenteral nutrition (TPN), the administration of antibiotics, and the maintenance of electrolyte balances or hydration | |
| B9004-RR | Parenteral nutrition infusion pump, portable | Yes | 1/M | 1 unit = 1 month rental |
| B9006-RR | Parenteral nutrition infusion pump, stationary | Yes | 1 unit = 1 month rental | |
| B9999 | Miscellaneous Parenteral supplies not otherwise classified | Yes | Include description and quantity on PAR. Do not use for items included in kits. Submit paper claim with manufactures invoice attached. | |
| E0779 | Ambulatory infusion pump, mechanical, reusable, for infusion 8 hours or greater | Yes | For rental, bill with RR and a date span. Prior authorization must substantiate the necessity for the use of an ambulatory pump. *Code is subject to the 2019 DME UPL | |
| E0780-KR | Ambulatory infusion pump, mechanical, reusable, for infusion less than 8 hours. | Yes | 1 unit = 1 pump Prior authorization must substantiate the necessity for the use of an ambulatory pump. | |
| E0781 | Ambulatory infusion pump, single or multiple channels, electric or battery operated, with administration equipment, worn by patient | Yes | *Code is subject to the 2019 DME UPL | |
| E0782 | Infusion pump, implantable, non-programmable (includes all components, e.g., pump, catheter, connectors, etc.) | None | ||
| E0783 | Infusion pump system, implantable, programmable (includes all components, e.g., pump, catheter, connectors, etc.) | None | ||
| E0785 | Implantable intraspinal (epidural/intrathecal) catheter used with implantable infusion pump, replacement | None | ||
| E0786 | Implantable programmable infusion pump, replacement (excludes implantable intraspinal catheter) | None | ||
| E0791 | Parenteral infusion pump, stationary, single or multi-channel | Yes | *Code is subject to the 2019 DME UPL | |
| K0455 | Infusion pump used for uninterrupted parenteral administration of medication, (e.g. epoprostenol or treprostinol) | Yes | 1/M | Bill with RR modifier. 1 unit = 1 system, 1 month rental *Code is subject to the 2019 DME UPL |
| K0552 | Supplies for external non-insulin drug infusion pump, syringe type cartridge, sterile, each | Yes | 31/M | 1 unit = 1 cartridge |
| K0601 | Replacement battery for external infusion pump owned by patient, silver oxide, 1.5 volt, each | None | 2/M | For member owned equipment only. 1 unit = 1 battery |
| K0602 | Replacement battery for external infusion pump owned by patient, silver oxide, 3 volt, each | None | 2/M | For member owned equipment only. 1 unit = 1 battery |
| K0603 | Replacement battery for external infusion pump owned by patient, alkaline, 1.5 volt, each | None | 2/M | For member owned equipment only. 1 unit = 1 battery |
| K0604 | Replacement battery for external infusion pump owned by patient, lithium,3.6 volt, each | None | 2/M | For member owned equipment only. 1 unit = 1 battery |
| K0605 | Replacement battery for external infusion pump owned by patient, lithium,4.5 volt, each | None | 2/M | For member owned equipment only. 1 unit = 1 battery |
| S5035 | Home infusion therapy, routine service of infusion device (e.g. pump maintenance) | Yes | For member owned equipment only. Cannot be billed with K0739 or K0739-MS. Do not use for skilled nursing visits for initial or subsequent pump set-ups. 1 unit = 15 minutes | |
| S5036 | Home infusion therapy, repair of infusion device (e.g. pump repair) | Yes | For member owned equipment only. Cannot be billed with k0739 or K0739-MS. Do not use for skilled nursing visits for initial or subsequent pump set-ups. | |
| S5520 | Home infusion therapy, all supplies (including catheter) necessary for a peripherally inserted central venous catheter (PICC) line insertion | Yes | Use for insertion supplies only. | |
| S5521 | Home infusion therapy, all supplies (including catheter) necessary for a midline catheter insertion | Yes | Use for insertion supplies only. | |
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Prosthetics and Orthotics
| Code | Description | PAR | Unit Limits | Comments |
|---|---|---|---|---|
| A4280 | Adhesive skin support attachment for use with external breast prosthesis, each | None | 1 unit = 1 attachment | |
| Diabetic Shoes - Fitting and Modifications | ||||
| A5500 | 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 | None | 2/Y | |
| A5501 | For diabetics only, fitting (including follow-up) custom preparation and supply of shoe molded from cast(s) of patient's foot (custom molded shoe), per shoe | No | 2/Y | |
| A5503 | 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 | No | ||
| A5504 | For diabetics only, modification (including fitting) of off-the-shelf depth- inlay shoe or custom molded shoe with wedge(s), per shoe | No | ||
| A5505 | For diabetics only, modification (including fitting) of off-the-shelf depth- inlay shoe or custom molded shoe with metatarsal bar, per shoe | No | ||
| A5506 | For diabetics only, modification (including fitting) of off-the-shelf depth- inlay shoe or custom molded shoe with off-set heel(s), per shoe | No | ||
| A5507 | For diabetics only, not otherwise specified modification (including fitting) of off-the-shelf. Depth-inlay shoe or custom molded shoe, per shoe | No | ||
| A5508 | For diabetics only, deluxe feature of off- the-shelf depth-inlay shoe or custom molded shoe, per shoe | No | ||
| A5510 | For diabetics only, direct formed, compression molded to patient's foot without external heat source, multiple density insert(s), prefabricated, per shoe | No | ||
| A5512 | 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 or ¼ inch material of shore a 35 durometer or 3/16 inch material of shore a 40 durometer (or higher), prefabricated, each | No | ||
| A5513 | 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 1/4 inch material of shore a 35 durometer or 3/16 inch material of shore a 40 durometer (or higher), includes arch filler and other shaping material, custom fabricated, each | No | ||
| A5514 | For diabetics only, multiple density insert, made by direct carving with cam technology from a rectified cad model created from a digitized scan of the patient, total contact with patient’s foot, including arch, base layer minimum of 3/16 inch material of shore a 35 durometer (or higher), includes arch filler and other shaping material, custom fabricated, each | No | ||
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| Orthotic Devices - Spinal | ||||
| Cervical | ||||
| L0112 | Cranial cervical orthosis, congenital torticollis type, with or without soft interface material, adjustable range of motion joint, custom fabricated | Yes | 1/Y | |
| L0113 | Cranial cervical orthosis, torticollis type, with or without joint, with or without soft interface material, prefabricated, includes fitting and adjustment | Yes | 1/Y | |
| L0120 | Cervical, flexible, nonadjustable (foam collar) | No | ||
| L0130 | Cervical, flexible, thermoplastic collar, molded to patient | Yes | 1/Y | |
| L0140 | Cervical, semi-rigid, adjustable (plastic collar) | Yes | 1/Y | |
| L0150 | Cervical, semi-rigid, adjustable molded chin cup (plastic collar with mandibular/occipital piece) | Yes | 1/Y | |
| L0160 | Cervical, semi-rigid, wire frame occipital/mandibular support | Yes | 1/Y | |
| L0170 | Cervical, collar, molded to patient model | Yes | *1/Y | *Effective April 1, 2019 |
| L0172 | Cervical, collar, semi-rigid thermoplastic foam, two (2) piece | Yes | *1/Y | *Effective April 1, 2019 |
| L0174 | Cervical, collar, semi-rigid, thermoplastic foam, two (2) piece, prefabricated, off- the-shelf | Yes | *1/Y | *Effective April 1, 2019 |
| S1040 | Cranial remolding orthosis, pediatric, rigid, with soft interface material, custom fabricated, includes fitting and adjustment(s) | Yes | *1/Y | *Effective April 1, 2019 |
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| Multiple Post Collar | ||||
| L0180 | Cervical, multiple post collar occipital/mandibular supports, adjustable | Yes | *1/Y | *Effective April 1, 2019 |
| L0190 | Cervical, multiple post collar, occipital/mandibular supports, adjustable cervical bars (Somi, Guilford, Taylor types) | Yes | *1/Y | *Effective April 1, 2019 |
| L0200 | Cervical, multiple post collar, occipital/ mandibular supports, adjustable cervical bars, and thoracic extension | Yes | *1/Y | *Effective April 1, 2019 |
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| Thoracic | ||||
| L0220 | Thoracic rib belt, custom fabricated | Yes | *1/Y | *Effective April 1, 2019 |
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| Thoracic-Lumbar-Sacral Orthosis (TLSO) Flexible | ||||
| L0450 | 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, off-the-shelf | No | ||
| L0452 | 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 | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
| L0454 | 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 item that has been trimmed, bent, molder, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise | No | ||
| L0455 | 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, off-the-shelf | No | ||
| L0456 | TLSO, flexible, provides trunk support, thoracic region, rigid posterior panel and soft anterior apron, extends from the 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 item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
| L0457 | TLSO, flexible, provides trunk support, thoracic region, rigid posterior panel and soft anterior apron, extends from the 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, off-the-shelf | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
| L0458 | TLSO, triplanar control, modular segmented spinal system, two (2) rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
| L0460 | TLSO, triplanar control, modular segmented spinal system, two (2) rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
| L0462 | TLSO, triplanar control, modular segmented spinal system, three (3) rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
| L0464 | TLSO, triplanar control, modular segmented spinal system, four (4) rigid plastic shells, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
| L0466 | 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 item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise | No | ||
| L0467 | 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, prefabricated, off-the-shelf | No | ||
| L0468 | 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 item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise | No | ||
| L0469 | 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, prefabricated, off- the-shelf | No | ||
| L0470 | 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, provides intracavitary pressure to reduce load on the intervertebral disks, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment | No | ||
| L0472 | TLSO, triplanar control, hyperextension, rigid anterior and lateral frame extends from symphysis pubis to sternal notch with two (2) anterior components (one (1) pubic and one (1) 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 | No | ||
| L0480 | TLSO, triplanar control, one (1) 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 | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
| L0482 | TLSO, triplanar control, one (1) 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 | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
| L0484 | TLSO, triplanar control, two (2) 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 | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
| L0486 | TLSO, triplanar control, two (2) 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 | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
| L0488 | TLSO, triplanar control, one (1) 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 | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
| L0490 | TLSO, sagittal-coronal control, one (1) piece rigid plastic shell, with overlapping reinforced anterior, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates at or before the T-9 vertebra, anterior extends from symphysis pubis to xiphoid, anterior opening, restricts gross trunk motion in sagittal and coronal planes, prefabricated, includes fitting and adjustment | No | ||
| L0491 | TLSO, sagittal-coronal control, modular segmented spinal system, two (2) rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal and coronal planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
| L0492 | TLSO, sagittal-coronal control, modular segmented spinal system, three (3) rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal and coronal planes, lateral strength is provided by overlapping plastic and stabilizing closure, includes straps and closures, prefabricated, includes fitting and adjustment | No | ||
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| Lumbar-Sacral Orthosis (LSO) | ||||
| L0625 | Lumbar orthosis, 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, off-the-shelf | No | Support is not for obstetrical or obesity diagnosis. | |
| L0626 | Lumbar orthosis, 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 item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise | No | ||
| L0627 | Lumbar orthosis, sagittal control, with rigid anterior and posterior panels, 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 item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise | No | ||
| L0628 | Lumbar-sacral orthosis, flexible, provides lumbo-sacral support, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include stays, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf | No | Support is not for obstetrical or obesity diagnosis. | |
| L0629 | Lumbar-sacral orthosis, 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, includes fitting and adjustment | Yes | 1/Y | Support is not for obstetrical or obesity diagnosis. *Effective April 1, 2019, a prior authorization is required. |
| L0630 | Lumbar-sacral orthosis, 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 item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise | No | ||
| L0631 | Lumbar-sacral orthosis, 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, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
| L0632 | Lumbar-sacral orthosis, 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 | No | ||
| L0633 | Lumbar-sacral orthosis, 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 item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise | No | ||
| L0634 | Lumbar-sacral orthosis, 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 | No | ||
| L0635 | Lumbar-sacral orthosis, 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 intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, prefabricated, includes fitting and adjustment | No | ||
| L0636 | Lumbar-sacral orthosis, 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 intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, custom fabricated | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
| L0637 | Lumbar-sacral orthosis, 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 intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
| L0638 | Lumbar-sacral orthosis, 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 intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, custom fabricated | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
| L0639 | Lumbar-sacral orthosis, 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 intervertebral discs, overall strength is provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise | No | ||
| L0640 | Lumbar-sacral orthosis, 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 intervertebral discs, overall strength is provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, custom fabricated | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
| L0641 | Lumbar orthosis, 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, off-the-shelf | No | ||
| L0642 | Lumbar orthosis, sagittal control, with rigid anterior and posterior panels, 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, off-the-shelf | No | ||
| L0643 | Lumbar-sacral orthosis, 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, off-the-shelf | No | ||
| L0648 | Lumbar-sacral orthosis, 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, prefabricated, off-the-shelf | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
| L0649 | Lumbar-sacral orthosis, 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 intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf | No | ||
| L0650 | Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf | No | ||
| L0651 | Lumbar-sacral orthosis, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra, anterior extends from symphysis pubis to xyphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, prefabricated, off-the-shelf | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
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| Sacroiliac - Flexible | ||||
| L0621 | Sacroiliac orthosis, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, prefabricated, off-the- shelf | No | ||
| L0622 | Sacroiliac orthosis, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricated. | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
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| Sacroiliac - Semi-Rigid | ||||
| L0623 | Sacroiliac orthosis, 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, off-the-shelf | No | ||
| L0624 | Sacroiliac orthosis, 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 | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
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| Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLSO) | ||||
| Anterior-Posterior-Lateral Control | ||||
| L0700 | CTLSO, anterior-posterior-lateral control, molded to patient model (Minerva type) | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
| L0710 | CTLSO, anterior-posterior-lateral control, molded to patient model, with interface material (Minerva type) | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
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| Halo Procedure | ||||
| L0810 | Halo procedure, cervical halo incorporated into jacket vest | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
| L0820 | Halo procedure, cervical halo incorporated into plaster body jacket | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
| L0830 | Halo procedure, cervical halo incorporated into Milwaukee type orthosis | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
| L0861 | Addition to halo procedure, replacement liner/interface material | No | ||
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| Additions to Spinal Orthosis | ||||
| L0970 | TLSO, corset front | No | ||
| L0972 | LSO, corset front | No | ||
| L0974 | TLSO, full corset | No | ||
| L0976 | LSO, full corset | No | ||
| L0978 | Axillary crutch extension | No | ||
| L0980 | Peroneal straps, off-the-shelf, pair | No | ||
| L0982 | Stocking supporter grips, prefabricated, off-the-shelf, set of four (4) | No | ||
| L0984 | Protective body sock, prefabricated, off- the-shelf, each | No | ||
| L0999 | Addition to spinal orthosis, NOS | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
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| Orthotic Devices - Scoliosis Procedure | ||||
| Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLSO) (Milwaukee) | ||||
| L1000 | CTLSO (Milwaukee), inclusive of furnishing initial orthosis, including model | Yes | 2/Y | *Effective April 1, 2019, a prior authorization is required. |
| L1001 | Cervical thoracic lumbar sacral orthosis, immobilizer, infant size, prefabricated, includes fitting and adjustment | No | ||
| L1005 | Tension based scoliosis orthosis and accessory pads, includes fitting and adjustment | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
| L1010 | Addition to CTLSO or scoliosis orthosis, axilla sling | No | ||
| L1020 | Addition to CTLSO or scoliosis orthosis, kyphosis pad | No | ||
| L1025 | Addition to CTLSO or scoliosis orthosis, kyphosis pad, floating | No | ||
| L1030 | Addition to CTLSO or scoliosis orthosis, lumbar bolster pad | No | ||
| L1040 | Addition to CTLSO or scoliosis orthosis, lumbar or lumbar rib pad | No | ||
| L1050 | Addition to CTLSO or scoliosis orthosis, sternal pad | No | ||
| L1060 | Additions to CTLSO or scoliosis orthosis, thoracic pad | No | ||
| L1070 | Addition to CTLSO or scoliosis orthosis, trapezius sling | No | ||
| L1080 | Addition to CTLSO or scoliosis orthosis, outrigger | No | ||
| L1085 | Addition to CTLSO or scoliosis orthosis, outrigger, bilateral with vertical extensions | No | ||
| L1090 | Addition to CTLSO or scoliosis orthosis, lumbar sling | No | ||
| L1100 | Addition to CTLSO or scoliosis orthosis, ring flange, plastic or leather | No | ||
| L1110 | Addition to CTLSO or scoliosis orthosis, ring flange, plastic or leather, molded to patient model | No | ||
| L1120 | Addition to CTLSO or scoliosis orthosis, cover for upright, each | No | ||
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| Thoracic-Lumbar-Sacral Orthosis (TLSO) (Low Profile) | ||||
| L1200 | TLSO, inclusive of furnishing initial orthosis only | Yes | 4/Y | *Effective April 1, 2019, a prior authorization is required. |
| L1210 | Addition to TLSO, (low profile), lateral thoracic extension | No | ||
| L1220 | Addition to TLSO, (low profile), anterior thoracic extension | No | ||
| L1230 | Addition to TLSO, (low profile), Milwaukee type superstructure | No | ||
| L1240 | Addition to TLSO, (low profile), lumbar derotation pad | No | 1/D | |
| L1250 | Addition to TLSO, (low profile), anterior ASIS pad | No | ||
| L1260 | Addition to TLSO, (low profile), anterior thoracic derotation pad | No | ||
| L1270 | Addition to TLSO, (low profile), abdominal pad | No | ||
| L1280 | Addition to TLSO, (low profile), rib gusset (elastic), each | No | ||
| L1290 | Addition to TLSO, (low profile), lateral trochanteric pad | No | ||
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| Other Scoliosis Procedures | ||||
| L1300 | Other scoliosis procedure, body jacket molded to patient model | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
| L1310 | Other scoliosis procedure, postoperative body jacket | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
| L1320 | Thoracic, pectus carinatum orthosis, sternal compression, rigid circumferential frame with anterior and posterior rigid pads, custom fabricated | Yes | Code opened 04-01-2024. | |
| L1499 | Spinal orthosis, not otherwise specified | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
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| Orthotic Devices - Lower Limb | ||||
| Hip Orthosis (HO) - Flexible | ||||
| L1600 | HO, abduction control of hip joints, flexible, Frejka type with cover, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise | No | ||
| L1610 | HO, abduction control of hip joints, flexible, (Frejka cover only), prefabricated, includes fitting and adjustment | No | ||
| L1620 | HO abduction control of hip joints, flexible, (Pavlik harness), prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise | No | ||
| L1630 | HO abduction control of hip joints, semi- flexible (Von Rosen type), custom fabricated | No | ||
| L1640 | HO, abduction control of hip joints, static, pelvic band or spreader bar, thigh cuffs, custom fabricated | No | ||
| L1650 | HO, abduction control of hip joints, static, adjustable (Ilfled type), prefabricated, includes fitting and adjustment | No | ||
| L1652 | Hip orthosis, bilateral thigh cuffs with adjustable abductor spreader bar, adult size, prefabricated, includes fitting and adjustment, any type | No | ||
| L1660 | HO abduction control of hip joints, static, plastic, prefabricated, includes fitting and adjustment | No | ||
| L1680 | HO abduction control of hip joints, dynamic, pelvic control, adjustable hip motion control, thigh cuffs (Rancho hip action type), custom fabricated | Yes | 2/Y | *Effective April 1, 2019, a prior authorization is required. |
| L1685 | HO abduction control of hip joint, postoperative hip abduction type, custom fabricated | Yes | 2/Y | *Effective April 1, 2019, a prior authorization is required. |
| L1686 | HO abduction control of hip joint, postoperative hip abduction type, prefabricated, includes fitting and adjustment | Yes | 2/Y | *Effective April 1, 2019, a prior authorization is required. |
| L1690 | Combination, bilateral, lumbo-sacral, hip, femur orthosis providing adduction and internal rotation control, prefabricated, includes fitting and adjustment | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
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| Legg Perthes | ||||
| L1700 | Legg Perthes orthosis, (Toronto type), custom fabricated | Yes | 2/Y | *Effective April 1, 2019, a prior authorization is required. |
| L1710 | Legg Perthes orthosis, (Newington type), custom fabricated | Yes | 2/Y | *Effective April 1, 2019, a prior authorization is required. |
| L1720 | Legg Perthes orthosis, trilateral, (Tachdijan type), custom fabricated | Yes | 2/Y | *Effective April 1, 2019, a prior authorization is required. |
| L1730 | Legg Perthes orthosis, (Scottish Rite type), custom fabricated | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
| L1755 | Legg Perthes orthosis, (Patten bottom type), custom fabricated | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
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| Knee Orthosis (KO) | ||||
| E1810 | Dynamic adjustable knee extension/ flexion device, includes soft interface material | No | *Code is subject to the 2019 DME UPL | |
| E1811 | Static progressive stretch knee device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories | Yes | 1/Y | *Code is subject to the 2019 DME UPL |
| E1812 | Dynamic knee, extension/flexion device with active resistance control | No | *Code is subject to the 2019 DME UPL | |
| L1810 | KO, elastic with joints, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise | No | ||
| L1812 | Knee orthosis, elastic with joints, prefabricated, off-the-shelf | No | ||
| L1820 | Knee orthosis, elastic with condylar pads and joints, with or without patellar control, prefabricated, includes fitting and adjustment | No | ||
| L1830 | KO, immobilizer, canvas longitudinal, prefabricated, off-the-shelf | No | ||
| L1831 | Knee orthosis, locking knee joint(s), positional orthosis, prefabricated, includes fitting and adjustment | No | ||
| L1832 | Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise | Yes | 2/Y | *Effective April 1, 2019, a prior authorization is required. |
| L1833 | Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the shelf | No | ||
| L1834 | KO, without knee joint, rigid, custom fabricated | Yes | 2/Y | *Effective April 1, 2019, a prior authorization is required. |
| L1836 | KO, rigid, without joint(s), includes soft interface material, prefabricated, off-the- shelf | No | ||
| L1840 | KO, derotation, medial-lateral, anterior cruciate ligament, custom fabricated | Yes | 2/Y | *Effective April 1, 2019, a prior authorization is required. |
| L1843 | Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise | Yes | 2/Y | *Effective April 1, 2019, a prior authorization is required. |
| L1844 | Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated | Yes | 2/Y | *Effective April 1, 2019, a prior authorization is required. |
| L1845 | Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise | Yes | 2/Y | *Effective April 1, 2019, a prior authorization is required. |
| L1846 | Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, custom fabricated | Yes | 2/Y | *Effective April 1, 2019, a prior authorization is required. |
| L1847 | KO, double upright with adjustable joint, with inflatable air chamber(s), prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise | Yes | 2/Y | *Effective April 1, 2019, a prior authorization is required. |
| L1848 | Knee orthosis, double upright with adjustable joint, with inflatable air support chamber(s), prefabricated, off- the-shelf | No | ||
| L1850 | KO, Swedish type, prefabricated off-the- shelf | No | ||
| L1851 | Knee orthosis (ko), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf | No | New code effective 01/01/2017. This code replaces K0901. | |
| L1852 | Knee orthosis (ko), double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf | No | New code effective 01/01/2017. This code replaces K0902. | |
| L1860 | KO, modification of supracondylar prosthetic socket, custom fabricated (SK) | Yes | 2/Y | *Effective April 1, 2019, a prior authorization is required. |
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| Ankle-Foot Orthosis (AFO) | ||||
| A9283 | Foot pressure off loading/supportive device, any type, each | No | ||
| E1815 | Dynamic adjustable ankle extension/flexion, includes soft interface material | No | *Code is subject to the 2019 DME UPL | |
| E1816 | Static progressive stretch ankle device, flexion and/or extension, with or without range of motion adjustment, includes all components and accessories | Yes | 1/Y | *Code is subject to the 2019 DME UPL |
| L1900 | AFO, spring wire, dorsiflexion assist calf band, custom fabricated | No | ||
| L1902 | Ankle orthosis, ankle gauntlet or similar, with or without joints, prefabricated, off- the-shelf | No | ||
| L1904 | Ankle orthosis, ankle gauntlet or similar, with or without joints, custom fabricated | Yes | 2/Y | *Effective April 1, 2019, a prior authorization is required. |
| L1906 | Ankle foot orthosis, multiligamentous ankle support, prefabricated, off-the- shelf | No | ||
| L1907 | Ankle orthosis, supramalleolar with straps, with or without interface/pads, custom fabricated | Yes | 2/Y | *Effective April 1, 2019, a prior authorization is required. |
| L1910 | AFO, posterior, single bar, clasp attachment to shoe counter, prefabricated, includes fitting and adjustment | No | ||
| L1920 | AFO, single upright with static or adjustable stop (Phelps or Peristein type), custom fabricated | No | ||
| L1930 | AFO, plastic or other material, prefabricated, includes fitting and adjustment | No | ||
| L1932 | AFO, rigid anterior tibial section, total carbon fiber or equal material, prefabricated, includes fitting and adjustment | Yes | 2/Y | *Effective April 1, 2019, a prior authorization is required. |
| L1940 | AFO, plastic or other material, custom fabricated | Yes | 2/Y | *Effective April 1, 2019, a prior authorization is required. |
| L1945 | AFO, molded to patient model, plastic, rigid anterior tibial section (floor reaction), custom fabricated | Yes | 2/Y | *Effective April 1, 2019, a prior authorization is required. |
| L1950 | AFO, spiral, (Institute of Rehabilitative Medicine type), plastic, custom fabricated | Yes | 2/Y | *Effective April 1, 2019, a prior authorization is required. |
| L1951 | AFO, spiral, (Institute of Rehabilitative Medicine type), plastic or other material, prefabricated, includes fitting and adjustment | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
| L1960 | AFO, posterior solid ankle, plastic, custom fabricated | Yes | 4/Y | *Effective April 1, 2019, a prior authorization is required. |
| L1970 | AFO, plastic, with ankle joint, custom fabricated | Yes | 2/Y | *Effective April 1, 2019, a prior authorization is required. |
| L1971 | AFO, plastic or other material with ankle joint, prefabricated, includes fitting and adjustment | No | ||
| L1980 | AFO, single upright free plantar dorsiflexion, solid stirrup, calf band/cuff (single bar "BK" orthosis), custom fabricated | No | ||
| L1990 | AFO, double upright free plantar dorsiflexion, solid stirrup, calf band/cuff (double bar "BK" orthosis), custom fabricated | Yes | 2/Y | *Effective April 1, 2019, a prior authorization is required. |
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| Knee-Ankle-Foot Orthosis (KAFO) | ||||
| L2000 | KAFO, single upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar "AK" orthosis), custom fabricated | Yes | 2/Y | *Effective April 1, 2019, a prior authorization is required. |
| L2005 | Knee-ankle-foot orthosis, any material, single or double upright, stance control, automatic lock and swing phase release, any type activation, includes ankle joint, any type, custom fabricated | Yes | 2/Y | *Effective April 1, 2019, a prior authorization is required. |
| L2010 | KAFO, single upright, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar "AK" orthosis), without knee joint, custom fabricated | Yes | 2/Y | *Effective April 1, 2019, a prior authorization is required. |
| L2020 | KAFO, double upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (double bar "AK" orthosis), custom fabricated | Yes | 2/Y | *Effective April 1, 2019, a prior authorization is required. |
| L2030 | KAFO, double upright, free ankle, solid stirrup, thigh and calf bands/cuffs, (double bar "AK" orthosis), without knee joint, custom fabricated | Yes | 2/Y | *Effective April 1, 2019, a prior authorization is required. |
| L2034 | Knee ankle foot orthosis, full plastic, single upright, with or without free motion knee, medial lateral rotation control, with or without free motion ankle, custom fabricated | Yes | 2/Y | *Effective April 1, 2019, a prior authorization is required. |
| L2035 | Knee ankle foot orthosis, full plastic, static, (pediatric size), without free motion ankle, prefabricated, includes fitting and adjustment | No | ||
| L2036 | Knee ankle foot orthosis, full plastic, double upright, with or without free motion knee, with or without free motion ankle, custom fabricated | Yes | 2/Y | *Effective April 1, 2019, a prior authorization is required. |
| L2037 | Knee ankle foot orthosis, full plastic, single upright, with or without free motion knee, with or without free motion ankle, custom fabricated | Yes | 2/Y | *Effective April 1, 2019, a prior authorization is required. |
| L2038 | Knee ankle foot orthosis, full plastic, with or without free motion knee, multi- axis ankle, custom fabricated | Yes | 2/Y | *Effective April 1, 2019, a prior authorization is required. |
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| Torsion Control: Hip-Knee-Ankle-Foot Orthosis (HKAFO) | ||||
| L2040 | HKAFO, torsion control, bilateral rotation straps, pelvic band/belt, custom fabricated | No | ||
| L2050 | HKAFO, torsion control, bilateral torsion cables, hip joint, pelvic band/belt, custom fabricated | No | ||
| L2060 | HKAFO, torsion control, bilateral torsion cables, ball bearing hip joint, pelvic band/belt, custom fabricated | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
| L2070 | HKAFO, torsion control, unilateral rotation straps, pelvic band/belt, custom fabricated | No | ||
| L2080 | HKAFO, torsion control, unilateral torsion cable, hip joint, pelvic band/belt, custom fabricated | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
| L2090 | HKAFO, torsion control, unilateral torsion cable, ball bearing hip joint, pelvic band/belt, custom fabricated | No | ||
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| Fracture Orthosis (Lower Body) | ||||
| L2106 | AFO, fracture orthosis, tibial fracture cast orthosis, thermoplastic type casting material, custom fabricated | Yes | 2/Y | *Effective April 1, 2019, a prior authorization is required. |
| L2108 | AFO, fracture orthosis, tibial fracture cast orthosis, custom fabricated | Yes | 2/Y | *Effective April 1, 2019, a prior authorization is required. |
| L2112 | AFO, fracture orthosis, tibial fracture orthosis, soft, prefabricated, includes fitting and adjustment | No | ||
| L2114 | AFO, fracture orthosis, tibial fracture orthosis, semi-rigid, prefabricated, includes fitting and adjustment | No | ||
| L2116 | AFO, fracture orthosis, tibial fracture orthosis, rigid, prefabricated, includes fitting and adjustment | Yes | 2/Y | *Effective April 1, 2019, a prior authorization is required. |
| L2126 | KAFO, fracture orthosis, femoral fracture cast orthosis, thermoplastic type casting material, custom fabricated | Yes | 2/Y | *Effective April 1, 2019, a prior authorization is required. |
| L2128 | KAFO, fracture orthosis, femoral fracture cast orthosis, custom fabricated | Yes | 2/Y | *Effective April 1, 2019, a prior authorization is required. |
| L2132 | KAFO, fracture orthosis, femoral fracture cast orthosis, soft, prefabricated, includes fitting and adjustment | Yes | 2/Y | *Effective April 1, 2019, a prior authorization is required. |
| L2134 | KAFO, fracture orthosis, femoral fracture cast orthosis, semi-rigid, prefabricated, includes fitting and adjustment | Yes | 2/Y | *Effective April 1, 2019, a prior authorization is required. |
| L2136 | KAFO, fracture orthosis, femoral fracture cast orthosis, rigid, prefabricated, includes fitting and adjustment | Yes | 2/Y | *Effective April 1, 2019, a prior authorization is required. |
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| Additions to Fracture Orthosis | ||||
| L2180 | Addition to lower extremity fracture orthosis, plastic shoe insert with ankle joints | No | ||
| L2182 | Additions to lower extremity fracture orthosis, drop lock knee joint | No | ||
| L2184 | Addition to lower extremity fracture orthosis, limited motion knee joint | No | ||
| L2186 | Addition to lower extremity fracture orthosis, adjustable motion knee joint, Lerman type | No | ||
| L2188 | Addition to lower extremity fracture orthosis, quadrilateral brim | No | ||
| L2190 | Addition to lower extremity fracture orthosis, waist belt | No | ||
| L2192 | Addition to lower extremity fracture orthosis, hip joint, pelvic band, thigh flange, and pelvic belt | No | ||
| Back to Top | Back to DMEPOS Manual | |||
| Additions to Lower Extremity Orthosis: Shoe-Ankle-Shin-Knee | ||||
| L2200 | Addition to lower extremity, limited ankle motion, each joint | No | ||
| L2210 | Addition to lower extremity, dorsiflexion assist (plantar flexion resist), each joint | No | ||
| L2220 | Addition to lower extremity, dorsiflexion and plantar flexion assist/resist, each joint | No | ||
| L2230 | Addition to lower extremity, split flat caliper stirrups and plate attachment | No | ||
| L2232 | Addition to lower extremity orthosis, rocker bottom for total contact ankle foot orthosis, for custom fabricated orthosis only | No | ||
| L2240 | Addition to lower extremity, round caliper and plate attachment | No | ||
| L2250 | Addition to lower extremity, foot plate, molded to patient model, stirrup attached | No | ||
| L2260 | Addition to lower extremity, reinforced solid stirrup (Scott-Craig type) | No | ||
| L2265 | Addition lower extremity, long tongue stirrup | No | ||
| L2270 | Addition to lower extremity, varus/valgus correction ("T") strap, padded/lined or malleolus pad | No | ||
| L2275 | Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined | No | 2/D | Maximum number of items are indicated for each extremity. |
| L2280 | Addition to lower extremity, molded inner boot | No | ||
| L2300 | Addition to lower extremity, abduction bar (bilateral hip involvement), jointed, adjustable | No | ||
| L2310 | Addition to lower extremity, abduction bar, straight | No | ||
| L2320 | Addition to lower extremity, non-molded lacer, for custom fabricated orthosis only | No | ||
| L2330 | Addition to lower extremity, lacer molded to patient, for custom fabricated orthosis only | No | ||
| L2335 | Addition to lower extremity, anterior swing band | No | ||
| L2340 | Addition to lower extremity, pretibial shell, molded to patient model | No | ||
| L2350 | Addition to lower extremity, prosthetic type, (BK) socket, molded to patient model, (used for "PTB", "AFO" orthoses) | Yes | 4/Y | *Effective April 1, 2019, a prior authorization is required. |
| L2360 | Addition to lower extremity, extended steel shank | No | ||
| L2370 | Addition to lower extremity, Patten bottom | No | ||
| L2375 | Addition to lower extremity, torsion control, ankle joint and half solid stirrup | No | ||
| L2380 | Addition to lower extremity, torsion control, straight knee joint, each joint | No | ||
| L2385 | Addition to lower extremity, straight knee joint, heavy duty, each joint | No | ||
| L2387 | Addition to lower extremity, polycentric knee joint, for custom fabricated knee ankle foot orthosis, each joint | No | ||
| L2390 | Addition to lower extremity, offset knee joint, each joint | No | ||
| L2395 | Addition to lower extremity, offset knee joint, heavy duty, each joint | No | ||
| L2397 | Addition to lower extremity orthosis, suspension sleeve | No | ||
| Back to Top | Back to DMEPOS Manual | |||
| Additions to Straight Knee or Offset Knee Joints | ||||
| L2405 | Addition to knee joint, drop lock, each | No | ||
| L2415 | Addition to knee lock with integrated release mechanism (bail, cable or equal), any material, each joint | No | ||
| L2425 | Addition to knee joint, disc or dial lock for adjustable knee flexion, each joint | No | ||
| L2430 | Addition to knee joint, ratchet lock for active and progressive knee extension, each joint | No | ||
| L2492 | Addition to knee joint, lift loop for drop lock ring | No | ||
| Back to Top | Back to DMEPOS Manual | |||
| Additions: Thigh/Weight Bearing - Gluteal/Ischial Weight Bearing | ||||
| L2500 | Addition to lower extremity, thigh/weight bearing, gluteal/ischial weight bearing, ring | No | ||
| L2510 | Addition to lower extremity, thigh/weight bearing, quadri-lateral brim, molded to patient model | Yes | 4/Y | *Effective April 1, 2019, a prior authorization is required. |
| L2520 | Addition to lower extremity, thigh/weight bearing, quadri-lateral brim, custom fitted | No | ||
| L2525 | Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim molded to patient model | Yes | 4/Y | *Effective April 1, 2019, a prior authorization is required. |
| L2526 | Addition lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim, custom fitted | Yes | 4/Y | *Effective April 1, 2019, a prior authorization is required. |
| L2530 | Addition to lower extremity, thigh/weight bearing, lacer, non-molded | No | ||
| L2540 | Addition to lower extremity, thigh/weight bearing, lacer, molded to patient model | No | ||
| L2550 | Addition to lower extremity, thigh/weight bearing, high roll cuff | No | ||
| Back to Top | Back to DMEPOS Manual | |||
| Additions: Pelvic and Thoracic Control | ||||
| L2570 | Addition to lower extremity, pelvic control, hip joint, Clevis type, two (2) position joint, each | No | ||
| L2580 | Addition to lower extremity, pelvic control, pelvic sling | No | ||
| L2600 | Addition to lower extremity, pelvic control, hip joint, Clevis type, or thrust bearing, free, each | No | ||
| L2610 | Addition to lower extremity, pelvic control, hip joint, Clevis or thrust bearing, lock, each | No | ||
| L2620 | Addition to lower extremity, pelvic control, hip joint, heavy-duty, each | No | ||
| L2622 | Addition to lower extremity, pelvic control, hip joint, adjustable flexion, each | No | ||
| L2624 | Addition to lower extremity, pelvic control, hip joint, adjustable flexion, extension, abduction control, each | No | ||
| L2627 | Addition to lower extremity, pelvic control, plastic, molded to patient model, reciprocating hip joint and cables | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
| L2628 | Addition to lower extremity, pelvic control, metal frame, reciprocating hip joint and cables | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
| L2630 | Addition to lower extremity, pelvic control, band and belt, unilateral | No | ||
| L2640 | Addition to lower extremity, pelvic control, band and belt, bilateral | No | ||
| L2650 | Addition to lower extremity, pelvic and thoracic control, gluteal pad, each | No | ||
| L2660 | Addition to lower extremity, thoracic control, thoracic band | No | ||
| L2670 | Addition to lower extremity, thoracic control, paraspinal uprights | No | ||
| L2680 | Addition to lower extremity, thoracic control, lateral support uprights | No | ||
| Back to Top | Back to DMEPOS Manual | |||
| Additions: General | ||||
| E1830 | Dynamic adjustable toe extension/flexion device, includes soft interface material | No | *Code is subject to the 2019 DME UPL | |
| E1831 | Static progressive stretch toe device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories | No | *Code is subject to the 2019 DME UPL | |
| K0672 | Addition to lower extremity orthosis, removable soft interface, all components, replacement only, each | No | ||
| L2750 | Addition to lower extremity orthosis, plating chrome or nickel, per bar | No | ||
| L2755 | Addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepreg composite, per segment, for custom fabricated orthosis only | No | ||
| L2760 | Addition to lower extremity orthosis, extension, per extension, per bar (for lineal adjustment for growth) | No | ||
| L2768 | Orthotic side bar disconnect device, per bar | No | ||
| L2780 | Addition to lower extremity orthosis, non-corrosive finish, per bar | No | ||
| L2785 | Addition to lower extremity orthosis, drop lock retainer, each | No | ||
| L2795 | Addition to lower extremity orthosis, knee control, full kneecap | No | ||
| L2800 | Addition to lower extremity orthosis, knee control, kneecap, medial or lateral pull, for use with custom fabricated orthosis only | No | ||
| L2810 | Addition to lower extremity orthosis, knee control, condylar pad | No | ||
| L2820 | Addition to lower extremity orthosis, soft interface for molded plastic, below knee section | No | ||
| L2830 | Addition to lower extremity orthosis soft interface for molded plastic, above knee section | No | ||
| L2840 | Addition to lower extremity orthosis, tibial length sock, fracture or equal, each | No | ||
| L2850 | Addition to lower extremity orthosis, femoral length sock, fracture or equal, each | No | ||
| L2861 | Addition to lower extremity joint, knee or ankle, concentric adjustable torsion style mechanism for custom fabricated orthotics only, each | No | ||
| L2999 | Lower extremity orthoses, NOS | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
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Orthopedic Shoes
| Code | Description | PAR | Unit Limits | Comments |
|---|---|---|---|---|
| Inserts | ||||
| L3000 | Foot insert, removable, molded to patient model, "UCB" type, Berkeley shell, each | Yes | 4/Y | |
| L3001 | Foot insert, removable, molded to patient model, Spenco, each | Yes | 2/Y | |
| L3002 | Foot insert, removable, molded to patient model, Plastazote or equal, each | Yes | 2/Y | |
| L3003 | Foot insert, removable, molded to patient model, silicone gel, each | Yes | 2/Y | |
| L3010 | Foot insert, removable, molded to patient model, longitudinal arch support, each | Yes | 2/Y | |
| L3020 | Foot insert, removable, molded to patient model, longitudinal/metatarsal support, each | Yes | 2/Y | |
| L3030 | Foot insert, removable, formed to patient foot, each | Yes | 2/Y | |
| L3031 | Foot, insert/plate, removable, addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepreg composite, each | Yes | 2/Y | |
| L3040 | Foot, arch support, removable, pre- molded, longitudinal, each | Yes | 2/Y | |
| L3050 | Foot, arch support, removable, pre- molded, metatarsal, each | Yes | 2/Y | |
| L3060 | Foot, arch support, removable, pre- molded, longitudinal/metatarsal, each | Yes | *2/Y | *Effective April 1, 2019 |
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| Arch Support, Non-Removable and Attached to Shoe | ||||
| L3070 | Foot, arch support, non-removable, attached to shoe, longitudinal, each | Yes | *2/Y | *Effective April 1, 2019 |
| L3080 | Foot, arch support, non-removable attached to shoe, metatarsal, each | Yes | *2/Y | *Effective April 1, 2019 |
| L3090 | Foot, arch support, non-removable attached to shoe, longitudinal/metatarsal, each | Yes | *2/Y | *Effective April 1, 2019 |
| L3100 | Hallus-valgus night dynamic splint, prefabricated, off-the-shelf | Yes | *2/Y | *Effective April 1, 2019 |
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| Abduction and Rotation Bars | ||||
| L3140 | Foot, abduction rotation bar, including shoes | Yes | *2/Y | *Effective April 1, 2019 |
| L3150 | Foot, abduction rotation bar, without shoes | Yes | *2/Y | *Effective April 1, 2019 |
| L3160 | Foot, adjustable shoe-styled positioning device | Yes | *2/Y | *Effective April 1, 2019 |
| L3161 | Foot, adductus positioning device, adjustable | Yes | Code opened 01-01-2024. | |
| L3170 | Foot, plastic, silicone or equal, heel stabilizer, prefabricated, off-the-shelf, each | Yes | *2/Y | *Effective April 1, 2019 |
| Back to Top | Back to DMEPOS Manual | |||
| Orthopedic Footwear | ||||
| L3201 | Orthopedic shoe, oxford with supinator or pronator, Infant | No | ||
| L3202 | Orthopedic shoe, oxford with supinator or pronator, Child | No | ||
| L3203 | Orthopedic shoe, oxford with supinator or pronator, Junior | No | ||
| L3204 | Orthopedic shoe, high top with supinator or pronator, Infant | No | ||
| L3206 | Orthopedic shoe, high top with supinator or pronator, Child | No | ||
| L3207 | Orthopedic shoe, high top with supinator or pronator, Junior | No | ||
| L3208 | Surgical boot, each, infant | No | ||
| L3209 | Surgical boot, each, child | No | ||
| L3211 | Surgical boot, each, junior | No | ||
| L3212 | Benesch boot, pair, infant | No | ||
| L3213 | Benesch boot, pair, child | No | ||
| L3214 | Benesch boot, pair, junior | No | ||
| L3215 | Orthopedic footwear, ladies shoe, oxford, each | Yes | *2/Y | *Effective April 1, 2019 |
| L3216 | Orthopedic footwear, ladies shoe, depth inlay, each | Yes | *2/Y | *Effective April 1, 2019 |
| L3217 | Orthopedic footwear, ladies shoe, high-top, depth inlay, each | Yes | *2/Y | *Effective April 1, 2019 |
| L3219 | Orthopedic footwear, men's shoe, oxford, each | Yes | *2/Y | *Effective April 1, 2019 |
| L3221 | Orthopedic footwear, men's shoe, depth inlay, each | Yes | *2/Y | *Effective April 1, 2019 |
| L3222 | Orthopedic footwear, men's shoe, high-top, depth inlay, each | Yes | *2/Y | *Effective April 1, 2019 |
| L3224 | Orthopedic footwear woman's shoe, oxford, used as an integral part of a brace (orthosis) | Yes | *2/Y | *Effective April 1, 2019 |
| L3225 | Orthopedic footwear man's shoe, oxford, used as an integral part of a brace (orthosis) | Yes | *2/Y | *Effective April 1, 2019 |
| L3230 | Orthopedic footwear, custom shoe, depth inlay, each | Yes | *2/Y | *Effective April 1, 2019 |
| L3250 | Orthopedic footwear, custom molded shoe, removable inner mold, prosthetic shoe, each | Yes | *2/Y | *Effective April 1, 2019 |
| L3251 | Foot, shoe molded to patient model, silicone shoe, each | Yes | *2/Y | *Effective April 1, 2019 |
| L3252 | Foot, shoe molded to patient model, Plastazote (or similar), custom fabricated, each | Yes | *2/Y | *Effective April 1, 2019 |
| L3253 | Foot, molded shoe Plastozote (or similar), custom fitted, each | Yes | *2/Y | *Effective April 1, 2019 |
| L3254 | Nonstandard size or width | Yes | *2/Y | *Effective April 1, 2019 |
| L3255 | Nonstandard size or length | Yes | *2/Y | *Effective April 1, 2019 |
| L3257 | Orthopedic footwear, additional charge for split size | Yes | SEE NCCI MUE LIMIT | Updated per NCCI requirements. 1 unit per foot is allowed and must be billed with the appropriate LT/RT modifier on separate lines. |
| L3260 | Surgical boot/shoe, each | Yes | *2/Y | *Effective April 1, 2019 |
| L3265 | Plastazote sandal, each | Yes | *2/Y | *Effective April 1, 2019 |
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| Shoe Modifications - Lifts | ||||
| L3300 | Lift, elevation, heel, tapered to metatarsals, per inch | Yes | *3/Y | *Effective April 1, 2019 |
| L3310 | Lift, elevation, heel and sole, neoprene, per inch | Yes | *3/Y | *Effective April 1, 2019 |
| L3320 | Lift, elevation, heel and sole, cork, per inch | Yes | *3/Y | *Effective April 1, 2019 |
| L3330 | Lift, elevation, metal extension (skate) | Yes | *3/Y | *Effective April 1, 2019 |
| L3332 | Lift, elevation, inside shoe, tapered, up to one-half inch | Yes | *3/Y | *Effective April 1, 2019 |
| L3334 | Lift, elevation, heel, per inch | Yes | *3/Y | *Effective April 1, 2019 |
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| Shoe Modifications - Wedges | ||||
| L3340 | Heel wedge, SACH | Yes | *2/Y | *Effective April 1, 2019 |
| L3350 | Heel wedge | Yes | *2/Y | *Effective April 1, 2019 |
| L3360 | Sole wedge, outside sole | Yes | *2/Y | *Effective April 1, 2019 |
| L3370 | Sole wedge, between sole | Yes | *2/Y | *Effective April 1, 2019 |
| L3380 | Clubfoot wedge | Yes | *2/Y | *Effective April 1, 2019 |
| L3390 | Outflare wedge | Yes | *2/Y | *Effective April 1, 2019 |
| L3400 | Metatarsal bar wedge, rocker | Yes | *2/Y | *Effective April 1, 2019 |
| L3410 | Metatarsal bar wedge, between sole | Yes | *2/Y | *Effective April 1, 2019 |
| L3420 | Full sole and heel wedge, between sole | Yes | *2/Y | *Effective April 1, 2019 |
| Back to Top | Back to DMEPOS Manual | |||
| Shoe Modifications - Heels | ||||
| L3430 | Heel, counter, plastic reinforced | Yes | *2/Y | *Effective April 1, 2019 |
| L3440 | Heel, counter, leather reinforced | Yes | *2/Y | *Effective April 1, 2019 |
| L3450 | Heel, SACH cushion type | Yes | *2/Y | *Effective April 1, 2019 |
| L3455 | Heel, new leather, standard | Yes | *2/Y | *Effective April 1, 2019 |
| L3460 | Heel, new rubber, standard | Yes | *2/Y | *Effective April 1, 2019 |
| L3465 | Heel, Thomas with wedge | Yes | *2/Y | *Effective April 1, 2019 |
| L3470 | Heel, Thomas extended to ball | Yes | *2/Y | *Effective April 1, 2019 |
| L3480 | Heel, pad and depression for spur | Yes | *2/Y | *Effective April 1, 2019 |
| L3485 | Heel, pad, removable for spur | Yes | *2/Y | *Effective April 1, 2019 |
| Back to Top | Back to DMEPOS Manual | |||
| Miscellaneous Shoe Additions | ||||
| L3500 | Orthopedic shoe addition, insole, leather | Yes | *2/Y | *Effective April 1, 2019 |
| L3510 | Orthopedic shoe addition, insole, rubber | Yes | *2/Y | *Effective April 1, 2019 |
| L3520 | Orthopedic shoe addition, insole, felt covered with leather | Yes | *2/Y | *Effective April 1, 2019 |
| L3530 | Orthopedic shoe addition, sole, half | Yes | *2/Y | *Effective April 1, 2019 |
| L3540 | Orthopedic shoe addition, sole, full | Yes | *2/Y | *Effective April 1, 2019 |
| L3550 | Orthopedic shoe addition, toe tap, standard | Yes | *2/Y | *Effective April 1, 2019 |
| L3560 | Orthopedic shoe addition, toe tap, horseshoe | Yes | *2/Y | *Effective April 1, 2019 |
| L3570 | Orthopedic shoe addition, special extension to instep (leather with eyelets) | Yes | *2/Y | *Effective April 1, 2019 |
| L3580 | Orthopedic shoe addition, convert instep to Velcro closure | Yes | *2/Y | *Effective April 1, 2019 |
| L3590 | Orthopedic shoe addition, convert firm shoe counter to soft counter | Yes | *2/Y | *Effective April 1, 2019 |
| L3595 | Orthopedic shoe addition, March bar | Yes | *2/Y | *Effective April 1, 2019 |
| Back to Top | Back to DMEPOS Manual | |||
| Transfer or Replacement | ||||
| L3600 | Transfer of an orthosis from one (1) shoe to another, caliper plate, existing | Yes | *2/Y | *Effective April 1, 2019 |
| L3610 | Transfer of an orthosis from one (1) shoe to another, caliper plate, new | Yes | *2/Y | *Effective April 1, 2019 |
| L3620 | Transfer of an orthosis from one (1) shoe to another, solid stirrup, existing | Yes | *2/Y | *Effective April 1, 2019 |
| L3630 | Transfer of an orthosis from one (1) shoe to another, solid stirrup, new | Yes | *2/Y | *Effective April 1, 2019 |
| L3640 | Transfer of an orthosis from one (1) shoe to another, Dennis Browne splint (Riveton), both shoes | Yes | *1/Y | *Effective April 1, 2019 |
| L3649 | Orthopedic shoe, modification, additional or transfer, NOS | Yes | *1/Y | *Effective April 1, 2019 |
| Back to Top | Back to DMEPOS Manual | |||
Orthotic Devices - Upper Limbs
| Code | Description | PAR | Unit Limits | Comments |
|---|---|---|---|---|
| Shoulder Orthosis (SO) | ||||
| L3650 | SO, figure of eight design abduction re- strainer, prefabricated, off-the-shelf | No | ||
| L3660 | SO, figure of eight design abduction restrainer, canvas and webbing, prefabricated, off-the-shelf | No | ||
| L3670 | SO, acromi/clavicular (canvas and webbing type), prefabricated, off-the- shelf | No | ||
| L3671 | Shoulder orthosis, shoulder joint design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment | Yes | *2/Y | *Effective April 1, 2019, a prior authorization is required. |
| L3674 | SO, abduction positioning (airplane design), thoracic component and support bar, with or without nontorsion joint/turnbuckle, may include soft interface, straps, custom fabricated, includes fitting and adjustment | No | ||
| L3675 | SO, vest type abduction restrainer, canvas webbing type or equal, prefabricated, off-the-shelf | No | ||
| L3677 | SO, shoulder joint design, without joints, may include soft interface, straps, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise | No | ||
| L3678 | Shoulder orthosis, shoulder joint design, without joints, may include soft interface, straps, prefabricated, off-the- shelf | No | ||
| Back to Top | Back to DMEPOS Manual | |||
| Elbow Orthosis (EO) | ||||
| E1800 | Dynamic adjustable elbow extension/flexion device, includes soft interface material | No | *Code is subject to the 2019 DME UPL | |
| E1801 | Static progressive stretch elbow device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories | Yes | 1/Y | *Code is subject to the 2019 DME UPL *Effective April 1, 2019, a prior authorization is required. |
| E1802 | Dynamic adjustable forearm pronation/supination device, includes soft interface material | Yes | 1/Y | *Code is subject to the 2019 DME UPL |
| E1818 | Static progressive stretch forearm pronation/supination device with or without range of motion adjustment, includes all components and accessories | Yes | 1/Y | *Code is subject to the 2019 DME UPL |
| L3702 | Elbow orthosis, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment | No | ||
| L3710 | EO, elastic with metal joints, prefabricated, off-the-shelf | No | ||
| L3720 | EO, double upright with forearm/arm cuffs, free motion custom fabricated | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
| L3730 | EO, double upright with forearm/arm cuffs, extension/flexion assist, custom fabricated | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
| L3740 | EO, double upright with forearm/arm cuffs, adjustable position lock with active control, custom fabricated | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
| L3760 | EO, with adjustable position locking joint(s), prefabricated, item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise | No | ||
| L3761 | EO, with adjustable position locking joint(s), prefabricated, off-the-shelf | No | New code effective 01/01/2018 | |
| L3762 | EO, rigid, without joints, includes soft interface material, prefabricated, off-the- shelf | No | ||
| Back to Top | Back to DMEPOS Manual | |||
| Wrist-Hand Orthosis | ||||
| L3916 | Wrist hand orthosis, includes one or more nontorsion joint(s), elastic bands, turnbuckles, may include soft interface, straps, prefabricated, off-the-shelf | No | ||
| Back to Top | Back to DMEPOS Manual | |||
| Elbow-Wrist-Hand Orthosis | ||||
| L3763 | Elbow wrist hand orthosis, rigid, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment | Yes | 2/Y | *Effective April 1, 2019, a prior authorization is required. |
| L3764 | Elbow wrist hand orthosis, includes one (1) or more non-torsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment | Yes | 2/Y | *Effective April 1, 2019, a prior authorization is required. |
| Back to Top | Back to DMEPOS Manual | |||
| Elbow-Wrist-Hand-Finger Orthosis | ||||
| L3765 | Elbow wrist hand finger orthosis, rigid, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment | Yes | 2/Y | *Effective April 1, 2019, a prior authorization is required. |
| L3766 | Elbow wrist hand finger orthosis, includes one (1) or more non-torsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment | Yes | 2/Y | *Effective April 1, 2019, a prior authorization is required. |
| Back to Top | Back to DMEPOS Manual | |||
| Wrist-Hand-Finger Orthosis (WHFO) | ||||
| L3806 | WHFO, includes one (1) or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, custom fabricated, includes fitting and adjustment | No | ||
| L3807 | WHFO, without joint(s), prefabricated, item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise | No | ||
| L3808 | WHFO, rigid without joints, may include soft interface material, straps, custom fabricated, includes fitting and adjustment | No | ||
| L3809 | Wrist hand finger orthosis, without joint(s), prefabricated, off-the-shelf, any type | No | ||
| Back to Top | Back to DMEPOS Manual | |||
| Additions - General | ||||
| L3891 | Addition to upper extremity joint, wrist or elbow, concentric adjustable torsion style mechanism for custom fabricated orthotics only, each | No | ||
| Back to Top | Back to DMEPOS Manual | |||
| Dynamic Flexor Hinge, Reciprocal Wrist Extension/Flexion, Finger Flexion/Extension | ||||
| E1805 | Dynamic adjustable wrist extension/flexion device, includes soft interface material | No | *Code is subject to the 2019 DME UPL | |
| E1806 | Static progressive stretch wrist device, flexion and/or extension, with or without range of motion adjustment, includes all components and accessories | Yes | 1/Y | *Code is subject to the 2019 DME UPL |
| E1825 | Dynamic adjustable finger extension/flexion device, includes soft interface material | Yes | 1/Y | *Code is subject to the 2019 DME UPL |
| L3900 | WHFO, dynamic flexor hinge, reciprocal wrist extension/flexion, finger flexion/extension, wrist or finger driven, custom fabricated | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
| L3901 | WHFO, dynamic flexor hinge, reciprocal wrist extension/flexion, finger flexion/extension, cable driven, custom fabricated | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
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| External Power | ||||
| L3904 | WHFO, external powered, electric, custom fabricated | No | ||
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| Other WHFOs - Custom Fitted | ||||
| L3905 | Wrist hand orthosis, includes one (1) or more non-torsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment | No | ||
| L3906 | Wrist hand orthosis, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment | No | ||
| L3908 | WHO, wrist extension control cock-up, non-molded, prefabricated, off-the-shelf | No | ||
| L3912 | HFO, flexion glove with elastic finger control, prefabricated, off-the-shelf | No | ||
| L3913 | Hand finger orthosis, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment | No | ||
| L3915 | WHFO, includes one (1) or more nontorsion joint(s), elastic bands, turnbuckles, may include soft interface, straps, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise | No | ||
| L3917 | Hand orthosis, metacarpal fracture orthosis, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise | No | ||
| L3918 | Hand orthosis, metacarpal fracture orthosis, prefabricated, off-the-shelf | No | ||
| L3919 | Hand orthosis, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment | No | ||
| L3921 | Hand finger orthosis, includes one (1) or more non-torsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment | No | ||
| L3923 | Hand finger orthosis, without joints, may include soft interface, straps, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise | No | ||
| L3924 | Hand finger orthosis, without joints, may include soft interface, straps, prefabricated, off-the-shelf | No | ||
| L3925 | FO, proximal interphalangeal (PIP)/distal interphalangeal (DIP), non-torsion joint/spring, extension/flexion, may include soft interface material, prefabricated, off-the-shelf | No | ||
| L3927 | FO, proximal interphalangeal (PIP)/distal interphalangeal (DIP), without joint/spring, extension/flexion (e.g., static or ring type), may include soft interface material, prefabricated, off-the-shelf | No | ||
| L3929 | HFO, includes one (1) or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise | No | ||
| L3930 | Hand finger orthosis, includes one (1) or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, prefabricated, off-the-shelf | No | ||
| L3931 | WHFO, includes one (1) or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, prefabricated, includes fitting and adjustment | No | ||
| L3933 | Finger orthosis, without joints, may include soft interface, custom fabricated, includes fitting and adjustment | No | ||
| L3935 | Finger orthosis, non-torsion joint, may include soft interface, custom fabricated, includes fitting and adjustment | No | ||
| L3956 | Addition of joint to upper extremity orthosis, any material, per joint | No | ||
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| Shoulder-Elbow-Wrist-Hand Orthosis (SEWHO) | ||||
| L3960 | SEWHO, abduction positioning, airplane design prefabricated, includes fitting and adjustment | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
| L3961 | Shoulder elbow wrist hand orthosis, shoulder cap design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
| L3962 | SEWHO, abduction positioning, Erb palsy design, prefabricated, includes fitting and adjustment | No | ||
| L3967 | Shoulder elbow wrist hand orthosis, abduction positioning (airplane design), thoracic component and support bar, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
| L3971 | Shoulder elbow wrist hand orthosis, shoulder cap design, includes one (1) or more non-torsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
| L3973 | Shoulder elbow wrist hand orthosis, abduction positioning (airplane design), thoracic component and support bar, includes one (1) or more non-torsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
| L3975 | Shoulder elbow wrist hand finger orthosis, shoulder cap design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
| L3976 | 121BShoulder elbow wrist hand finger orthosis, abduction positioning (airplane design), thoracic component and support bar, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
| L3977 | Shoulder elbow wrist hand finger orthosis, shoulder cap design, includes one (1) or more non-torsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
| L3978 | 131BShoulder elbow wrist hand finger orthosis, abduction positioning (airplane design), thoracic component and support bar, includes one (1) or more non-torsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
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| Fracture Orthosis (Upper Extremity) | ||||
| L3980 | Upper extremity fracture orthosis, humeral, prefabricated, includes fitting and adjustment | No | ||
| L3981 | Upper extremity fracture orthosis, humeral, prefabricated, includes shoulder cap design, with or without joints, forearm section, may include soft interface, straps, includes fitting and adjustments | No | ||
| L3982 | Upper extremity fracture orthosis, radius/ulna, prefabricated, includes fitting and adjustment | No | ||
| L3984 | Upper extremity fracture orthosis, wrist, prefabricated, includes fitting and adjustment | No | ||
| L3995 | Addition to upper extremity orthosis, sock, fracture or equal, each | No | ||
| L3999 | Upper limb orthosis, NOS | Yes | 2/Y | *Effective April 1, 2019, a prior authorization is required. |
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| Specific Repairs | ||||
| E1820 | Replacement soft interface material, dynamic adjustable extension/flexion device | No | *Code is subject to the 2019 DME UPL | |
| E1821 | Replacement soft interface material/cuffs for bi-directional static progressive stretch device | No | *Code is subject to the 2019 DME UPL | |
| L4000 | Replace girdle for spinal orthosis (CTLSO or SO) | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
| L4002 | Replacement strap, any orthosis, includes all components, any length, any type | Yes | 2/Y | *Effective April 1, 2019, a prior authorization is required. |
| L4010 | Replace trilateral socket brim | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
| L4020 | Replace quadrilateral socket brim, molded to patient model | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
| L4030 | Replace quadrilateral socket brim, custom fitted | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
| L4040 | Replace molded thigh lacer, for custom fabricated orthosis only | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
| L4045 | Replace non-molded thigh lacer, for custom fabricated orthosis only | No | ||
| L4050 | Replace molded calf lacer, for custom fabricated orthosis only | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
| L4055 | Replace non-molded calf lacer, for custom fabricated orthosis only | No | ||
| L4060 | Replace high roll cuff | No | ||
| L4070 | Replace proximal and distal upright for KAFO | No | ||
| L4080 | Replace metal bands KAFO, proximal thigh | No | ||
| L4090 | Replace metal bands KAFO-AFO, calf or distal thigh | No | ||
| L4100 | Replace leather cuff KAFO, proximal thigh | No | ||
| L4110 | Replace leather cuff KAFO-AFO, calf or distal thigh | No | ||
| L4130 | Replace pretibial shell | No | ||
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| Repairs | ||||
| L4205 | Repair of orthotic device, labor component, per 15 minutes | No | ||
| L4210 | Repair of orthotic device, repair or replace minor parts | No | ||
| L4350 | Ankle control orthosis, stirrup style, rigid, includes any type interface (e.g., pneumatic, gel), prefabricated, off-the- shelf | No | ||
| L4360 | Walking boot, pneumatic and/or vacuum, with or without joints, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise | No | ||
| L4361 | Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated, off-the-shelf | Yes | 2/Y | *Effective April 1, 2019, prior authorization is required. |
| L4370 | Pneumatic full leg splint, prefabricated, off-the-shelf | No | ||
| L4386 | Walking boot, non-pneumatic, with or without joints, with or without interface material, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise | No | ||
| L4387 | Walking boot, non-pneumatic, with or without joints, with or without interface material, prefabricated, off-the-shelf | No | ||
| L4392 | Replacement soft interface material, static AFO | No | ||
| L4394 | Replace soft interface material, foot drop splint | No | ||
| L4396 | Static or dynamic ankle foot orthosis, including soft interface material, adjustable for fit, for positioning, may be used for minimal ambulation, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise | No | ||
| L4398 | Foot drop splint recumbent positioning device, prefabricated, off-the-shelf | No | ||
| L4631 | Ankle foot orthosis, walking boot type, varus/valgus correction, rocker bottom, anterior tibial shell, soft interface, custom arch support, plastic or other material, includes straps and closures, custom fabricated | Yes | 1/Y | *Effective April 1, 2019, a prior authorization is required. |
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Prosthetic Procedures L5000-L9999
| Code | Description | PAR | Unit Limits | Comments |
|---|---|---|---|---|
| Lower Limb | ||||
| Partial Foot | ||||
| L5000 | Partial foot, shoe insert with longitudinal arch, toe filler | No | ||
| L5010 | Partial foot, molded socket, ankle height, with toe filler | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5020 | Partial foot, molded socket, tibial tubercle height, with toe filler | Yes | 2/5Y | One (1) molded partial per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
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| Ankle | ||||
| L5050 | Ankle, Symes, molded socket, SACH foot | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5060 | Ankle, Symes, metal frame, molded leather socket, articulated ankle/foot | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
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| Below Knee | ||||
| L5100 | Below knee, molded socket, shin, SACH foot | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5105 | Below knee, plastic socket, joints and thigh lacer, SACH foot | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
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| Knee Disarticulation | ||||
| L5150 | Knee disarticulation (or through knee), molded socket, external knee joints, shin, SACH foot | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5160 | Knee disarticulation (or through knee), molded socket, bent knee configuration, external knee joints, shin, SACH foot | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
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| Above Knee | ||||
| L5200 | Above knee, molded socket, single axis constant friction knee, shin, SACH foot | Yes | 2/5Y | One (1) per right and left side, every five (5) years. Effective April 1, 2019, a prior authorization is required. |
| L5210 | Above knee, short prosthesis, no knee joint ("stubbies"), with foot blocks, no ankle joints, each | Yes | 2/5Y | One (1) per right and left side, every five (5) years. Effective April 1, 2019, a prior authorization is required. |
| L5220 | Above knee, short prosthesis, no knee joint (stubbies), with articulated ankle/foot, dynamically aligned, each | Yes | 2/5Y | One (1) per right and left side, every five (5) years. Effective April 1, 2019, a prior authorization is required. |
| L5230 | Above knee, for proximal femoral focal deficiency, constant friction knee, shin, SACH foot | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
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| Hip Disarticulation | ||||
| L5250 | Hip disarticulation, Canadian type, molded socket, hip joint, single axis constant friction knee, shin, SACH foot | Yes | 2/5Y | One (1) per right and left side, every five (5) years. Effective April 1, 2019, a prior authorization is required. |
| L5270 | Hip disarticulation, tilt table type, molded socket, locking hip joint, single axis constant friction knee, shin SACH foot | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
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| Hemipelvectomy | ||||
| L5280 | Hemipelvectomy, Canadian type, molded socket, hip joint, single axis constant friction knee, shin, SACH foot | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5301 | Below knee, molded socket, shin, SACH foot, endoskeletal system | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5312 | Knee disarticulation (or through knee), molded socket, single axis knee, pylon, SACH foot, endoskeletal system | Yes | 2/5Y | *Effective April 1, 2019 |
| L5321 | Above knee, molded socket, open end, SACH foot, endoskeletal system, single axis knee | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5331 | Hip disarticulation, Canadian type, molded socket, endoskeletal system, hip joint, single axis knee, SACH foot | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5341 | Hemipelvectomy, Canadian type, molded socket, endoskeletal system, hip joint, single axis knee, SACH foot | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
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| Immediate Post-Surgical or Early Fitting Procedures | ||||
| L5400 | Immediate post-surgical or early fitting, application of initial rigid dressing, including fitting, alignment, suspension, and one (1) cast change, below knee | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5410 | Immediate post-surgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension, blow knee, each additional cast change and realignment | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5420 | Immediate post-surgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension and one (1) cast change "AK" or knee disarticulation | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5430 | Immediate post-surgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension, "AK" or knee disarticulation, each additional cast change and realignment | No | ||
| L5450 | Immediate post-surgical or early fitting, application of non-weight-bearing rigid dressing, below knee | No | ||
| L5460 | Immediate post-surgical or early fitting, application of non-weight-bearing rigid dressing, above knee | No | ||
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| Initial Prosthesis | ||||
| L5500 | Initial, below knee "PTB" type socket, non-alignable system, pylon, no cover, Sach foot, plaster socket, direct formed | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5505 | Initial, above knee - knee disarticulation, ischial level socket, non- alignable system, pylon, no cover, sach foot plaster socket, direct formed | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
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| Preparatory Prosthesis | ||||
| L5510 | Preparatory, below knee "PTB" type socket, non-alignable system, pylon, no cover, SACH foot, plaster socket, molded to model | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5520 | Preparatory, below knee "PTB" type socket, non-alignable system, pylon, no cover, SACH foot, thermoplastic or equal, direct formed | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5530 | Preparatory, below knee "PTB" type socket, non-alignable system, pylon, no cover, SACH foot, thermoplastic or equal, molded to model | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5535 | Preparatory, below knee "PTB" type socket, non-alignable system, pylon, no cover, SACH foot, prefabricated, adjustable open-end socket | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5540 | Preparatory, below knee "PTB" type socket, non-alignable system, pylon, no cover, sach foot, laminated socket, molded to model | No | ||
| L5560 | Preparatory, above knee-knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, SACH foot, plaster socket, molded to model | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5570 | Preparatory, above knee-knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, SACH foot, thermoplastic or equal, direct formed | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5580 | Preparatory, above knee-knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, SACH foot, thermoplastic or equal, molded to model | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5585 | Preparatory, above knee - knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, SACH foot, prefabricated adjustable open-end socket | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5590 | Preparatory, above knee-knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, SACH foot, laminated socket, molded to model | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5595 | Preparatory, hip disarticulation - hemipelvectomy, pylon, no cover, sach foot, thermoplastic or equal, molded to patient model | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5600 | Preparatory, hip disarticulation - hemipelvectomy, pylon, no cover, SACH foot, laminated socket, molded to patient model | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
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| Additions: Lower Extremity | ||||
| L5610 | Addition to lower extremity, endoskeletal system, above knee, hydracadence system | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5611 | Addition to lower extremity, endoskeletal system, above knee - knee disarticulation, 4-bar linkage, with friction swing phase control | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5613 | Addition to lower extremity, endoskeletal system, above knee - knee disarticulation, 4-bar linkage, with hydraulic swing phase control | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5614 | Addition to lower extremity, endoskeletal system, above knee - knee disarticulation, 4-bar linkage, with pneumatic swing phase control | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5615 | Addition, endoskeletal knee-shin system, 4 bar linkage or multiaxial, fluid swing and stance phase control | Yes | Code opened 01-01-2024. | |
| L5616 | Addition to lower extremity, endoskeletal system, above knee, universal multiplex system, friction swing phase control | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5617 | Addition to lower extremity, quick change self-aligning unit, above or below knee, each | No | ||
| K1014 | Addition, endoskeletal knee-shin system, 4 bar linkage or multiaxial, fluid swing and stance phase control | Yes | 2/5Y | One (1) per right and left side, every five (5) years. |
| Back to Top | Back to DMEPOS Manual | |||
| Additions: Test Sockets | ||||
| L5618 | Addition to lower extremity, test socket, Symes | No | ||
| L5620 | Addition to lower extremity, test socket, below knee | No | ||
| L5622 | Addition to lower extremity, test socket, knee disarticulation | No | ||
| L5624 | Addition to lower extremity, test socket, above knee | No | ||
| L5626 | Addition to lower extremity, test socket, hip disarticulation | No | ||
| L5628 | Addition to lower extremity, test socket, hemipelvectomy | No | ||
| L5629 | Addition to lower extremity, below knee, acrylic socket | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| Back to Top | Back to DMEPOS Manual | |||
| Additions: Socket Variations | ||||
| L5630 | Addition to lower extremity, Symes type, expandable wall socket | No | ||
| L5631 | Addition to lower extremity, above knee or knee disarticulation, acrylic socket | No | ||
| L5632 | Addition to lower extremity, Symes type, "PTB" brim design socket | No | ||
| L5634 | Addition to lower extremity, Symes type, posterior opening (Canadian) socket | No | ||
| L5636 | Addition to lower extremity, Symes type, medial opening socket | No | ||
| L5637 | Addition to lower extremity, below knee, total contact | No | ||
| L5638 | Addition to lower extremity, below knee, leather socket | No | ||
| L5639 | Addition to lower extremity, below knee, wood socket | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5640 | Addition to lower extremity, knee disarticulation, leather socket | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5642 | Addition to lower extremity, above knee, leather socket | No | ||
| L5643 | Addition to lower extremity, hip disarticulation, flexible inner socket, external frame | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5644 | Addition to lower extremity, above knee, wood socket | No | ||
| L5645 | Addition to lower extremity, below knee, flexible inner socket, external frame | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5646 | Addition to lower extremity, below knee, air, fluid, gel or equal, cushion socket | No | ||
| L5647 | Addition to lower extremity, below knee, suction socket | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5648 | Addition to lower extremity, above knee, air, fluid, gel or equal, cushion socket | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5649 | Addition to lower extremity, ischial containment/narrow M-L socket | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5650 | Addition to lower extremity, total contact, above knee or knee disarticulation socket | No | ||
| L5651 | Addition to lower extremity, above knee, flexible inner socket, external frame | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5652 | Addition to lower extremity, suction suspension, above knee or knee disarticulation socket | No | ||
| L5653 | Addition to lower extremity, knee disarticulation, expandable wall socket | No | ||
| L5654 | Addition to lower extremity, socket insert, Symes (Kemblo, Pelite, Aliplast, Plastazote or equal) | No | ||
| L5655 | Addition to lower extremity, socket insert, below knee (Kemblo, Pelite, Aliplast, Plastazote or equal) | No | ||
| L5656 | Addition to lower extremity, socket insert, knee disarticulation (Kemblo, Pelite, Aliplast, Plastazote or equal) | No | ||
| L5658 | Addition to lower extremity, socket insert, above knee (Kemblo, Pelite, Aliplast, Plastazote or equal) | No | ||
| L5661 | Addition to lower extremity, socket insert, multidurometer, Symes | No | ||
| L5665 | Addition to lower extremity, socket insert, multidurometer, below knee | No | ||
| L5666 | Addition to lower extremity, below knee, cuff suspension | No | ||
| L5668 | Addition to lower extremity, below knee, molded distal cushion | No | ||
| L5670 | Addition to lower extremity, below knee, molded supracondylar suspension ("PTS" or similar) | No | ||
| L5671 | Addition to lower extremity, below knee/above knee suspension locking mechanism (shuttle, lanyard or equal), excludes socket insert | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5672 | Addition to lower extremity, below knee, removable medial brim suspension | No | ||
| L5673 | Addition to lower extremity, below knee/above knee, custom fabricated from existing mold or elastomeric or equal, for use with locking mechanism | Yes | 4/Y | Two (2) per right and left side, every 12 months. *Effective April 1, 2019, a prior authorization is required. |
| L5676 | Addition to lower extremity, below knee, knee joints single axis, pair | No | ||
| L5677 | Addition to lower extremity, below knee, knee joints, polycentric, pair | No | ||
| L5678 | Addition to lower extremity, below knee joint covers, pair | No | ||
| 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 | Yes | 4/Y | Two (2) per right and left side, every 12 months. *Effective April 1, 2019, a prior authorization is required. |
| L5680 | Addition to lower extremity, below knee, thigh lacer, non-molded | No | ||
| 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 code L5673 or L5679) | Yes | 4/Y | Two (2) per right and left side, every 12 months. *Effective April 1, 2019, a prior authorization is required. |
| L5682 | Addition to lower extremity, below knee, thigh lacer, gluteal/ischial, molded | Yes | 2/Y | One (1) per right and left side, every 12 months. *Effective April 1, 2019, a prior authorization is required. |
| 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 code L5673 or L5679) | Yes | 4/Y | Two (2) per right and left side, every 12 months. *Effective April 1, 2019, a prior authorization is required. |
| L5684 | Addition to lower extremity, below knee, fork strap | No | ||
| L5685 | Addition to lower extremity prosthesis, below knee, suspension/sealing sleeve, with or without valve, any material, each | No | ||
| L5686 | Addition to lower extremity, below knee, back check (extension control) | No | ||
| L5688 | Addition to lower extremity, below knee, waist belt, webbing | No | ||
| L5690 | Addition to lower extremity, below knee, waist belt, padded and lined | No | ||
| L5692 | Addition to lower extremity, above knee, pelvic control belt, light | No | ||
| L5694 | Addition to lower extremity, above knee, pelvic control belt, padded and lined | No | ||
| L5695 | Addition to lower extremity, above knee, pelvic control, sleeve suspension, neoprene or equal, each | No | ||
| L5696 | Addition to lower extremity, above knee or knee disarticulation, pelvic joint | No | ||
| L5697 | Addition to lower extremity, above knee or knee disarticulation, pelvic band | No | ||
| L5698 | Addition to lower extremity, above knee or knee disarticulation, Silesian bandage | No | ||
| L5699 | All lower extremity prostheses, shoulder harness | No | ||
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| Replacements | ||||
| L5700 | Replacement, socket, below knee, molded to patient model | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5701 | Replacement, socket, above knee/knee disarticulation, including attachment plate, molded to patient model | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5702 | Replacement, socket, hip disarticulation, including hip joint, molded to patient model | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5703 | Ankle, Symes, molded to patient model, socket without solid ankle cushion heel (SACH) foot, replacement only | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5704 | Custom shaped protective cover, below knee | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5705 | Custom shaped protective cover, above knee | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5706 | Custom shaped protective cover, knee disarticulation | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5707 | Custom shaped protective cover, hip disarticulation | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
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| Additions: Exoskeletal Knee-Shin System | ||||
| L5710 | Addition, exoskeletal knee-shin system, single axis, manual lock | No | ||
| L5711 | Addition, exoskeletal knee-shin system, single axis, manual lock, ultra-light material | No | ||
| L5712 | Addition, exoskeletal knee-shin system, single axis, friction swing and stance phase control (safety knee) | No | ||
| L5714 | Addition, exoskeletal knee-shin system, single axis, variable friction swing phase control | No | ||
| L5716 | Addition, exoskeletal knee-shin system, polycentric, mechanical stance phase lock | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5718 | Addition, exoskeletal knee-shin system, polycentric, friction swing and stance phase control | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5722 | Addition, exoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase control | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5724 | Addition, exoskeletal knee-shin system, single axis, fluid swing phase control | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5726 | Addition, exoskeletal knee-shin system, single axis, external joints, fluid swing phase control | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5728 | Addition, exoskeletal knee-shin system, single axis, fluid swing and stance phase control | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5780 | Addition, exoskeletal knee-shin system, single axis, pneumatic/hydra pneumatic swing phase control | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5781 | Addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5782 | Addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system, heavy duty | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5783 | Addition to lower extremity, user adjustable, mechanical, residual limb volume management system | Yes | Code opened 04-01-2024. | |
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| Component Modification | ||||
| L5785 | Addition, exoskeletal system, below knee, ultra-light material (titanium, carbon fiber or equal) | No | ||
| L5790 | Addition, exoskeletal system, above knee, ultra-light material (titanium, carbon fiber or equal) | No | ||
| L5795 | Addition, exoskeletal system, hip disarticulation, ultra-light material (titanium, carbon fiber or equal) | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| Back to Top | Back to DMEPOS Manual | |||
| Additions: Endoskeletal Knee-Shin System | ||||
| L5810 | Addition, endoskeletal knee-shin system, single axis, manual lock | No | ||
| L5811 | Addition, endoskeletal knee-shin system, single axis, manual lock, ultra-light material | No | ||
| L5812 | Addition, endoskeletal knee-shin system, single axis, friction swing and stance phase control (safety knee) | No | ||
| L5814 | Addition, endoskeletal knee-shin system, polycentric, hydraulic swing phase control, mechanical stance phase lock | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5816 | Addition, endoskeletal knee-shin system, polycentric, mechanical stance phase lock | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5818 | Addition, endoskeletal knee-shin system, polycentric, friction swing and stance phase control | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5822 | Addition, endoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase control | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5824 | Addition, endoskeletal knee-shin system, single axis, fluid swing phase control | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5826 | Addition, endoskeletal knee-shin system, single axis, hydraulic swing phase control, with miniature high activity frame | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5828 | Addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5830 | Addition, endoskeletal knee-shin system, single axis, pneumatic/swing phase control | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5840 | Addition, endoskeletal knee-shin system, 4-bar linkage or multiaxial, pneumatic swing phase control | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5841 | Addition, endoskeletal knee-shin system, polycentric, pneumatic swing, and stance phase control | Yes | Code opened 04-01-2024. | |
| L5845 | Addition, endoskeletal knee-shin system, stance flexion feature, adjustable | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5848 | Addition to endoskeletal, knee-shin system, fluid stance extension, dampening feature, with or without adjustability | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5850 | Addition, endoskeletal system, above knee or hip disarticulation, knee extension assist | No | ||
| L5855 | Addition, endoskeletal system, hip disarticulation, mechanical hip extension assist | No | ||
| L5856 | Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5857 | Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing phase only, includes electronic sensor(s), any type | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5858 | Addition to lower extremity prosthesis, endoskeletal knee shin system, microprocessor control feature, stance phase only, includes electronic sensor(s), any type | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5910 | Addition, endoskeletal system, below knee, alignable system | No | ||
| L5920 | Addition, endoskeletal system, above knee or hip disarticulation, alignable system | No | ||
| L5925 | Addition, endoskeletal system, above knee, knee disarticulation or hip disarticulation, manual lock | No | Code opened 01-01-2024. | |
| L5926 | Addition to lower extremity prosthesis, endoskeletal, knee disarticulation, above knee, hi disarticulation, positional rotation unit, any type | Yes | ||
| L5930 | Addition, endoskeletal system, high activity knee control frame | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5940 | Addition, endoskeletal system, below knee, ultra-light material (titanium, carbon fiber or equal) | No | ||
| L5950 | Addition, endoskeletal system, above knee, ultra-light material (titanium, carbon fiber or equal) | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5960 | Addition, endoskeletal system, hip disarticulation, ultra-light material (titanium, carbon fiber or equal) | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5961 | Addition, endoskeletal system, polycentric hip joint, pneumatic or hydraulic control, rotation control, with or without flexion and/or extension control | Yes | 2/5Y | *Effective April 1, 2019, a prior authorization is required. |
| L5962 | Addition, endoskeletal system, below knee, flexible protective outer surface covering system | No | ||
| L5964 | Addition, endoskeletal system, above knee, flexible protective outer surface covering system | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5966 | Addition, endoskeletal system, hip disarticulation, flexible protective outer surface covering system | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5968 | Addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5970 | All lower extremity prostheses, foot, external keel, SACH foot | No | ||
| L5971 | All lower extremity prosthesis, solid ankle cushion hell (SACH) foot, replacement only | No | ||
| L5972 | All lower extremity prostheses, foot, flexible keel | No | ||
| L5973 | Endoskeletal ankle foot system, microprocessor-controlled feature, dorsiflexion and/or plantar flexion control, includes power source | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5974 | All lower extremity prostheses, foot, single axis ankle/foot | No | ||
| L5975 | All lower extremity prosthesis, foot, combination single axis ankle and flexible keel foot | No | ||
| L5976 | All lower extremity prostheses, energy storing foot (Seattle Carbon Copy II or equal) | No | ||
| L5978 | All lower extremity prostheses, foot, multi-axial ankle/foot | No | ||
| L5979 | All lower extremity prostheses, multi- axial ankle, dynamic response foot, one (1) piece system | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5980 | All lower extremity prostheses, flex-foot system | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5981 | All lower extremity prostheses, flex-walk system or equal | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5982 | All exoskeletal lower extremity prostheses, axial rotation unit | No | ||
| L5984 | All endoskeletal lower extremity prostheses, axial rotation unit, with or without adjustability | No | ||
| L5985 | All endoskeletal lower extremity prostheses, dynamic prosthetic pylon | No | ||
| L5986 | All lower extremity prostheses, multi- axial rotation unit ("MCP" or equal) | No | ||
| L5987 | All lower extremity prostheses, shank foot system with vertical loading pylon | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5988 | Addition to lower limb prosthesis, vertical shock reducing pylon feature | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5990 | Addition to lower extremity prosthesis, user adjustable heel height | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L5999 | Lower extremity prosthesis not otherwise specified | No | Per CMS guidelines, real time gait assessment and other tasks shall not be billed under L5999. | |
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Upper Limb
The procedures in L6000-L6599 are considered as "base" or "basic procedures" and may be modified by listing procedures from the "addition" sections. The base procedures include only standard friction wrist and control cable system unless otherwise specified.
| Code | Description | PAR | Unit Limits | Comments |
|---|---|---|---|---|
| Partial Hand | ||||
| L6000 | Partial hand, thumb remaining | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L6010 | Partial hand, little and/or ring finger remaining | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L6020 | Partial hand, no finger remaining | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L6026 | Transcarpal/metacarpal or partial hand disarticulation prosthesis, external power, self-suspended, inner socket with removable forearm section, electrodes and cables, two batteries, charger, myoelectric control of terminal device, excludes terminal device(s) | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
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| Wrist Disarticulation | ||||
| L6050 | Wrist disarticulation, molded socket, flexible elbow hinges, triceps pad | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L6055 | Wrist disarticulation molded socket with expandable interface, flexible elbow hinges, triceps pad | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
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| Below Elbow | ||||
| L6100 | Below elbow, molded socket, flexible elbow hinge, triceps pad | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L6110 | Below elbow, molded socket, (Muenster or Northwestern suspension types) | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L6120 | Below elbow, molded double wall split socket, step-up hinges, half cuff | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L6130 | Below elbow, molded double wall split socket, stump activated locking hinge, half cuff | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
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| Elbow Disarticulation | ||||
| L6200 | Elbow disarticulation, molded socket, outside locking hinge, forearm | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L6205 | Elbow disarticulation, molded socket with expandable interface, outside locking hinges, forearm | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
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| Above Elbow | ||||
| E1840 | Dynamic adjustable shoulder flexion/abduction/rotation device, includes soft interface material | Yes | 2/Y | *Code is subject to the 2019 DME UPL |
| L6250 | Above elbow molded double wall socket, internal locking elbow, forearm | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
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| Shoulder Disarticulation | ||||
| L6300 | Shoulder disarticulation, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearm | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L6310 | Shoulder disarticulation, passive restoration (complete prosthesis) | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L6320 | Shoulder disarticulation, passive restoration (shoulder cap only) | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
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| Interscapular Thoracic | ||||
| L6350 | Interscapular thoracic, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearm | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L6360 | Interscapular thoracic, passive restoration (complete prosthesis) | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L6370 | Interscapular thoracic, passive restoration (shoulder cap only) | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
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| Immediate and Early Post-Surgical Procedures | ||||
| L6380 | Immediate post-surgical or early fitting, application of initial rigid dressing, including fitting alignment and suspension of components, and one (1) cast change, wrist disarticulation or below elbow | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L6382 | Immediate post-surgical or early fitting, application of initial rigid dressing including fitting alignment and suspension of components, and one (1) cast change, elbow disarticulation or above elbow | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L6384 | Immediate post-surgical or early fitting, application of initial rigid dressing including fitting, alignment and suspension of components, and one (1) cast change, shoulder disarticulation or interscapular thoracic | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L6386 | Immediate post-surgical or early fitting, each additional cast change and realignment | No | ||
| L6388 | Immediate post-surgical or early fitting, application of rigid dressing only | No | ||
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| Endoskeletal: Below Elbow | ||||
| L6400 | Below elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
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| Endoskeletal: Elbow Disarticulation | ||||
| L6450 | Elbow disarticulation, molded socket, endoskeletal system including soft prosthetic tissue shaping | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
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| Endoskeletal: Above Elbow | ||||
| L6500 | Above elbow, molded socket, endoskeletal system including soft prosthetic tissue shaping | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
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| Endoskeletal: Shoulder Disarticulation | ||||
| L6550 | Shoulder disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue shaping | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
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| Endoskeletal: Interscapular Thoracic | ||||
| L6570 | Interscapular thoracic, molded socket, endoskeletal system, including soft prosthetic tissue shaping | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L6580 | Preparatory, wrist disarticulation or below elbow, single wall plastic socket, friction wrist, flexible elbow hinges, figure of eight harness, humeral cuff, Bowden cable control, "USMC" or equal pylon, no cover, molded to patient model | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L6582 | Preparatory, wrist disarticulation or below elbow, single wall socket, friction wrist, flexible elbow hinges, figure of eight harness, humeral cuff, Bowden cable control, "USMC" or equal pylon, no cover, direct formed | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L6584 | Preparatory, wrist disarticulation or above elbow, single wall plastic socket, friction wrist, locking elbow, figure of eight harness, fair lead cable control, "USMC" or equal pylon, no cover, molded to patient model | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L6586 | Preparatory, elbow disarticulation or above elbow, single wall socket, friction wrist, locking elbow, figure of eight harness, fair lead cable control, "USMC" or equal pylon, no cover, direct formed | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L6588 | Preparatory, shoulder disarticulation or interscapular thoracic, single wall plastic socket, shoulder joint, locking elbow, friction wrist, chest strap, fair lead cable control, "USMC" or equal pylon, no cover, molded to patient model | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L6590 | Preparatory, shoulder disarticulation or interscapular thoracic, single wall socket, shoulder joint, locking elbow, friction wrist, chest strap, fair lead cable control, "USMC" or equal pylon, no cover, direct formed | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
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| 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 the base procedure, at the time of the original order. | ||||
| L6600 | Upper extremity additions, polycentric hinge, pair | No | ||
| L6605 | Upper extremity additions, single pivot hinge, pair | No | ||
| L6610 | Upper extremity additions, flexible metal hinge, pair | No | ||
| L6611 | Addition to upper extremity prosthesis, external powered, additional switch, any type | No | ||
| L6615 | Upper extremity addition, disconnect locking wrist unit | No | ||
| L6616 | Upper extremity addition, additional disconnect insert for locking wrist unit, each | No | ||
| L6620 | Upper extremity addition, flexion-friction wrist unit, with or without friction | No | ||
| L6621 | Upper extremity prosthesis addition, flexion/extension wrist with or without friction, for use with external powered terminal device | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L6623 | Upper extremity addition, spring assisted rotational wrist unit with latch release | No | ||
| L6624 | Upper extremity addition, flexion/extension and rotation wrist unit | No | ||
| L6625 | Upper extremity addition, rotation wrist unit with cable lock | No | ||
| L6628 | Upper extremity addition, quick disconnect hook adapter, Otto Bock or equal | No | ||
| L6629 | Upper extremity addition, quick disconnect lamination collar with coupling piece, Otto Bock or equal | No | ||
| L6630 | Upper extremity addition, stainless steel, any wrist | No | ||
| L6632 | Upper extremity addition, latex suspension sleeve, each | No | ||
| L6635 | Upper extremity addition, life assist for elbow | No | ||
| L6637 | Upper extremity addition, nudge control elbow lock | No | ||
| L6638 | Upper extremity addition to prosthesis, electric locking feature, only for use with manually powered elbow | No | ||
| L6640 | Upper extremity additions, shoulder abduction joint, pair | No | ||
| L6641 | Upper extremity addition, excursion amplifier, pulley type | No | ||
| L6642 | Upper extremity addition, excursion amplifier, lever type | No | ||
| L6645 | Upper extremity addition, shoulder flexion-abduction joint, each | No | ||
| L6646 | Upper extremity addition, shoulder joint, multi-positional locking, flexion, adjustable abduction friction control, for use with body powered or external powered system | No | ||
| L6647 | Upper extremity addition, shoulder lock mechanism, body powered actuator | No | ||
| L6648 | Upper extremity addition, shoulder lock mechanism, external powered actuator | No | ||
| L6650 | Upper extremity addition, shoulder universal joint, each | No | ||
| L6655 | Upper extremity addition, standard control cable, extra | No | ||
| L6660 | Upper extremity addition, heavy duty control cable | No | ||
| L6665 | Upper extremity addition, Teflon, or equal, cable lining | No | ||
| L6670 | Upper extremity addition, hook to hand, cable adapter | No | ||
| L6672 | Upper extremity addition, harness, chest or shoulder, saddle type | No | ||
| L6675 | Upper extremity addition, harness, (e.g. figure of eight type), single cable design | No | ||
| L6676 | Upper extremity addition, harness, (e.g. figure of eight type), dual cable design | No | ||
| L6677 | Upper extremity addition, harness, triple control, simultaneous operation of terminal device and elbow | No | ||
| L6680 | Upper extremity addition, test socket, wrist disarticulation or below elbow | No | ||
| L6682 | Upper extremity addition, test socket, elbow disarticulation or above elbow | No | ||
| L6684 | Upper extremity addition, test socket, shoulder disarticulation or interscapular thoracic | No | ||
| L6686 | Upper extremity addition, suction socket | No | ||
| L6687 | Upper extremity addition, frame type socket, below elbow or wrist disarticulation | No | ||
| L6688 | Upper extremity addition, frame type socket, above elbow or elbow disarticulation | No | ||
| L6689 | Upper extremity addition, frame type socket, shoulder disarticulation | No | ||
| L6690 | Upper extremity addition, frame type socket, interscapular-thoracic | No | ||
| L6691 | Upper extremity addition, removable insert, each | No | ||
| L6692 | Upper extremity addition, silicone gel insert or equal, each | No | ||
| L6693 | Upper extremity addition, locking elbow, forearm counterbalance | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L6694 | Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, for use with locking mechanism | No | ||
| L6695 | Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, not for use with locking mechanism | No | ||
| L6696 | Addition to upper extremity prosthesis, below 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) | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L6697 | Addition to upper extremity prosthesis, below 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) | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L6698 | Addition to upper extremity prosthesis, below elbow/above elbow, lock mechanism, excludes socket insert | No | ||
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| Terminal Devices | ||||
| L6703 | Terminal device, passive hand/mitt, any material, any size | No | ||
| L6704 | Terminal device, sport/recreation/work attachment, any material, any size | Yes | *2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019 |
| L6706 | Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined | No | ||
| L6707 | Terminal device, hook, mechanical, voluntary closing, any material, any sized, lined or unlined | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L6708 | Terminal device, hand, mechanical, voluntary opening, any material, any size | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L6709 | Terminal device, hand, mechanical, voluntary closing, any material, any size | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L6711 | Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined, pediatric | No | ||
| L6712 | Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined, pediatric | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L6713 | Terminal device, hand, mechanical, voluntary opening, any material, any size, pediatric | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L6714 | Terminal device, hand, mechanical, voluntary closing, any material, any size, pediatric | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L6715 | Terminal device, multiple articulating digit, includes motor(s), initial issue or replacement | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L6721 | Terminal device, hook or hand, heavy duty, mechanical, voluntary opening, any material, any size, lined or unlined | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L6722 | Terminal device, hook or hand, heavy duty, mechanical, voluntary closing, any material, any size, lined or unlined | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L6805 | Addition to terminal device, modifier wrist unit | No | ||
| L6810 | Addition to terminal device, precision pinch device | No | ||
| L6880 | Electric hand, switch or myoelectric controlled, independently articulating digits, any grasp pattern or combination of grasp patterns, includes motor(s) | Yes | *2/5Y | *Effective April 1, 2019 |
| L6881 | Automatic grasp feature, addition to upper limb electric prosthetic terminal device | Yes | 2/5Y | *Effective April 1, 2019, a prior authorization is required. |
| L6882 | Microprocessor control feature, addition to upper limb prosthetic terminal device | Yes | 2/5Y | *Effective April 1, 2019, a prior authorization is required. |
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| Replacement Sockets | ||||
| L6883 | Replacement socket, below elbow/wrist disarticulation, molded to patient model, for use with or without external power | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L6884 | Replacement socket, above elbow/elbow disarticulation, molded to patient model, for use with or without external power | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L6885 | Replacement socket, shoulder disarticulation/interscapular thoracic, molded to patient model, for use with or without external power | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
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| Gloves for Above Hands | ||||
| L6890 | Addition to upper extremity prosthesis, glove for terminal device, any material, prefabricated, includes fitting and adjustment | Yes | ||
| L6895 | Addition to upper extremity prosthesis, glove for terminal device, any material, custom fabricated | Yes | *2/5Y | *Effective April 1, 2019 |
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| Hand Restoration | ||||
| L6900 | Hand restoration (casts, shading and measurements included), partial hand, with glove, thumb or one (1) finger remaining | Yes | *2/5Y | *Effective April 1, 2019 |
| L6905 | Hand restoration (casts, shading and measurements included), partial hand, with glove, multiple fingers remaining | Yes | *2/5Y | *Effective April 1, 2019 |
| L6910 | Hand restoration (casts, shading and measurements included), partial hand, with glove, no fingers remaining | Yes | *2/5Y | *Effective April 1, 2019 |
| L6915 | Hand restoration (shading and measurements included), replacement glove for above | Yes | *2/5Y | *Effective April 1, 2019 |
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| External Power Base Devices | ||||
| L6920 | Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal switch, cables, two (2) batteries and one (1) charger, switch control of terminal device | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L6925 | Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal electrodes, cables, two (2) batteries and one (1) charger, myoelectronic control of terminal device | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L6930 | Below elbow, external power, self- suspended inner socket, removable forearm shell, Otto Bock or equal switch, cables, two (2) batteries and one (1) charger, switch control of terminal device | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L6935 | Below elbow, external power, self- suspended inner socket, removable forearm shell, Otto Bock or equal electrodes, cables, two (2) batteries and one (1) charger, myoelectronic control of terminal device | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L6940 | Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, Otto Bock or equal switch, cables, two (2) batteries and one (1) charger, switch control of terminal device | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L6945 | Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, Otto Bock or equal electrodes, cables, two (2) batteries and one (1) charger, myoelectronic control of terminal device | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L6950 | Above elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, Otto Bock or equal switch, cables, two (2) batteries and one (1) charger, switch control of terminal device | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L6955 | Above elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, Otto Bock or equal electrodes, cables, two (2) batteries and one charger, myoelectronic control of terminal device | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L6960 | Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal switch, cables, two (2) batteries and one (1) charger, switch control of terminal device | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L6965 | Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal electrodes, cables, two (2) batteries and one (1) charger, myoelectronic control of terminal device | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L6970 | Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal switch, cables, two (2) batteries and one (1) charger, switch control of terminal device | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L6975 | Interscapular thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal electrodes, cables, two (2) batteries and one (1) charger, myoelectronic control of terminal device | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L7007 | Electric hand, switch or myoelectric, controlled, adult | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L7008 | Electric hand, switch or myoelectric, controlled, pediatric | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L7009 | Electric hook, switch or myoelectric controlled, adult | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L7040 | Prehensile actuator, switch controlled | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L7045 | Electronic hook, switch or myoelectric controlled, pediatric | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
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| Electronic Elbow | ||||
| L7170 | Electronic elbow, Hosmer or equal, switch controlled | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L7180 | Electronic elbow, microprocessor sequential control of elbow and terminal device | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L7181 | Electronic elbow, microprocessor simultaneous control of elbow and terminal device | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L7185 | Electronic elbow, adolescent, Variety Village or equal, switch controlled | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L7186 | Electronic elbow, child, Variety Village or equal, switch controlled | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L7190 | Electronic elbow, adolescent, Variety Village or equal, myoelectronically controlled | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L7191 | Electronic elbow, child, Variety Village or equal, myoelectronically controlled | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
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| Battery Components | ||||
| L7360 | Six (6) volt battery, each | Yes | 2/Y | *Effective April 1, 2019, a prior authorization is required. |
| L7362 | Battery charger, six (6) volt, each | Yes | 2/5Y | *Effective April 1, 2019, a prior authorization is required. |
| L7364 | 12-volt battery, each | Yes | 2/Y | *Effective April 1, 2019, a prior authorization is required. |
| L7366 | Battery charger, 12 volt, each | Yes | 2/5Y | *Effective April 1, 2019, a prior authorization is required. |
| L7367 | Lithium ion battery, replacement | Yes | 2/Y | *Effective April 1, 2019, a prior authorization is required. |
| L7368 | Lithium ion battery charger, replacement only | Yes | 2/5Y | *Effective April 1, 2019, a prior authorization is required. |
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| Addition to Upper Extremity Prosthesis | ||||
| L7400 | Addition to upper extremity prosthesis, below elbow/wrist disarticulation, ultralight material (titanium, carbon fiber or equal) | No | ||
| L7401 | Addition to upper extremity prosthesis, above elbow disarticulation, ultralight material (titanium, carbon fiber or equal) | No | ||
| L7402 | Addition to upper extremity prosthesis, shoulder disarticulation/interscapular thoracic, ultralight material (titanium, carbon fiber or equal) | No | ||
| L7403 | Addition to upper extremity prosthesis, below elbow/wrist disarticulation, acrylic material | No | ||
| L7404 | Addition to upper extremity prosthesis, above elbow disarticulation, acrylic material | No | ||
| L7405 | Addition to upper extremity prosthesis, shoulder disarticulation/interscapular thoracic, acrylic material | No | ||
| L7499 | Upper extremity prosthesis, NOS | Yes | *Effective April 1, 2019, a prior authorization is required. | |
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| Repairs | ||||
| L7510 | Repair of prosthetic device, repair or replace minor parts | No | ||
| L7520 | Repair prosthetic device, labor component, per 15 minutes | No | ||
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| Prostheses | ||||
| L8000 | Breast prosthesis, mastectomy bra | No | ||
| L8001 | Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, unilateral, any size, any type | No | ||
| L8002 | Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, bilateral, any size, any type | No | ||
| L8010 | Breast prosthesis, mastectomy sleeve | No | ||
| L8015 | External breast prosthesis garment, with mastectomy form, post-mastectomy | No | ||
| L8020 | Breast prosthesis, mastectomy form | No | ||
| L8030 | Breast prosthesis, silicone or equal, without integral adhesive | Yes | 2/Y | *Effective April 1, 2019 |
| L8031 | Breast prosthesis, silicone or equal, with integral adhesive | Yes | 2/5Y | *Effective April 1, 2019 |
| L8032 | Nipple prosthesis, reusable, any type, each | Yes | 2/5Y | *Effective April 1, 2019 |
| L8035 | Custom breast prosthesis, post mastectomy, molded to patient model | Yes | 2/5Y | One (1) per right and left side, every five (5) years. *Effective April 1, 2019, a prior authorization is required. |
| L8039 | Breast prosthesis, NOS | Yes | 2/5Y | *Effective April 1, 2019 |
| L8040 | Nasal prosthesis, provided by a non- physician | Yes | 1/5Y | *Effective April 1, 2019 |
| L8041 | Midfacial prosthesis, provided by a non- physician | Yes | 1/5Y | *Effective April 1, 2019 |
| L8042 | Orbital prosthesis, provided by a non- physician | Yes | 2/5Y | *Effective April 1, 2019 |
| L8043 | Upper facial prosthesis, provided by a non-physician | Yes | 1/5Y | *Effective April 1, 2019 |
| L8044 | Hemi-facial prosthesis, provided by a non-physician | Yes | 1/5Y | *Effective April 1, 2019 |
| L8045 | Auricular prosthesis, provided by a non- physician | Yes | 2/5Y | *Effective April 1, 2019 |
| L8046 | Partial facial prosthesis, provided by a non-physician | Yes | 1/5Y | *Effective April 1, 2019 |
| L8047 | Nasal septal prosthesis, provided by a non-physician | Yes | *1/5Y | *Effective April 1, 2019 |
| L8048 | Unspecified maxillofacial prosthesis, by report, provided by a non-physician | Yes | ||
| L8049 | Repair or modification of maxillofacial prosthesis, labor component, 15-minute increments, provided by a non-physician | Yes | ||
| L8499 | Unlisted procedure for miscellaneous prosthetic services | Yes | ||
| L8600 | Implantable breast prosthesis, silicone or equal | None | ||
| L8612 | Aqueous shunt | None | ||
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| Trusses | ||||
| L8300 | Truss, single with standard pad | No | ||
| L8310 | Truss, double with standard pads | No | ||
| L8320 | Truss, addition to standard pads, water pad | No | ||
| L8330 | Truss, addition to standard pads, scrotal pad | No | ||
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| Prosthetic Socks | ||||
| L7600 | Prosthetic donning sleeve, any material, each | No | ||
| L8400 | Prosthetic sheath, below knee, each | No | ||
| L8410 | Prosthetic sheath, above knee, each | No | ||
| L8415 | Prosthetic sheath upper limb each | No | ||
| L8417 | Prosthetic sheath/sock, including a gel cushion layer, below knee or above knee, each | No | ||
| L8420 | Prosthetic sock, multiple ply, below knee, each | No | ||
| L8430 | Prosthetic sock, multiple ply, above knee, each | No | ||
| L8435 | Prosthetic sock, multiple ply, upper limb, each | No | ||
| L8440 | Prosthetic shrinker, below knee, each | No | ||
| L8460 | Prosthetic shrinker, above knee, each | No | ||
| L8465 | Prosthetic shrinker, upper limb, each | No | ||
| L8470 | Prosthetic sock, single ply, fitting, below knee, each | No | ||
| L8480 | Prosthetic sock, single ply, fitting, above knee, each | No | ||
| L8485 | Prosthetic sock, single ply, fitting, upper limb, each | No | ||
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| Prosthetic Implants | ||||
| Integumentary System | ||||
| L8500 | Artificial larynx, any type | Yes | 1/5Y | *Effective April 1, 2019, a prior authorization is required. |
| L8501 | Tracheostomy speaking valve | No | ||
| L8505 | Artificial larynx replacement battery/accessory, any type | Yes | *1/Y | *Effective April 1, 2019 |
| L8507 | Tracheo-esophageal voice prosthesis, patient inserted, any type, each | Yes | *1/Y | *Effective April 1, 2019 |
| L8509 | Tracheo-esophageal voice prosthesis, inserted by a licensed health care provider, any type | Yes | *1/Y | *Effective April 1, 2019 |
| L8510 | Voice amplifier | Yes | ||
| L8511 | Insert for indwelling tracheoesophageal prosthesis, with or without valve, replacement only, each | No | ||
| L8512 | Gelatin capsules or equivalent, for use with tracheoesophageal voice prosthesis, replacement only, per 10 | No | ||
| L8513 | Cleaning device used with tracheoesophageal voice prosthesis, pipet, brush, or equal, replacement only, each | No | ||
| L8514 | Tracheoesophageal puncture dilator, replacement only, each | No | ||
| L8515 | Gelatin capsule application device for use with tracheoesophageal voice prosthesis, each | No | 31/M | |
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| Hand and Foot | ||||
| L8630 | Metacarpophalangeal joint implant | None | ||
| L8631 | Metacarpal phalangeal joint replacement, two or more pieces, metal (e.g., stainless steel of cobalt chrome), ceramic-like material (e.g., pyrocarbon), for surgical implantation (all sizes, includes entire system) | None | ||
| L8641 | Metatarsal joint implant | None | ||
| L8642 | Hallux implant | None | ||
| L8658 | Interphalangeal joint spacer, silicone or equal, each | None | ||
| L8659 | Interphalangeal finger joint replacement, 2 or more pieces, metal (e.g., stainless steel or cobalt chrome), ceramic-like material (e.g., pyrocarbon) for surgical implantation, any size | None | ||
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| Miscellaneous Implants | ||||
| L8699 | Prosthetic Implant, not otherwise specified | None | ||
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| Head: Skull, Facial Bones and Temporomandibular Joint | ||||
| L8610 | Ocular implant | Yes | *2/5Y | *Effective April 1, 2019 |
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| Alternative and Augmentative Communication Devices (AACDs) | ||||
| A4601 | Lithium ion battery for non-prosthetic use, replacement | Yes | ||
| E1399-AV | Tablet computer for use as a communication device | Yes | Device must be under full manufacturer warranty at the time of delivery to the member. If TPL requires a different code, note the other code in the comments. EOB must be attached. Required: F2F | |
| E1902 | Communication board, non-electronic augmentative or alternative communication device | Yes | ||
| E2500 | Speech generating device, digitalized speech, using pre-recorded messages, less than or equal to 8 minutes recording time | Yes | *Code is subject to the 2019 DME UPL | |
| E2502 | Speech generating device, digitalized speech, using pre-recorded messages, greater than 8 minutes but less than or equal to 20 minutes recording time | Yes | Required: F2F *Code is subject to the 2019 DME UPL | |
| E2504 | Speech generating device, digitalized speech, using pre-recorded messages, greater than 20 minutes but less than or equal to 40 minutes recording time | Yes | Required: F2F | |
| E2506 | Speech generating device, digitalized speech, using pre-recorded messages, greater than 40 minutes recording time | Yes | Required: F2F *Code is subject to the 2019 DME UPL | |
| E2508 | Speech generating device, synthesized speech, requiring message formulation by spelling and access by physical contact with the device | Yes | Required: F2F *Code is subject to the 2019 DME UPL | |
| E2510 | Speech generating device, synthesized speech, permitting multiple methods of message formulation and multiple methods of device access | Yes | Required: F2F *Code is subject to the 2019 DME UPL | |
| E2511 | Speech generating software program, for personal computer or personal digital assistant | Yes | ||
| E2512 | Accessory for speech generating device, mounting system | Yes | ||
| E2599 | Accessory for speech generating device, not otherwise classified | Yes | ||
| E3000 | Speech volume modulation system, any type, including all components and accessories | Yes | Code opened 01-01-2024. | |
| L9900 | Orthotic and prosthetic supply, accessory, and/or service component of another HCPCS L code | Yes | ||
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