Durable Medical Equipment HCPCS Codes

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
A7048 Vacuum drainage collection unit and tubing kit, including all supplies needed for collection unit change, for use with implanted catheter, each No SEE NCCI MUE LIMIT NCCI MUE - cannot be overridden with a PAR.
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 & quantities on PAR. For rental, must submit manufacturer's invoice with PAR. Rental based on percentage of invoice & 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 & 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.
K0108 Wheelchair component or accessory, not otherwise specified Yes   Use for wheelchair parts and accessories only when an appropriate code is not available.
L7259 Electronic wrist rotator, any type Yes 2/5Y 1 per right and left side, every five 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 1/1/2018
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.
See the October 2017 Provider Bulletin for details.
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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 & 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 & 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 & 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 & 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    
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 *NCCI MUE - cannot be overridden with a PAR.
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 & 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 & 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 & 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 & 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    
E0315 Bed accessory: board, table, or support device any type Yes   Bed cane. Do not use for over bed table.
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.
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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, ACCESSORIES – GENERAL USE

Providers are instructed to submit the HCPCS code most closely describing the wheelchair or related equipment being requested on the PAR form. Please refer to 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 & 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    
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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 wheel chair, 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 200 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
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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 1/1/2018
E0954 Wheelchair accessory, foot box, any type, includes attachment and mounting hardware, each foot Yes   New code effective 1/1/2018
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.
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Wheelchair Replacement Parts & 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
Required: F2F
E0981 Wheelchair accessory, seat upholstery, replacement only, each Con 1/Y For repair only.
Over 1 requires PAR.
Required: F2F
E0982 Wheelchair accessory, back upholstery replacement only, each Con 1/Y For repair only.
Over 1 requires PAR.
Required: F2F
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 PAR required for purchase but not required for repair. 1 unit = 1 tire.
Over 2 units requires PAR.
E2212 Manual wheelchair accessory, tube for pneumatic propulsion tire, any size, each Con 2/Y PAR required for purchase but not required for repair. 1 unit = 1 tire tube.
Over 2 units requires PAR.
E2213 Manual wheelchair accessory, insert for pneumatic propulsion tire (removable), any type, any size, each Con 2/Y PAR required for purchase but not required for repair. 1 unit = 1 tire insert.
Over 2 units requires PAR.
E2214 Manual wheelchair accessory, pneumatic caster tire, any size, each Con 2/Y PAR required for purchase but not required for repair. 1 unit = 1 tire.
Over 2 units requires PAR.
E2215 Manual wheelchair accessory, tube for pneumatic caster tire, any size, each Con 2/Y PAR required for purchase but not required for repair. 1 unit = 1 tire tube.
Over 2 units requires PAR.
E2216 Manual wheelchair accessory, foam filled propulsion tire, any size, each Con 2/Y PAR required for purchase but not required for repair. 1 unit = 1 tire.
Over 2 units requires PAR.
E2217 Manual wheelchair accessory, foam filled caster tire, any size, each Con 2/Y PAR required for purchase but not required for repair. 1 unit = 1 tire.
Over 2 units requires PAR.
E2218 Manual wheelchair accessory, foam propulsion tire, any size, each Con 2/Y PAR required for purchase but not required for repair. 1 unit = 1 tire.
Over 2 units requires PAR.
E2219 Manual wheelchair accessory, foam caster tire, any size, each Con 2/Y PAR required for purchase but not required for repair. 1 unit = 1 tire.
Over 2 units requires PAR.
E2220 Manual wheelchair accessory, solid (rubber/plastic) propulsion tire, any size, replacement only, each Con 2/Y PAR required for purchase but not required for repair. 1 unit = 1 tire.
Over 2 units requires PAR.
E2221 Manual wheelchair accessory, solid (rubber/plastic) caster tire (removable), any size, replacement only, each Con 2/Y PAR required for purchase but not required for repair. 1 unit = 1 tire.
Over 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 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 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 2 units requires PAR.
E2226 Manual wheelchair accessory, caster fork, any size, replacement only, each Con 2/Y PAR required for purchase but not required for repair. 1 unit = 1 caster fork
Over 2 units requires PAR.
E2227 Manual wheelchair accessory, gear reduction drive wheel, each Con   PAR required for purchase but not required for repair. 1 unit = 1 gear reduction drive wheel.
Required: F2F
E2228 Manual wheelchair accessory, wheel braking system and lock, complete, each Con   PAR required for purchase but not required for repair. 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 SEE NCCI MUE LIMIT PAR required for purchase but not for repair. NCCI MUE – Do not provide more than 1 per DOS.
E2367 Power wheelchair accessory, battery charger, dual mode, for use with either battery type, sealed or non-sealed, each Con 1/Y PAR required for purchase but not for repair.
E2368 Power wheelchair component, drive wheel motor, replacement only Con 2 per 3 Y PAR required for more than 2 per 3 fiscal years.
E2369 Power wheelchair component, drive wheel gear box, replacement only Con 2 per 3 Y PAR required for more than 2 per 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 2 per 3 fiscal years.
E2371 Power wheelchair accessory, group 27 sealed lead acid battery, (e.g. gel cell, absorbed glassmat), each Con   PAR required for purchase but not for repair.
E2372 Power wheelchair accessory, group 27 non-sealed lead acid battery, each Con   PAR required for purchase but not for repair.
E2375 Power wheelchair accessory, non- expandable controller, including all related electronics and mounting hardware, replacement only Con 1/Y Over 1 unit requires PAR.
E2378 Power wheelchair component, actuator, replacement only Yes 3/Y 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 PAR required for purchase but not for repair.
Over 2 units require PAR.
E2382 Power wheelchair accessory, tube for pneumatic drive wheel tire, any size, replacement only, each Con 2/Y PAR required for purchase but not for repair.
Over 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 PAR required for purchase but not for repair.
Over 2 units requires PAR.
E2384 Power wheelchair accessory, pneumatic caster tire, any size, replacement only, each Con 2/Y PAR required for purchase but not for repair.
Over 2 units requires PAR.
E2385 Power wheelchair accessory, tube for pneumatic caster tire, any size, replacement only, each Con 2/Y PAR required for purchase but not for repair.
Over 2 units requires PAR.
E2386 Power wheelchair accessory, foam filled drive wheel tire, any size, replacement only, each Con 2/Y PAR required for purchase but not for repair.
Over 2 units requires PAR.
E2387 Power wheelchair accessory, foam filled caster tire, any size, replacement only, each Con 2/Y PAR required for purchase but not for repair.
Over 2 units requires PAR.
E2388 Power wheelchair accessory, foam drive wheel tire, any size, replacement only, each Con 2/Y PAR required for purchase but not for repair.
Over 2 units requires PAR.
E2389 Power wheelchair accessory, foam caster tire, any size, replacement only, each Con 2/Y PAR required for purchase but not for repair.
Over 2 units requires PAR.
E2390 Power wheelchair accessory, solid (rubber/plastic) drive wheel tire, any size, replacement only, each Con 2/Y PAR required for purchase but not for repair.
Over 2 units requires PAR.
E2391 Power wheelchair accessory, solid (rubber/plastic) caster tire (removable), any size, replacement only, each Con 2/Y PAR required for purchase but not for repair.
Over 2 units requires PAR.
E2392 Power wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel, any size, replacement only, each Con 2/Y PAR required for purchase but not for repair.
Over 2 units requires PAR.
E2394 Power wheelchair accessory, drive wheel excludes tire, any size, replacement only, each Con 2/Y PAR required for purchase but not for repair.
Over 2 units requires PAR.
E2395 Power wheelchair accessory, caster wheel excludes tire, any size, replacement only, each Con 2/Y PAR required for purchase but not for repair.
Over 2 units requires PAR.
E2396 Power wheelchair accessory, caster fork, any size, replacement only, each Con 2/Y PAR required for purchase but not for repair.
Over 2 units requires PAR.
E2397 Power wheelchair accessory, lithium based battery, each Con   PAR required for purchase but not for repair.
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 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 2 units requires PAR.
K0041 Large size footplate, each Con 2/Y 1 unit = 1 footplate
Over 2 units requires PAR.
K0042 Standard size footplate, replacement only, each Con 2/Y 1 unit = 1 footplate
Over 2 units requires PAR.
K0043 Footrest, lower extension tube, replacement only, each Con 2/Y For repair only, slider extension tubes
Over 2 units requires PAR.
K0044 Footrest, upper hanger bracket, replacement only, each Con 2/Y For repair only.
Over 2 units requires PAR.
K0045 Footrest, complete assembly, replacement only, each Con 2/Y Swing away
Over 2 units requires PAR.
K0046 Elevating legrest, lower extension tube, replacement only, each Con 2/Y For repair only.
PAR required for more than 2 per fiscal year.
K0047 Elevating legrest, upper hanger bracket, replacement only, each Con 2/Y For repair only.
PAR required for more than 2 per fiscal year.
K0050 Ratchet assembly, replacement only Yes   For repair only.
K0051 Cam release assembly, footrest or legrest, replacement only, each Yes   For repair only.
K0052 Swingaway, detachable footrests, replacement only, each Con 2/Y New or repair.
Over 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   PAR required for purchase but not required for repair.
K0070 Rear wheel assembly, complete, with pneumatic tire, spokes or molded, each Con 2/Y PAR required for purchase but not required for repair. 1 unit = 1 assembly.
Over 2 units requires PAR.
K0071 Front caster assembly, complete, with pneumatic tire, replacement only, each Con 2 per 3/Y PAR required for purchase but not required for repair. 1 unit = 1 assembly.
PAR required for more than 2 per 3 fiscal years.
K0072 Front caster assembly, complete, with semi-pneumatic tire, replacement only, each Con 2 per 3 Y PAR required for purchase but not required for repair.
1 unit = 1 assembly.
PAR required for more than 2 per 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 purchase but not required for repair. 1 unit = 1 tire.
PAR required for more than 2 per 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   PAR required for purchase but not for repair.
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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 & 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    
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.
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 1/1/2018
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
L8694 Auditory osseointegrated device, transducer/actuator, replacement only, each Yes SEE NCCI MUE LIMIT New code effective 1/1/2018
NCCI MUE - cannot be overridden with a PAR.
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DIABETIC MONITORING EQUIPMENT & 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    
A4250 Urine test or reagent strips or tablets, each No   1 unit = 1 strip/tablet 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.
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    
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
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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 62/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 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    
A4452 Tape, waterproof, per 18 square inches Yes 31/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, rubber, any type No    
A4562 Pessary, non-rubber, any type No    
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.
See the October 2017 Provider Bulletin for details.
A4927 Gloves, non-sterile, per 100 No 2/M 1 unit = 100 gloves
Over 2 boxes requires PAR.
A4930 Gloves, sterile, per pair No 5/D 1 unit = 1 pair
Limit 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 1/1/2017
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
A4397 Irrigation supply, sleeve, each No   1 unit = 1 sleeve
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.
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 240 per calendar month in any combination of diapers, liners, and undergarments. Combined quantities above 240 require a PAR.
T4521 Adult sized disposable incontinence product, brief/diaper, small, each Con 240/M Diaper. COMBINATION LIMIT
T4522 Adult sized disposable incontinence product, brief/diaper, medium, each Con 240/M Diaper. COMBINATION LIMIT
T4523 Adult sized disposable incontinence product, brief/diaper, large, each Con 240/M Diaper. COMBINATION LIMIT
T4524 Adult sized disposable incontinence product, brief/diaper, extra-large, each Con 240/M Diaper. COMBINATION LIMIT
T4525 Adult sized disposable incontinence product, protective underwear/pull-on, small size, each Con 240/M Pull-up. COMBINATION LIMIT
T4526 Adult sized disposable incontinence product, protective underwear/pull-on, medium size, each Con 240/M Pull-up. COMBINATION LIMIT
T4527 Adult sized disposable incontinence product, protective underwear/pull-on, large size, each Con 240/M Pull-up. COMBINATION LIMIT
T4528 Adult sized disposable incontinence product, protective underwear/pull-on, extra-large size, each Con 240/M Pull-up. COMBINATION LIMIT
T4529 Pediatric sized disposable incontinence product, brief/diaper, small/medium size, each Con 240/M Diaper. COMBINATION LIMIT
T4530 Pediatric size disposable incontinence product brief/diaper, large size, each Con 240/M Diaper. COMBINATION LIMIT
T4531 Pediatric size disposable incontinence product, protective underwear/pull-on, small/medium size, each Con 240/M Pull-up. COMBINATION LIMIT
T4532 Pediatric sized disposable incontinence product, protective underwear/pull-on, large size, each Con 240/M Pull-up. COMBINATION LIMIT
T4533 Youth sized disposable incontinence product, brief/diaper, each Con 240/M Diaper. COMBINATION LIMIT
T4534 Youth sized disposable incontinence product, protective underwear/pull-on, each Con 240/M Pull-up. COMBINATION LIMIT
T4535 Disposable liner/shield/guard/pad/undergarment, for incontinence, each Con 240/M Liner. COMBINATION LIMIT
T4543 Adult sized disposable incontinence product, protective brief/diaper, above extra-large, each Con 240/M Brief. COMBINATION LIMIT
T4544 Adult sized disposable incontinence product, protective underwear/pull-on, above extra-large, each Con 240/M Pull-Up. COMBINATION LIMIT
A4553 Non-disposable underpads, all sizes No 16/Y New code effective 1/1/2017 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 & 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 120/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 1/1/2017. 1 unit = 1 week's supply
A4225 Supplies for external insulin infusion pump, syringe type cartridge, sterile, each No 31/M New code effective 1/1/2017. 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 & 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.
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 120/M  
A4354 Insertion tray with drainage bag, without catheter, each No SEE NCCI MUE LIMIT 1 unit = 1 tray & 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  
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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 Yes   New code effective 1/1/2017
E0235 Paraffin bath unit, portable each Yes   1 unit = 1 unit
*Code is subject to the 2019 DME UPL
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ELASTIC SUPPORTS & 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 1/1/2017
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
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    
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HEAT & 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 & 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
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   Required: Q6
Purchase is required after a two (2) month rental period. Total reimbursement, including rental, shall not exceed the purchase price.

For members under 3 years of age only:
Equipment may be rented by members for a period of up to 3 years or until age 3. For rental periods exceeding 2 months, purchase is required when the member reaches age 3.

Rental:
  • RR 1 unit = 1 month
  • KR 1 unit = 1 day – use only for overnight or 24-hour test period use. (PAR not required)
E0610 Pacemaker monitor, self-contained (checks battery depletion, includes audible & visual check systems), each Yes    
E0615 Pacemaker monitor, self-contained, checks battery depletion & other pacemaker components, includes digital/visual check systems, each Yes    
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 & 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 & 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 & water vapor enriching system with heated delivery Yes    
E1406 Oxygen & water vapor enriching system without heated delivery Yes    
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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, & 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 & 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 & refill adaptor.
E0439 Stationary liquid oxygen system, rental; includes container, contents, regulator, flow meter, humidifier, nebulizer, cannula or mask, & tubing No   Bill with RR modifier
Also use for multiple member use of reservoir. Bill usual & 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 & 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 & 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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
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 & headgear. Use A7030 for mask purchase. Use A7035 for headgear purchase.
*See CPAP/BiPAP under the Benefits section 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 & headgear. Use A7030 for mask purchase. Use A7035 for headgear purchase.
*See CPAP/BiPAP under the Benefits section 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
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 & headgear. Use A7030 for mask purchase. Use A7035 for headgear purchase.
*See CPAP/BiPAP under the Benefits section 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
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 & headgear. Use A7030 for mask purchase. Use A7035 for headgear purchase.
Required: F2F
*See CPAP/BiPAP under the Benefits section 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, 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 & 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.
NCCI MUE - cannot be overridden with a PAR.
*Code is subject to the 2019 DME UPL

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 & RELATED SERVICES

Note: All belts, leads, pads, & 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, hand held 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 & SUPPLIES - GENERAL USE

Note: require 2-month trial rental before purchase. Requires Questionnaire #9. See TENS/NMES

Code Description PAR Unit Limits Comments
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 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.
E0720 Transcutaneous Electrical Nerve Stimulation (TENS) device, two (2) lead, localized stimulation Yes   Required: F2F, Q9
See TENS/NMES
*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
See TENS/NMES
*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
E0744 Neuromuscular stimulator for scoliosis, each Yes   Required: F2F
See TENS/NMES
E0745 Neuromuscular stimulator electronic shock unit, each Yes   Required: F2F
See TENS/NMES
*Code is subject to the 2019 DME UPL
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
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
See TENS/NMES
E0770 Functional electrical stimulator, transcutaneous stimulation of nerve and/or muscle groups, any type, complete system, not otherwise specified Yes   Required: Q9
See TENS/NMES
S8130 Interferential current stimulator, 2 channel Yes    
S8131 Interferential current stimulator, 4 channel Yes    
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TRAPEZE, TRACTION & 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 & 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    
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 & 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 Con    
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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 & ENTERAL NUTRITION, FORMULAS, EQUIPMENT & 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    
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.
S9433 Medical food nutritionally complete, administered orally, providing 100% of nutritional intake Yes    
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Enteral Equipment & 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 1/M  
B4088 Gastrostomy/jejunostomy tube, low- profile, any material, any type, each Yes 1/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
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 & quantities on PAR. For rental, must submit manufacturer's invoice with PAR. Rental based on percentage of invoice & 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
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Breastfeeding Equipment & Supplies
E0602 Breast Pump, manual, any type None   Includes kit and all supplies. Only available for use with premature infants and infants in critical care.
E0603-KR Breast Pump, electric (AC and/or DC), any type Yes 1
31/M
Includes breast pump and all supplies. Purchase is available only for use with premature infants and infants in critical care, and only during period of anticipated infant hospitalization of 54 days or more. Rental is available only for periods of infant hospitalization anticipated to be less than 54 days. When renting: 1 unit = 1 day. Submit under mom's ID.
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.
A4286 Locking ring for breast pump, replacement Yes   Purchase for member owned equipment only.
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 & 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 & 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 & microfilter, pump cassettes, clamps, extension sets & 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 & 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
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 & 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    
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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, toricollis 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.
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 1/1/2017. 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 1/1/2017. 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
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    
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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    
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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    
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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    
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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    
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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, knee cap, 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, 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
L3170 Foot, plastic, silicone or equal, heel stabilizer, prefabricated, off-the-shelf, each Yes *2/Y *Effective April 1, 2019
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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 Modification - 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 modification - 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
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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
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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
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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
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Orthotic Devices – Upper Limb

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/calvicular (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    
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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 1/1/2018
L3762 EO, rigid, without joints, includes soft interface material, prefabricated, off-the- shelf No    
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.
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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.
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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    
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Additions - general
L3891 Addition to upper extremity joint, wrist or elbow, concentric adjustable torsion style mechanism for custom fabricated orthotics only, each No    
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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‘s 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
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 Repair
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 1 per right and left side, every five years.*Effective April 1, 2019, a prior authorization is required.
L5020 Partial foot, molded socket, tibial tubercle height, with toe filler Yes 2/5Y 1 molded partial per right and left side, every five 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 1 per right and left side, every five years.
*Effective April 1, 2019, a prior authorization is required.
L5060 Ankle, Symes, metal frame, molded leather socket, articulated ankle/foot Yes 2/5Y 1 per right and left side, every five 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 1 per right and left side, every five years.
*Effective April 1, 2019, a prior authorization is required.
L5105 Below knee, plastic socket, joints and thigh lacer, SACH foot Yes 2/5Y 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five years.
*Effective April 1, 2019, a prior authorization is required.
L5301 Below knee, molded socket, shin, SACH foot, endoskeletal system Yes 2/5Y 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5616 Addition to lower extremity, endoskeletal system, above knee, universal multiplex system, friction swing phase control Yes 2/5Y 1 per right and left side, every five 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    
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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 1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
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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 1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5640 Addition to lower extremity, knee disarticulation, leather socket Yes 2/5Y 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5649 Addition to lower extremity, ischial containment/narrow M-L socket Yes 2/5Y 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 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 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 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 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 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five years.
*Effective April 1, 2019, a prior authorization is required.
L5704 Custom shaped protective cover, below knee Yes 2/5Y 1 per right and left side, every five years.
*Effective April 1, 2019, a prior authorization is required.
L5705 Custom shaped protective cover, above knee Yes 2/5Y 1 per right and left side, every five years.
*Effective April 1, 2019, a prior authorization is required.
L5706 Custom shaped protective cover, knee disarticulation Yes 2/5Y 1 per right and left side, every five years.
*Effective April 1, 2019, a prior authorization is required.
L5707 Custom shaped protective cover, hip disarticulation Yes 2/5Y 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five years.
*Effective April 1, 2019, a prior authorization is required.
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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 1 per right and left side, every five years.
*Effective April 1, 2019, a prior authorization is required.
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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 1 per right and left side, every five years.
*Effective April 1, 2019, a prior authorization is required.
L5816 Addition, endoskeletal knee-shin system, polycentric, mechanical stance phase lock Yes 2/5Y 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five years.
*Effective April 1, 2019, a prior authorization is required.
L5845 Addition, endoskeletal knee-shin system, stance flexion feature, adjustable Yes 2/5Y 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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    
L5930 Addition, endoskeletal system, high activity knee control frame Yes 2/5Y 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five years.
*Effective April 1, 2019, a prior authorization is required.
L5980 All lower extremity prostheses, flex-foot system Yes 2/5Y 1 per right and left side, every five years.
*Effective April 1, 2019, a prior authorization is required.
L5981 All lower extremity prostheses, flex-walk system or equal Yes 2/5Y 1 per right and left side, every five 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 1 per right and left side, every five years.
*Effective April 1, 2019, a prior authorization is required.
L5988 Addition to lower limb prosthesis, vertical shock reducing pylon feature Yes 2/5Y 1 per right and left side, every five years.
*Effective April 1, 2019, a prior authorization is required.
L5990 Addition to lower extremity prosthesis, user adjustable heel height Yes 2/5Y 1 per right and left side, every five 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 1 per right and left side, every five years.
*Effective April 1, 2019, a prior authorization is required.
L6010 Partial hand, little and/or ring finger remaining Yes 2/5Y 1 per right and left side, every five years.
*Effective April 1, 2019, a prior authorization is required.
L6020 Partial hand, no finger remaining Yes 2/5Y 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L6110 Below elbow, molded socket, (Muenster or Northwestern suspension types) Yes 2/5Y 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five years.
*Effective April 1, 2019, a prior authorization is required.
L6310 Shoulder disarticulation, passive restoration (complete prosthesis) Yes 2/5Y 1 per right and left side, every five years.
*Effective April 1, 2019, a prior authorization is required.
L6320 Shoulder disarticulation, passive restoration (shoulder cap only) Yes 2/5Y 1 per right and left side, every five 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 1 per right and left side, every five years.
*Effective April 1, 2019, a prior authorization is required.
L6360 Interscapular thoracic, passive restoration (complete prosthesis) Yes 2/5Y 1 per right and left side, every five years.
*Effective April 1, 2019, a prior authorization is required.
L6370 Interscapular thoracic, passive restoration (shoulder cap only) Yes 2/5Y 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five years.
*Effective April 1, 2019, a prior authorization is required.
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 1 per right and left side, every five 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 counter balance Yes 2/5Y 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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    
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 1 per right and left side, every five 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 1 per right and left side, every five years.
*Effective April 1, 2019, a prior authorization is required.
L6708 Terminal device, hand, mechanical, voluntary opening, any material, any size Yes 2/5Y 1 per right and left side, every five years.
*Effective April 1, 2019, a prior authorization is required.
L6709 Terminal device, hand, mechanical, voluntary closing, any material, any size Yes 2/5Y 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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.
Replacement Sockets
L6883 Replacement socket, below elbow/wrist disarticulation, molded to patient model, for use with or without external power Yes 2/5Y 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
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
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
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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five 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 1 per right and left side, every five years.
*Effective April 1, 2019, a prior authorization is required.
L6975 Intercapsular 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 1 per right and left side, every five years.
*Effective April 1, 2019, a prior authorization is required.
L7007 Electric hand, switch or myoelectric, controlled, adult Yes 2/5Y 1 per right and left side, every five years.
*Effective April 1, 2019, a prior authorization is required.
L7008 Electric hand, switch or myoelectric, controlled, pediatric Yes 2/5Y 1 per right and left side, every five years.
*Effective April 1, 2019, a prior authorization is required.
L7009 Electric hook, switch or myoelectric controlled, adult Yes 2/5Y 1 per right and left side, every five years.
*Effective April 1, 2019, a prior authorization is required.
L7040 Prehensile actuator, switch controlled Yes 2/5Y 1 per right and left side, every five years.
*Effective April 1, 2019, a prior authorization is required.
L7045 Electronic hook, switch or myoelectric controlled, pediatric Yes 2/5Y 1 per right and left side, every five years.
*Effective April 1, 2019, a prior authorization is required.
Electronic Elbow
L7170 Electronic elbow, Hosmer or equal, switch controlled Yes 2/5Y 1 per right and left side, every five years.
*Effective April 1, 2019, a prior authorization is required.
L7180 Electronic elbow, microprocessor sequential control of elbow and terminal device Yes 2/5Y 1 per right and left side, every five years.
*Effective April 1, 2019, a prior authorization is required.
L7181 Electronic elbow, microprocessor simultaneous control of elbow and terminal device Yes 2/5Y 1 per right and left side, every five years.
*Effective April 1, 2019, a prior authorization is required.
L7185 Electronic elbow, adolescent, Variety Village or equal, switch controlled Yes 2/5Y 1 per right and left side, every five years.
*Effective April 1, 2019, a prior authorization is required.
L7186 Electronic elbow, child, Variety Village or equal, switch controlled Yes 2/5Y 1 per right and left side, every five years.
*Effective April 1, 2019, a prior authorization is required.
L7190 Electronic elbow, adolescent, Variety Village or equal, myoelectronically controlled Yes 2/5Y 1 per right and left side, every five years.
*Effective April 1, 2019, a prior authorization is required.
L7191 Electronic elbow, child, Variety Village or equal, myoelectronically controlled Yes 2/5Y 1 per right and left side, every five years.
*Effective April 1, 2019, a prior authorization is required.
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 1 per right and left side, every five 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    
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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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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    
L9900 Orthotic and prosthetic supply, accessory, and/or service component of another HCPCS L code Yes    
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