Prosthetics Section II - Arkansas Medicaid

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212.600 Orthotic Appliances and Prosthetic Devices, All Ages .... Source: 42 U.S. Code of Federal Regulations §422.2 and §424.101. ...... manual equipment ( dealer discount), 30% power equipment (dealer discount), plus 35% (profit margin), ...
|Section ii - Prosthetics | | |CONTENTS | |

200.000 GENERAL INFORMATION 201.000 Arkansas Medicaid Participation Requirements for Prosthetics Providers 201.100 Providers in Arkansas and Bordering States 201.110 Routine Services Provider 201.200 Providers in Non-Bordering States 201.210 Limited Services Provider 202.000 The Prosthetics Provider Role in the Child Health Services (EPSDT) Program 203.000 Documentation Requirements 203.100 Documentation in Beneficiary’s Case Files 203.200 Reserved 203.300 Reserved 204.000 Electronic Signatures

210.000 PROGRAM COVERAGE 211.000 Scope 211.100 Condition for Provision of Services 211.200 Physician’s Role in the Prosthetics Program 211.300 Prosthetics Service Provision 211.400 Prescription and Referral Renewal 211.500 Service Initiation Delays 211.600 Termination of Services 211.700 Exclusions 211.800 Electronic Filing of Extension of Benefits 212.000 Services Provided 212.100 Diapers and Underpads for Individuals Age 3 and Older 212.200 Durable Medical Equipment (DME), All Ages 212.201 (DME) Apnea Monitors for Infants Under Age 1 212.202 (DME) Augmentative Communication Device (ACD), All Ages 212.203 Cochlear Implants for Beneficiaries Under Age 21 212.204 (DME) Electronic Blood Pressure Monitor and Cuff for Beneficiaries of All Ages 212.205 (DME) Enteral Nutrition Infusion Pump and Enteral Feeding Pump Supply Kit for Beneficiaries Under Age 21 212.206 (DME) Home Blood Glucose Monitor, Pregnant Women Only, All Ages 212.207 (DME) Insulin Pump and Supplies, All Ages 212.208 Reserved 212.209 (DME) MIC-KEY Skin Level Gastrostomy Tube (MIC-KEY Button) and Supplies for Beneficiaries of All Ages 212.210 DME MIC-KEY Percutaneous Cecostomy Tube (MIC-KEY button) for Beneficiaries of All Ages 212.211 Reserved 212.212 (DME) Specialized Rehabilitative Equipment, All Ages 212.213 (DME) Specialized Wheelchairs and Wheelchair Seating Systems for Individuals Age Two Through Adult 212.214 Reserved 212.300 Medical Supplies, All Ages 212.400 Nutritional Formulae for Individuals Under Age 21 212.500 Food Thickeners, All Ages 212.600 Orthotic Appliances and Prosthetic Devices, All Ages 212.700 Oxygen and Oxygen Supplies, All Ages

220.000 PRIOR AUTHORIZATION 221.000 Prosthetics Services Prior Authorization 221.100 Request for Prior Authorization 221.200 Filing for Prior Authorization 221.300 Approvals of Prior Authorization 221.400 Denial of Prior Authorization Request 221.500 Reconsideration of Denials 221.600 Fair Hearing Request

230.000 REIMBURSEMENT 231.000 Prosthetics Service Method of Reimbursement 231.010 Fee Schedule 232.000 Specialized Wheelchair, Seating and Rehabilitative Equipment Reimbursement for Repairs 233.000 Orthotic and Prosthetic Reimbursement for Repairs 234.000 Durable Medical Equipment (DME) Reimbursement for Repairs 235.000 Augmentative Communication Device Reimbursement for Repairs 236.000 Reimbursement for Repair of the Enteral Nutrition Pump 237.000 Rate Appeal Process

240.000 billing procedures 241.000 Introduction to Billing 242.000 CMS-1500 Billing Procedures 242.100 HCPCS Procedure Codes 242.105 Payment Methodology 242.110 Respiratory and Diabetic Equipment, All Ages 242.111 Initial Rental of a DME Item for Individuals of All Ages 242.112 Home Blood Glucose Monitor and Supplies – Pregnant Women Only, All Ages 242.120 Medical Supplies for Beneficiaries of All Ages 242.121 Food Thickeners, All Ages 242.122 Jobst Stocking for Beneficiaries of All Ages 242.123 Negative Pressure Wound Therapy Pump Accessories and Supplies for Beneficiaries Ages 2 Years and Older 242.130 Diapers and Underpads for Beneficiaries Ages 3 Years and Older 242.140 Electronic Blood Pressure Monitor and Cuff, All Ages 242.150 Nutritional Formulae for Child Health Services (EPSDT) Beneficiaries Under 21 Years of Age 242.151 Pedia-Pop 242.152 Enteral Nutrition Infusion Pump and Enteral Feeding Pump Supply Kit 242.153 MIC-KEY Skin Level Gastrostomy Tube (MIC-KEY Button) and MIC- KEY Percutaneous Cecostomy Tube and Supplies for Beneficiaries of All Ages 242.154 Nasogastric Tubing for Individuals Under Age 21 242.155 Billing and Reimbursement Protocol for FM (Frequency Modulation) System and Replacement Cochlear Implant Parts 242.160 Durable Medical Equipment, All Ages 242.161 Reserved 242.170 Apnea Monitors for Beneficiaries Under 1 Year of Age 242.180 Orthotic Appliances for Beneficiaries of All Ages 242.190 Prosthetic Devices for Beneficiaries of All Ages 242.191 Wheelchairs and Wheelchair Seating Systems for Individuals Ages Two Through Adult 242.192 Specialized Rehabilitative Equipment for Beneficiaries of All Ages 242.193 Augmentative Communication Device for Beneficiaries of All Ages 242.194 Replacement, Growth and Modification of Specialized Wheelchairs and Wheelchair Seating Systems 242.195 Repairs of Specialized Wheelchairs and Wheelchair Systems 242.200 National Place of Service and Modifier Codes 242.300 Billing Instructions - Paper Only 242.310 Completion of CMS-1500 Claim Form 242.400 Special Billing Procedures 242.401 National Drug Codes (NDCs) 242.402 Billing of Multi-Use and Single-Use Vials 242.410 Completion of Form - Medicare/Medicaid Deductible And Coinsurance 242.420 Freight Charges, All Ages

|200.000 GENERAL INFORMATION | | |201.000 Arkansas Medicaid Participation Requirements for |11-1-09 | |Prosthetics Providers | |

Prosthetics providers must meet the Provider Participation and enrollment requirements contained within Section 140.000 of this manual as well as the following criteria to be eligible to participate in the Arkansas Medicaid Program: Durable Medical Equipment, Prosthetics, Orthotics and Medical Suppliers must be enrolled in the Title XVII (Medicare) Program as a durable medical equipment/oxygen, orthotic appliances or prosthetic device provider. A copy of the verification letter that reflects the provider’s Medicare supplier number must be submitted with the provider application and Medicaid contract. A separate letter and Medicare supplier number must be submitted for each Medicaid service location.

Providers must provide Arkansas Medicaid proof of DME Medicare accreditation and surety bond dated on or after October 1, 2009. New Providers will be required to submit Medicare accreditation and surety bond upon enrollment.

NOTE: The orthotics/prosthetics provider should maintain accreditation by the American Board for Certification in Orthotics and Prosthetics. The provider should ensure that staff providing patient care (including but not limited to direct care, evaluations, diagnoses, fabrication fittings and follow up care) are accredited by the American Board for Certification in Orthotics and Prosthetics and meet all national licensing and certification requirements and all licensing and certifications required by the State of Arkansas.

|201.100 Providers in Arkansas and Bordering States |10-13-03 |

Providers in Arkansas and the six bordering states (Louisiana, Mississippi, Missouri, Oklahoma, Tennessee and Texas) may be enrolled as routine services providers if they meet all Arkansas Medicaid participation requirements outlined above.

|201.110 Routine Services Provider |12-15-14 |

A. Routine services providers may be enrolled in the program as providers of routine services. B. Reimbursement may be available for durable medical equipment/oxygen, orthotic appliances and prosthetic devices covered in the Arkansas Medicaid Program. C. Claims must be filed according to the specifications in this manual. This includes assignment of ICD and HCPCS codes for all services rendered.

|201.200 Providers in Non-Bordering States |3-1-11 |

Providers in non-bordering states may enroll only as limited services providers.

|201.210 Limited Services Provider |3-1-11 |

A. Limited services providers may enroll in the Arkansas Medicaid program to provide prior authorized or emergency services only. B. Emergency services are defined as inpatient or outpatient hospital services that a prudent layperson with an average knowledge of health and medicine would reasonably believe are necessary to prevent death or serious impairment of health and which, because of the danger to life or health, require use of the most accessible hospital available and equipped to furnish those services. Source: 42 U.S. Code of Federal Regulations §422.2 and §424.101. C. Prior authorized services are those that are medically necessary and not available in Arkansas. Each request for these services must be made in writing, forwarded to the Division of Medical Services, Utilization Review Section and approved before the service is provided. See Section 220.000 of this manual for instructions for obtaining prior authorization. To enroll, a non-bordering state provider must download an Arkansas Medicaid application and contract from the Arkansas Medicaid website and submit the application, contract and claim to Arkansas Medicaid Provider Enrollment. A provider number will be assigned upon receipt and approval of the provider application and Medicaid contract. View or print the Utilization Review Section contact information. View or print the provider enrollment and contract package (Application Packet). View or print Medicaid Provider Enrollment Unit contact information. D. Limited services provider claims will be manually reviewed prior to processing to ensure that only emergency or prior authorized services are approved for payment. These claims should be mailed to the Arkansas Division of Medical Services Program Communications Unit. View or print the Arkansas Division of Medical Services Program Communications Unit contact information.

Providers such as pharmacies, home health agencies or hospitals which have agreements with Medicaid to provide services to Medicaid beneficiaries must complete a separate Medicaid contract and provider application to provide durable medical equipment/oxygen, orthotic appliances and prosthetic devices. A separate provider number will be assigned.

|202.000 The Prosthetics Provider Role in the Child Health |10-13-03 | |Services (EPSDT) Program | |

The Child Health Services (EPSDT) program is a federally mandated child health component of Medicaid. It is designed to bring comprehensive health care to individuals eligible for medical assistance from birth up to their 21st birthday. The purpose of this program is to detect and treat health problems in the early stages and to provide preventive health care, including necessary immunizations. Child Health Services (EPSDT) combines case management and support services with screening, diagnostic and treatment services delivered on a periodic basis.

If a condition is diagnosed through a Child Health Services (EPSDT) screen that requires treatment services not normally covered under the Arkansas Medicaid Program, those treatment services will also be considered for reimbursement if the service is medically necessary and permitted under federal Medicaid regulations.

Prosthetics providers who are Child Health Services (EPSDT) providers are encouraged to refer to the Child Heath Services (EPSDT) provider manual for additional information.

|203.000 Documentation Requirements |11-1-09 |

Prosthetics providers must keep and properly maintain written records. Along with the required enrollment documentation, which is located in Section 141.000, the following records must be included in the beneficiary’s case file maintained by the provider.

|203.100 Documentation in Beneficiary’s Case Files |11-1-09 |

The provider must develop and maintain sufficient written documentation to support each service for which billing is made. All entries in a beneficiary’s file must be signed and dated by the individual who provided the service, along with the individual’s title. The documentation must be kept in the beneficiary’s case file.

Documentation should consist of, at a minimum, material that includes: A. An audit trail between the prosthetics provider, the beneficiary, the beneficiary’s primary care physician and the Division of Medical Services. B. When applicable, documentation including the request for and approval of prior authorization and/or the request for and approval of extension of benefits for services provided. C. The prescription for prosthetics services, signed and dated by the beneficiary’s primary care physician. D. The prosthetics provider’s signed and dated: 1. Certification that used equipment is reconditioned, is in good working order and has no defects in workmanship or material 2. The beneficiary’s consent to receive services 3. Notification of termination of prosthetics services 4. Documentation to reflect that necessary training and orientation has been provided to the beneficiary and any other applicable persons 5. Any additional or special documentation, requested in writing, that is needed to provide fair and impartial review of individual cases, requested in writing.

|203.200 Reserved |11-1-09 | |203.300 Reserved |11-1-09 | |204.000 Electronic Signatures |10-8-10 |

Medicaid will accept electronic signatures provided the electronic signatures comply with Arkansas Code § 25-31-103 et seq.

|210.000 PROGRAM COVERAGE | | |211.000 Scope |10-13-03 |

There are several broad areas of service provision in the Prosthetics manual. Services provided include durable medical equipment, which also encompasses specialized wheelchairs, wheelchair seating systems, specialized rehabilitation equipment and the augmentative communication device. Other programs covered in the Prosthetics manual include medical supplies, nutritional formulas, diapers and underpads, prosthetic devices and orthotic appliances.

|211.100 Condition for Provision of Services |4-1-09 |

The following conditions must be met for the provision of services: A. The beneficiary must reside in the state of Arkansas. B. The individual must be an Arkansas Medicaid beneficiary. C. Services must be medically necessary and prescribed by the beneficiary’s primary care physician (PCP) unless the beneficiary is exempt from PCP requirements. D. A beneficiary is accepted for services on the basis of a reasonable expectation that his or her medical needs can be adequately met by the provider. E. When applicable, Form DMS-679, titled Medical Equipment Request for Prior Authorization and Prescription, must be utilized when requesting prior authorization for wheelchairs, wheelchair seating systems, wheelchair repairs, for eligible Medicaid beneficiaries. View or print form DMS-679 and instructions for completion. F. When applicable, form DMS-679A, titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components, must be utilized when requesting prior authorization for some medical supplies (i.e.: compression burn garments), orthotics appliances, prosthetic devices and durable medical equipment, excluding wheelchairs, wheelchair seating systems or wheelchair repairs, when these items are prescribed for eligible Medicaid beneficiaries. View or print form DMS-679A and instructions for completion. G. When applicable, form DMS-602, titled Request for Extension of Benefits for Medical Supplies for Medicaid Beneficiaries Under Age 21, must be utilized when requesting extension of benefits for medical supplies for beneficiaries under age 21. View or print form DMS-602 and instructions for completion. H. When applicable, form DMS-699, titled Request for Extension of Benefits, must be utilized when requesting extension of benefits for diapers and underpads for eligible beneficiaries ages three and older. View or print form DMS-699. I. The beneficiary must reside in his or her own dwelling, an apartment, relative’s or friend’s home, boarding home, residential care facility or any other type of supervised living situation that is not required to provide prosthetics services as part of the facility’s participation agreement as a service provider. A beneficiary’s place of residence for services may not include a hospital, skilled nursing facility, intermediate care facility or any other supervised living situation that is required to provide prosthetics services under a provider agreement or contract as required by federal, state or local regulation.

|211.200 Physician’s Role in the Prosthetics Program |4-1-09 |

At least once every 6 months, the primary care physician must certify the medical necessity for services and prescribe them by signing and dating a prescription. When applicable, the primary care physician must complete a prior authorization form; either a Medical Equipment Request for Prior Authorization and Prescription Form (form DMS-679) when prescribing services for wheelchairs and wheelchair seating systems, or wheelchair repairs or a form DMS-679A, titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components, when prescribing orthotic appliances, prosthetic devices or durable medical equipment. View or print form DMS-679 and instructions for completion. View or print form DMS-679A and instructions for completion.

|211.300 Prosthetics Service Provision |4-6-15 |

At least once every 6 months, the prosthetics provider must receive a prescription for prosthetics services from the beneficiary’s primary care physician and, when applicable: A. Prepare a Medical Equipment Request for Prior Authorization and Prescription Form (form DMS-679) for wheelchairs, wheelchair seating systems or wheelchair repairs for beneficiaries 21 years of age or older and for specified services for beneficiaries under age 21. View or print form DMS-679 and instructions for completion. B. Prepare a Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components for some medical supplies (i.e.: compression burn garments), orthotic appliances, prosthetic devices and durable medical equipment for beneficiaries 21 years of age or older and for specified services for beneficiaries under age 21. View or print form DMS-679A and instructions for completion. C. Send the prepared request for prior authorization to the beneficiary’s primary care physician for prescription and D. Send the completed Medical Equipment Request for Prior Authorization and Prescription Form (form DMS-679) to the Arkansas Foundation for Medical Care for prior authorization. View or print the AFMC contact information. E. Send the Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components to the Arkansas Foundation for Medical Care, Inc. (AFMC) for prior authorization. View or print the AFMC contact information.

As necessary, the provider must: A. Deliver and set up the prescribed equipment in the beneficiary’s home, B. Teach the beneficiary, families and caregivers the correct use and maintenance of equipment, C. Repair equipment within 3 working days of notification, D. Retrieve from the beneficiary’s home equipment no longer prescribed for the beneficiary and E. Provide necessary documentation.

|211.400 Prescription and Referral Renewal |4-1-09 |

At least once every 6 months, but within 30 working days before the end of currently prescribed or prior authorized prosthetics services, the prosthetics provider must obtain a new prescription from the beneficiary’s primary care physician and, if applicable, send a new prior authorization form to the applicable entity. The primary care physician must initially review either form DMS-679 or form DMS-679A, and, based upon the physician’s certification of medical necessity, prescribe services. Form DMS-679 or form DMS-679A must then be reviewed by the applicable entity and services must be prior authorized. If services are prescribed, and when applicable, prior authorized, services may be furnished for a maximum of 6 months from the date of the prescription.

|211.500 Service Initiation Delays |8-1-05 |

If all prescribed prosthetics services are not begun by the prosthetics provider within 30 working days of the prescription date, the prosthetics provider must notify the beneficiary and the beneficiary’s primary care physician in writing and explain the delay. The provider must retain documentation justifying the service delay.

|211.600 Termination of Services |8-1-05 |

If prosthetics services are terminated, the provider must notify the beneficiary’s primary care physician and the beneficiary (if not deceased) in writing, within 10 working days of the termination, documenting the effective date of and reasons for the termination.

|211.700 Exclusions |8-1-05 |

Services that are not covered under the Arkansas Medicaid Prosthetics Program include but are not limited to: A. Over-the-counter items provided through the Arkansas Medicaid Pharmacy Program (except as specified). B. Over-the-counter drugs (except as specified). C. Products that bear the Federal legend “Caution: Federal Law Prohibits Dispensing Without A Prescription” (except as specified). D. Specialized wheelchair equipment that has been previously purchased by any payer. Specialized wheelchair equipment may not be reordered unless the patient’s condition changes and necessitates a change in prescription. This change in condition must be thoroughly documented. E. Wheelchairs for individuals under 21 years of age within two years of the purchase of a specialized wheelchair. F. Wheelchairs for individuals age 21 and over within five years of the purchase or rental of a wheelchair. G. Foodstuffs. H. Hyperalimentation. I. Services that duplicate any other service provided to the patient or that replace existing patient supports.

|211.800 Electronic Filing of Extension of Benefits |4-1-09 |

Form DMS-699, titled Request for Extension of Benefits, serves as both a request form and a notification of approval or denial of extension of benefits when requesting diapers and underpads for beneficiaries age 3 and older. If the benefit extension is approved, the form returned to the provider will contain a Benefit Extension Control Number. The approval notification will also list the procedure codes approved for benefit extension, the approved dates or date-of-service range and the number of units of service (or dollars, when applicable) authorized.

Upon notification of a benefit extension approval, providers may file the benefit extension claims electronically, entering the assigned Benefit Extension Control Number in the Prior Authorization (PA) number field. Subsequent benefit extension requests to the Utilization Review Section will be necessary only when the Benefit Extension Control Number expires or when a beneficiary’s need for services unexpectedly exceeds the amount or number of services granted under the benefit extension.

Form DMS-679A, titled Prescription and Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components serves as a request form when requesting extension of benefits for the augmentative communication device. AFMC will notify providers of approval or denial by letter.

|212.000 Services Provided | | |212.100 Diapers and Underpads for Individuals Age 3 and Older |6-1-09 |

Diapers and underpads are covered by the Arkansas Medicaid Program but are benefit limited and must be medically necessary. A. Medical Necessity Diaper services must be medically necessary and the medical condition that prohibits the ability to potty train must be documented. Only patients with a medical condition that results in incontinence of the bladder and/or bowel may receive diapers through the Home Health and Prosthetics Programs. This coverage does not apply to infants who would be in diapers regardless of their medical condition. Medicaid does not cover underpads or diapers for beneficiaries under the age of 3 years. B. Benefit Limit The benefit limit for diapers and underpads is $130.00 per month, per beneficiary, for diapers of any size and underpads. The benefit limit applies to any diaper or underpad, or any combination, whether provided through the Prosthetics Program, the Home Health Program or both. The limit on diapers and underpads is separate from the limit established for home health and durable medical equipment (DME) medical supplies. The benefit may be extended with proper documentation. C. Extension of Benefits for Diapers and Underpads To obtain an extension of benefits for diapers and underpads, the following information must be submitted to the Prosthetics Services Reviewer, DMS Utilization Review. View or print the DMS Utilization Review contact information. 1. A completed Medicaid Form DMS-699, titled Request for Extension of Benefits for the requested time period prior to the delivery of the product. View or print form DMS-699. 2. Documentation supported by the medical record substantiating the medical necessity of an extension of benefits, including the prescription(s) for all prescribed incontinence products.

|212.200 Durable Medical Equipment (DME), All Ages |8-1-05 |

Durable medical equipment (DME) is equipment that can withstand repeated use and is used to serve a medical purpose.

Depending on the item involved, DME may be purchased for or by a beneficiary or may be rented. The equipment may be new or, in special circumstances, used equipment.

|212.201 (DME) Apnea Monitors for Infants Under Age 1 |3-1-10 |

Arkansas Medicaid covers apnea monitors only for infants less than one (1) year of age. Use of the apnea monitor must be medically necessary and prescribed by a physician.

A primary care physician (PCP) is not required until an infant's Medicaid eligibility has been determined. No PCP referral for medical services is required for retroactive eligibility periods.

For the initial certification, the prescribing physician must sign form DMS-679A titled Prescription and Prior Authorization Request for Medical Equipment Excluding Wheelchairs and Wheelchair Components. The physician’s signature must be an original, not a stamp. When an apnea monitor is prescribed during a hospital discharge, the physician ordering the apnea monitor must be in consultation with a neonatologist or pulmonologist.

As necessary, the primary care physician's (PCP’s) name and provider number must also be indicated on DMS-679A titled Prescription and Prior Authorization Request for Medical Equipment Excluding Wheelchairs and Wheelchair Components. The PCP's signature is not required on the initial certification but he or she must sign all re-certifications.

A prior authorization request for an apnea monitor must be submitted to AFMC on form DMS-679A titled Prescription and Prior Authorization Request for Medical Equipment Excluding Wheelchairs and Wheelchair Components. View or print form DMS-679 and instructions for completion. View or print AFMC contact information.

Compliance, and the download monitor report, must accompany the request for continued use of the apnea monitor following the initial sixty-day time period.

Prior authorization is not required for the initial sixty-day period of use of the monitor. If the apnea monitor is needed longer than an initial sixty-day period, prior authorization is required.

A new prescription, documentation of compliance during the initial sixty- day period and proof of medical necessity for the continuation of monitoring are required.

The following criteria, established by the American Academy of Pediatrics, are to be used to evaluate the need for an apnea monitor after the initial sixty-day period: A. Evidence exists that preterm infants are at greater risk of extreme apnea episodes until approximately 43 weeks post conceptual age. Monitoring may be indicated until 43 weeks post conceptual age unless extreme episodes persist beyond that time. Home monitoring may be indicated for other selected groups of infants, as well. B. Home cardiorespiratory monitoring may be warranted for premature infants who are at high risk of recurrent episodes of apnea, bradycardia, and hypoxemia after hospital discharge. The use of home cardiorespiratory monitoring in this population should be limited to approximately 43 weeks post conceptual age or after the cessation of extreme episodes, whichever comes last. C. Home cardiorespiratory monitoring may be warranted for infants who are technology dependent (tracheostomy, supplemental oxygen, continuous positive airway pressure, etc.), have unstable airways, have rare medical conditions affecting regulation of breathing or have symptomatic chronic lung disease. In many of these cases, the use of pulse oximetry monitoring is superior and preferred over simple cardiorespiratory monitoring. D. Other infants who may benefit from home cardiorespiratory home monitoring include: 1. Infants who have experienced an apparent life-threatening event (ALTE) An ALTE is defined as “an episode that is frightening to the observer and is characterized by some combination of apnea (central or occasionally obstructive), color change (usually cyanotic or pallid but occasionally erythematous or plethoric), marked change in muscle tone (usually marked limpness), choking or gagging.” 2. Infants with tracheotomies or anatomic abnormalities that may compromise their airway 3. Infants with metabolic or neurological abnormalities affecting respiratory control 4. Infants with chronic lung disease of prematurity (bronchopulmonary dysplasia, BPD), especially those requiring some form of respiratory support E. Parents or caregivers must be counseled regarding the purpose of the home cardiorespiratory monitoring and realistic expectations of what it can and cannot contribute to an infant’s well being. 1. When monitoring is used in the home, parents and other caregivers must be trained in observation techniques, operation of the monitor, and infant cardiopulmonary resuscitation prior to the use of the monitor. 2. Medical and technical support staff should always be available for direct or telephone consultation. F. Duration and discontinuation of home cardiorespiratory monitoring 1. When home monitoring is prescribed for apnea/bradycardia in preterm infants, the physician should establish a plan for review of clinical and event (download) data at 43 weeks post conceptual age. If monitoring is to be continued beyond that time, documentation should be provided as to why it should be continued as well as a plan for reevaluation. 2. Infants whose mothers have unsure dates (uncertain post- conceptual age) may be monitored until the infants are at least 43 weeks post conceptual age. 3. When home monitoring is prescribed for indications other than apnea/bradycardia in preterm infants, continuation of monitoring will be reviewed on a case-by-case basis. 4. Discontinuation of home monitoring should be a clinical decision based on a combination of clinical data and cardiorespiratory monitor event data. 5. Decisions regarding discontinuation of home monitoring should NOT be based on single-night pneumograms, which have no proven predictive value in this setting.

|212.202 (DME) Augmentative Communication Device (ACD), All |4-1-09 | |Ages | |

The augmentative communication device (ACD) is covered for beneficiaries of all ages. Coverage for beneficiaries under 21 years of age must result from an EPSDT screen. There is a $7,500.00 lifetime benefit for augmentative communication devices. When a beneficiary who is under age 21 has met the lifetime benefit and it is determined that additional equipment is medically necessary, the provider may request an extension of benefits by submitting form DMS-679A. View or print form DMS-679A.

The ACD is also covered for Medicaid beneficiaries 21 years old and older. Prior authorization is required on the device and on repairs of the device. For beneficiaries who are age 21 and above, there is a $7,500.00 lifetime benefit without benefit extensions.

The Arkansas Medicaid Program will not cover ACDs that are prescribed solely for social or educational development.

Training in the use of the device is not included and is not a covered cost.

Prior authorization must be requested for repairs of equipment or associated items after the expiration of the initial maintenance agreement.

The following information must be submitted when requesting prior authorization for ACDs for Medicaid beneficiaries.

Submit form DMS-679A, titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components. View or print form DMS-679A and instructions for completion. The form should be accompanied by: A. A current augmentative communication evaluation completed by a multidisciplinary team consisting of, at least, a speech/language pathologist and an occupational therapist. The team may consist of a physical therapist, regular and special educators, caregivers and parents. The speech-language pathologist must lead the team and sign the ACD evaluation report. (For the qualifications of the team members, see the Hospital/Critical Access Hospital/End Stage Renal Disease provider manual.) 1. The team must use an interdisciplinary approach in the evaluation, incorporating the goals, objectives, skills and knowledge of various disciplines. The team must use at least three ACD systems, with written documentation of each usage included in the ACD assessment. 2. The evaluation report must indicate the medical reason for the ACD. The report must give specific recommendations of the system and justification of why one system is more appropriate than another system. 3. The evaluation report must be submitted to the prosthetics provider who will request prior authorization for the ACD. B. Written denial from the insurance company if the individual has other insurance.

This information must be submitted to AFMC. View or print AFMC contact information.

Benefit Limit

There is a $7500 lifetime benefit for augmentative communication devices. When the beneficiary under age 21 has met the limit and it is determined that additional equipment is necessary, the provider may request an extension of benefits.

In order to obtain an extension of the $7,500.00 lifetime benefit for beneficiaries under 21 years of age, a medical necessity determination for additional equipment is required. The provider must submit a form DMS-679A, a completed Medicaid claim and medical records substantiating medical necessity that the beneficiary cannot function using his or her existing equipment and whether the equipment can be repaired or needs repair. The information must be sent to AFMC. View or print form DMS- 679A titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components. View or print the AFMC contact information.

The provider will be notified in writing of the approval or denial of the request for extended benefits.

|212.203 Cochlear Implants for Beneficiaries Under Age 21 |4-15-11 |

Cochlear implants are covered through the Arkansas Medicaid Physician or Prosthetics Programs for eligible Medicaid beneficiaries under the age of 21 years through the Child Health Services (EPSDT) program when prescribed by a physician.

The replacements of lost, stolen or damaged external components (not covered under the manufacturer’s warranty) are covered when prior authorized by Arkansas Medicaid.

Reimbursements for manufacturer’s upgrades will not be made. An upgrade of a speech processor to achieve aesthetic improvement, such as smaller profile components, or a switch from a body-worn, external sound processor to a behind-the-ear (BTE) model or technological advances in hardware are not considered medically necessary and will not be approved.

A. Speech Processor Arkansas Medicaid will not cover new generation speech processors if the existing one is still functional. Consideration of the replacement of the external speech processors will be made only in the following instances: 1. The beneficiary loses the speech processor. 2. The speech processor is stolen. 3. The speech processor is irreparably damaged. Additional medical documentation supporting medical necessity for replacement of external components should be attached to any requests for prior authorization. B. Personal FM (Frequency Modulation) Systems Arkansas Medicaid will reimburse for a personal FM system for use by a cochlear implant beneficiary when prior authorized and not available from any other source (i.e., educational services). The federal Individuals with Disabilities Education Act (IDEA) requires public school systems to provide FM systems for educational purposes for students starting at age three (3). Arkansas Medicaid does not cover FM systems for children who are eligible for this service through IDEA. A request for prior authorization may be submitted for medically necessary FM systems (procedure code V5273 for use with cochlear implant) that are not covered through IDEA; each request must be submitted with documentation of medical necessity. These requests will be reviewed on an individual basis. C. Replacement, Repair, Supplies The repair or replacement of the cochlear implant external speech processor and other supplies (including batteries, cords, battery charger and headsets) will be covered in accordance with the Arkansas Medicaid policy for the Physician and Prosthetics Programs. The covered services must be billed by an Arkansas Medicaid Physician or Prosthetics provider. The supplier is required to request prior authorization for repairs or replacements of external implant parts. D. Prior Authorization A request for prior authorization of a medically necessary FM system (V5273 for use with cochlear implant) and replacement cochlear implant parts requires a paper submission to the Arkansas Foundation for Medical Care (AFMC) using form DMS-679A. All documentation supporting medical necessity should be attached to the form. The provider will be notified in writing of the approval or denial of the request for prior authorization. View or print form DMS-679A and instructions for completion. Prior authorization does not guarantee payment for services or the amount of payment for services. Eligibility for, and payment of, services are subject to all terms, conditions and limitations of the Arkansas Medicaid Program. Documentation must support medical necessity. The provider must retain all documentation supporting medical necessity in the beneficiary’s medical record.

The following procedure codes must be prior authorized. Providers should use the following procedure codes when requesting prior authorization for replacement parts for cochlear implant devices. Applicable manufacturer warranty options must be exhausted before coverage is considered. Most warranties include one replacement for a stolen, lost or damaged piece of equipment free-of-charge by the manufacturer.

The table below contains new and existing HCPCS procedure codes for FM systems for use with cochlear implant and replacement cochlear implant parts.

NOTE: Coverage and billing requirements for the physician provider for cochlear device implantation are unchanged.

|Procedure |M1 |Age Restriction |PA |Payment | |Code | | | |Method | |L8627* |EP |0-20 |Y |Manually | | | | | |Priced | |L8628* |EP |0-20 |Y |Manually | | | | | |Priced | |L8629* |EP |0-20 |Y |Manually | | | | | |Priced |

*Denotes paper claim

See Section 242.155 for information on billing and reimbursement for FM system and replacement cochlear implant parts.

|212.204 (DME) Electronic Blood Pressure Monitor and Cuff for |4-1-09 | |Beneficiaries of All Ages | |

Arkansas Medicaid covers the automatic electronic blood pressure monitor for beneficiaries of all ages as a rental-only item. A provider must substantiate that an accurate blood pressure reading cannot be obtained by using a regular blood pressure monitor. Providers must also supply one disposable blood pressure cuff each month.

Prior authorization is required for the use of this item. Providers may request prior authorization by submitting form DMS-679A, Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components to AFMC. View or print form DMS-679A and instructions for completion. View or print AFMC contact information.

|212.205 (DME) Enteral Nutrition Infusion Pump and Enteral |4-1-09 | |Feeding Pump Supply Kit for Beneficiaries Under Age 21 | |

The request for an enteral nutrition pump is covered on a case-by-case basis for beneficiaries under age 21 who require supplemental feeding because of medical necessity. Sufficient medical documentation must be provided to establish that the enteral nutrition infusion pump is medically necessary (e.g., supplemental feeding must be given over an extended period of time due to reflux, cystic fibrosis, etc.). The PCP or appropriate physician specialist must prescribe the pump, citing the medical reason that bolus feeds are inappropriate.

Reimbursement for use in the home may be made for the pump supply kit when the feeding method involves an enteral nutrition infusion pump. The pump supply kit and the infusion pump require prior authorization from AFMC using form DMS-679A titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components. View or print AFMC contact information. View or print form DMS-679A and instructions for completion.

The enteral feeding pump supply kit, necessary for the administration of the nutrients when the feeding method involves an enteral nutrition infusion pump, is reimbursed on a per-unit basis with 1 day equaling 1 unit of service. A maximum of 1 unit per day is allowed. The pump supply kit includes pump sets, containers and syringes necessary for administration of the nutrients.

Reimbursement for the enteral nutrition infusion pump is based on a rent- to-purchase methodology. Each unit reimbursed by Medicaid will apply towards the purchase price established by Medicaid. Reimbursement will only be approved for new equipment. Used equipment will not be prior authorized. View or print form DMS-679A and instructions for completion.

Requests for prior authorization for enteral pump repairs must be mailed to AFMC. Form DMS-679A titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components, must be used to request prior authorization. View or print form DMS-679A and instructions for completion.

|212.206 (DME) Home Blood Glucose Monitor, Pregnant Women Only,|8-1-05 | | | | |All Ages | |

Arkansas Medicaid covers the home blood glucose monitor for pregnant women of all ages. Prior authorization is not required for use of this device. A. Patient Eligibility 1. Pregestational diabetes. Women on an oral hypoglycemic or insulin when the pregnancy is diagnosed. 2. Women that are being followed by a physician for elevated fasting hyperglycemia, but not on an oral hypoglycemic or insulin when the pregnancy is diagnosed. 3. Women demonstrating glucose intolerance during the pregnancy as demonstrated by an elevated three-hour glucose tolerance test. B. Criteria for glucose intolerance 1. Demonstration of an elevated one-hour glucose tolerance test of greater than 140 mg/deciliter on a non-fasting value. 2. Elevation of two or more values on a three-hour glucose tolerance test above the accepted cut-off points of: a. Fasting, less than 105 b. One-hour, less than 190 c. Two-hour, less than 165 d. Three-hour, less than 145

|212.207 (DME) Insulin Pump and Supplies, All Ages |4-1-09 |

Insulin pumps and supplies are covered by Arkansas Medicaid for beneficiaries of all ages.

Prior authorization is required for the insulin pump. A prescription and proof of medical necessity are required. The patient must be educated on the use of the pump, but the education is not a covered service.

Insulin is also not covered because it is covered in the prescription drug program.

The following criteria will be utilized in evaluating the need for the insulin pump: A. Insulin-dependent diabetes that is difficult to control. B. Fluctuation in blood sugars causing both high and low blood sugars in a patient on at least 3, if not 4, injections per day. C. Beneficiary’s motivation level in controlling diabetes and willingness to do frequent blood glucose monitoring. D. Beneficiary’s ability to learn how to use the pump effectively. This will have to be evaluated and documented by a professional with experience in the use of the pump. E. Determination of the beneficiary’s suitability to use the pump should be made by a diabetes specialist or endocrinologist. F. Beneficiaries not included in one of these categories will be considered on an individual basis.

Prior authorization requests for the insulin pump and supplies must be submitted on form DMS-679A titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components, to AFMC. View or print form DMS-679A and instructions for completion. View or print AFMC contact information.

|212.208 Reserved |8-1-05 | |212.209 (DME) MIC-KEY Skin Level Gastrostomy Tube (MIC-KEY |7-1-14 | |Button) | | |and Supplies for Beneficiaries of All Ages | |

The Arkansas Medicaid Program reimburses for the MIC-KEY Skin Level Gastrostomy Tube (MIC-KEY button) and supplies for Medicaid-eligible beneficiaries of all ages. Prior authorization (PA) from AFMC is required.

When requesting prior authorization, form DMS-679A titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components, must be completed and sent, along with sufficient medical documentation, to AFMC.

The MIC-KEY Kit is benefit-limited to 2 per state fiscal year (SFY). The accessories, extension sets and adapters are covered under the $250 medical supply benefit limit.

Benefit extensions will be considered on a case-by-case basis if proven to be medically necessary. Prior authorization must be obtained from AFMC for any extensions using form DMS-679A. View or print AFMC contact information. View or print form DMS-679A and instructions for completion.

|212.210 DME MIC-KEY Percutaneous Cecostomy Tube (MIC-KEY |10-1-15 | |button) for Beneficiaries of All Ages | |

The Arkansas Medicaid Program reimburses for the MIC-KEY Percutaneous Cecostomy Tube (MIC-KEY button) for Medicaid-eligible beneficiaries of all ages. Arkansas Medicaid will reimburse the MIC-KEY Skin Level Gastrostomy Tube for all ages, when used for the management of severe fecal incontinence (see diagnosis codes below) requiring percutaneous cecostomy tube placement for bowel evacuation. Prior authorization (PA) from AFMC is required.

When requesting prior authorization, form DMS-679A titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs and Wheelchair Components, must be completed and sent, along with sufficient medical documentation, to AFMC. View or print AFMC contact information. View or print form DMS-679A and instructions for completion.

The MIC-KEY button is benefit-limited to 2 per state fiscal year (SFY).

The MIC-KEY button for a Percutaneous Cecostomy Tube requires use of the following diagnosis codes. (View ICD codes.)

The MIC-KEY button for a Percutaneous Cecostomy Tube requires use of the following CPT codes:

|44300 |49442 |49450 |

|212.211 Reserved |8-1-05 | |212.212 (DME) Specialized Rehabilitative Equipment, All Ages |4-1-09 |

Arkansas Medicaid covers specialized rehabilitative equipment for Medicaid-eligible beneficiaries of all ages.

Some items of specialized equipment require prior authorization from AFMC. View or print form DMS-679A and instructions for completion. View or print AFMC contact information.

|212.213 (DME) Specialized Wheelchairs and Wheelchair Seating |4-6-15 | |Systems | | |for Individuals Age Two Through Adult | |

Arkansas Medicaid covers specialized wheelchairs and wheelchair seating systems for individuals age two through adulthood.

Some items of specialized equipment require prior authorization from the Arkansas Foundation for Medical Care (AFMC). View or print form DMS-679 and instructions for completion. View or print the AFMC contact information.

|212.214 Reserved |8-1-05 | |212.300 Medical Supplies, All Ages |7-1-17 |

The Arkansas Medicaid Program reimburses home health providers and prosthetics providers for covered medical supplies up to a maximum of $250.00 per month, per beneficiary. The $250.00 may be provided by the Home Health program, the Prosthetics program or a combination of the two.

A beneficiary may not receive more than a total of $250.00 of supplies per month unless an extension has been granted. Extensions will be considered for beneficiaries under age 21 in the Child Health Services (EPSDT) program if documentation verifies medical necessity.

A provider must request an extension of the benefit limit for a Medicaid beneficiary under age 21 by completing the Request for Extension of Benefits for Medical Supplies for Medicaid Recipients Under Age 21 (form DMS-602.) View or print form DMS-602 and instructions for completion.

The Arkansas Medicaid program covers medical supplies using a specific HCPCS procedure code for each specific item. Only supply items that are listed and have a corresponding payable HCPCS procedure code are covered.

Supplies are healthcare-related items that are consumable or disposable, or cannot withstand repeated use by more than one individual, and that are required to address an individual medical disability, illness or injury.

Equipment and appliances are items that are primarily and customarily used to serve a medical purpose; generally are not useful to an individual in the absence of a disability, illness or injury; can withstand repeated use; and can be reusable or removable. Medical coverage of equipment and appliances is not restricted to items covered as durable medical equipment in the Medicare program.

Arkansas has a list of preapproved medical equipment, supplies and appliances for administrative ease, but the state is prohibited from having absolute exclusions of coverage on medical equipment, supplies or appliances. Items not available on the preapproval list may be requested on a case-by-case basis. When denying a request, the state must inform the beneficiary of the right to a fair hearing.

|212.400 Nutritional Formulae for Individuals Under Age 21 |8-1-05 |

Nutritional formulae may be covered by the Arkansas Medicaid Program when prescribed by a physician and documented as medically necessary for beneficiaries under age 21 participating in the Child Health Services (EPSDT) Program. The Women, Infants and Children Program (WIC) must be accessed first for individuals who are age 0 through age 5.

Nutritional formula may not be billed for the same beneficiary by more than one provider or in more than one program (e.g., Prosthetics and Hyperalimentation) for the same date of service.

Covered formulae represent the nutritional supplements most requested for medical purposes. However, if none of the formulae are appropriate and another formula is prescribed by a physician as a result of Child Health Services (EPSDT) screening, the prescribed formula will be reviewed for medical necessity.

Formulae are covered as nutritional supplements rather than as the sole source of nutrition. Beneficiaries who require enteral nutrition as the sole source of nutrition, with the formulae being administered through a nasogastric, jejunostomy or gastrostomy tube, should be referred to a hyperalimentation provider enrolled in the Medicaid Program.

One unit of service equals 100 calories with an allowable maximum of 30 units per day. This is a separate benefit limit from the limit established for medical supplies. Supplies provided in conjunction with the nutritional formulae through the Prosthetics Program must be billed under the medical supply codes, if those supplies are covered by the program.

There are certain nutritional formulae available to eligible beneficiaries through the WIC Program and the Food Stamp Program. These two programs should be accessed by beneficiaries prior to requesting Medicaid reimbursement for nutritional formulae. The coverage of these formulae through the Medicaid Program is limited to beneficiaries requiring nutrition therapy due to medical necessity and only when prescribed by a physician.

|212.500 Food Thickeners, All Ages |8-1-05 |

Arkansas Medicaid covers food thickeners for Medicaid-eligible individuals who have impaired swallowing and a risk of food aspiration.

Food thickeners are not subject to the $250 benefit limit for other medical supplies.

|212.600 Orthotic Appliances and Prosthetic Devices, All Ages |7-1-12 |

A. The Arkansas Medicaid Program covers orthotic appliances and prosthetic devices for beneficiaries under age 21 in the Child Health Services (EPSDT) Program. Providers of orthotic appliances and prosthetic devices may be reimbursed by the Arkansas Medicaid Program when the items are prescribed by a physician and documented as medically necessary for beneficiaries under age 21 participating in the Child Health Services (EPSDT) Program. 1. No prior authorization is required to obtain these services for beneficiaries under age 21. 2. No benefit limits apply to orthotic appliances and prosthetic devices for beneficiaries under age 21. B. Arkansas Medicaid covers orthotic appliances for beneficiaries age 21 and over. The following provisions must be met before services may be provided. 1. Prior authorization is required for orthotic appliances valued at or above the Medicaid maximum allowable reimbursement rate of $500.00 per item for use by beneficiaries age 21 and over. Prior authorization may be requested by submitting form DMS-679A titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components to AFMC. View or print form DMS-679A and instructions for completion. View or print AFMC contact information. 2. For beneficiaries age 21 and over, a benefit limit of $3,000 per state fiscal year (SFY; July 1 through June 30) has been established for reimbursement for orthotic appliances. No extension of benefits will be granted. The following restrictions apply to the coverage of orthotic appliances for beneficiaries age 21 and over: a. Orthotic appliances may not be replaced for 12 months from the date of purchase. If a beneficiary’s condition warrants a modification or replacement and the $3,000.00 SFY benefit limit has not been met, the provider may submit documentation to AFMC, to substantiate medical necessity. If approved, AFMC will issue a prior authorization number. Section 221.000 of this provider manual may be referenced for information regarding prior authorization procedures. b. Custom-molded orthotic appliances are not covered for a diagnosis of carpal tunnel syndrome prior to surgery. C. Arkansas Medicaid covers prosthetic devices for beneficiaries age 21 and over; however, the following provisions must be met before services may be provided. 1. Prior authorization will be required for prosthetic device items valued at or in excess of the $1,000.00 per item Medicaid maximum allowable reimbursement rate for use by beneficiaries age 21 and over. Prior authorization may be requested by submitting form DMS-679A titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components to AFMC. View or print form DMS-679A and instructions for completion. 2. For beneficiaries age 21 and over, a benefit limit of $20,000 per SFY has been established for reimbursement for prosthetic devices. No extension of benefits will be granted. 3. The following restrictions apply to coverage of prosthetic devices for beneficiaries age 21 and over: a. Prosthetic devices may be replaced only after five years have elapsed from their date of purchase. If the beneficiary’s condition warrants a modification or replacement, and the $20,000 SFY benefit limit has not been met, the provider may submit documentation to AFMC to substantiate medical necessity. If approved, AFMC will issue a prior authorization number. Section 220.000 of this provider manual may be referenced for information regarding prior authorization procedures. b. Myoelectric prosthetic devices may be purchased only when needed to replace myoelectric devices received by beneficiaries who were under age 21 when they received the original device. D. The forms, listed below, are available for evaluating the need of beneficiaries age 21 and over for orthotic appliances and prosthetic devices, and prescribing the needed appliances and equipment. The Medicaid Program does not require providers to use the forms, but the information the forms are designed to collect is required by Medicaid to process requests for prior authorization of orthotic appliances and prosthetic devices for beneficiaries aged 21 and over. The appropriate forms (or the required information in a different format) must accompany the form DMS-679A. View or print DMS-679A titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components and instructions for completion. The forms and their titles are as follows: 1. DMS-647 Gait Analysis: Full Body. View or print form DMS- 647. 2. DMS-648 Upper-Limb Prosthetic Evaluation. View or print form DMS-648. 3. DMS-649 Upper-Limb Prosthetic Prescription. View or print form DMS-649. 4. DMS-650 Lower-Limb Prosthetic Evaluation. View or print form DMS-650. 5. DMS-651 Lower-Limb Prosthetic Prescription. View or print form DMS-651.

|212.700 Oxygen and Oxygen Supplies, All Ages |4-1-09 |

A prescription for oxygen must be accompanied by a current arterial blood gas (ABG) laboratory report from a certified laboratory or the beneficiary’s attending physician. A current laboratory report is defined as one performed within a maximum of 30 days prior to the prescription for oxygen.

A prescription for oxygen must specify the oxygen flow rate, frequency and duration of use, estimate of the period of need for oxygen and method of delivery of oxygen to the beneficiary (e.g., two liters per minute, 10 minutes per hour, by nasal cannula for a period of two months). A prescription containing only “oxygen PRN” is not sufficient.

The following medical criteria will be utilized in evaluating coverage of oxygen: A. Chronic Respiratory Disease 1. Continuous oxygen therapy Resting Pa02 less than 55 mm Hg 2. Nocturnal oxygen therapy Resting Pa02 less than 60 mm Hg 3. Exercise oxygen therapy Pa02 with exercise less than 55 mm Hg B. Congestive Heart Failure Symptomatic at rest, with Pa02 less than 60 mm Hg C. Carcinoma of the Lung Resting Pa02 less than 60 mm Hg D. Others Reviewed on an individual basis E. Children O2 saturation below 94% by pulse oximeter with elevated PCO2 by capillary blood gas or end-tidal CO2 on two separate occasions.

The prior authorization request for all oxygen and respiratory equipment must be submitted on form DMS-679A titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components to AFMC for beneficiaries of all ages. View or print form DMS-679A and instructions for completion.

|220.000 PRIOR AUTHORIZATION | | |221.000 Prosthetics Services Prior Authorization |4-1-09 |

Reimbursement for specified prosthetics services must be prior authorized. Prior authorization is required on items indicated (e.g., oxygen) or if the reimbursement for an item or items is $1000.00 or more (e.g., wheelchair and/or components).

|221.100 Request for Prior Authorization |4-1-09 |

The request for prior authorization must originate with the prosthetics provider. The provider is responsible for obtaining the required medical information and prescription needed for completion of the prior authorization request form. A. The Medical Equipment Request for Prior Authorization and Prescription Form (Form DMS-679) will be used when requesting prior authorization for wheelchairs, wheelchair seating systems and wheelchair repairs. The primary care physician must sign the DMS-679. The primary care physician’s signature must be an original, not a stamp. Form DMS-679 must contain a diagnosis of the disease(s) necessitating use of prosthetics services. View or print form DMS-679 and instructions for completion. B. The Arkansas Foundation for Medical Care, Inc., (AFMC) reviews requests for prior authorization for some medical supplies (i.e., compression burn garments), orthotic appliances, prosthetic devices and durable medical equipment, excluding wheelchairs, wheelchair seating systems and wheelchair repairs. Form DMS-679A, titled Prescription and Prior Authorization Request for Medicaid Equipment Excluding Wheelchairs & Wheelchair Components must be completed for use with those items of durable medical equipment, excluding wheelchairs, wheelchair seating systems and wheelchair repairs.

|221.200 Filing for Prior Authorization |4-6-15 |

Requests for prior authorization will be handled by the Arkansas Foundation for Medical Care (AFMC). A. To request prior authorization for wheelchair and wheelchair seating systems, providers must use form DMS-679 and send the information to AFMC. The original and the first copy of the Medical Equipment Request for Prior Authorization and Prescription Form (form DMS-679) must be forwarded to AFMC. The third copy of the form must be retained in the provider’s records. View or print the AFMC contact information. B. Requests for prior authorization of some medical supplies (i.e.: compression burn garments), orthotic appliances, prosthetic devices and all durable medical equipment, excluding wheelchairs and wheelchair seating systems, must be submitted to AFMC on the Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components Form (DMS-679A). View or print form DMS-679A.

|221.300 Approvals of Prior Authorization |4-6-15 |

A. The Arkansas Foundation for Medical Care (AFMC) reviews requests for prior authorization for wheelchair and wheelchair seating systems. If necessary, AFMC may request additional information. 1. When a request is approved for wheelchairs, wheelchair seating systems or wheelchair repair, a prior authorization control number will be assigned by AFMC. Determination of “purchase,” “rental only,” or “capped rental” will be made and an expiration date for “rental only” and “capped rental” items will be assigned. This information will be indicated on the copy of the form DMS-679 that is returned to the provider from AFMC within 30 working days of receipt of the prior authorization request. 2. Prior authorization may only be approved for a maximum of six (6) months (180 days) for beneficiaries of all ages. Within 30 working days before the end of currently prior authorized prosthetics services, the prosthetics provider must obtain a new prescription. If applicable, the provider must prepare and send a new Medical Equipment Request for Prior Authorization and Prescription Form (Form DMS-679), signed by the physician, to AFMC. 3. The effective date of the prior authorization will be the date on which the beneficiary’s physician prescribed prosthetics services or the day following the last day of the previously prior authorized time period, whichever comes last. B. Consideration of prior authorization requests by AFMC requires correct completion of all fields on the request form. The prior authorization request form must contain current medical documentation necessitating use of the required prosthetics. If necessary, AFMC may request additional information. 1. When a PA request is approved, a prior authorization control number will be assigned by AFMC. View or print AFMC contact information. Prior authorization approvals will be authorized for a maximum of six (6) months (180 days) for beneficiaries of all ages. The effective date of the prior authorization will be the date on which the beneficiary’s physician prescribed prosthetics services or the day following the last day of the previously prior authorized time period, whichever comes last. 2. Within 30 working days before the end of currently authorized prosthetics services, the provider must obtain a new prescription. If applicable, the provider must prepare and submit a new Prescription and Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components (form DMS-679A) signed by the prescribing physician. C. Providers should note the following authorization process exception. 1. Prior authorization numbers for “capped rental” items will be effective for the entire “capped rental” time period of 15 months. Therefore, only one prior authorization number is needed. a. Providers may use the one prior authorization number for billing of “capped rental” items for all 15 months. b. Previous prior authorization for an item will count toward the total 15-month period. c. Providers must resubmit a request for prior authorization after the first 180 days. d. Necessary information will be indicated on the copy of the notification letter sent to the provider within 30 working days of receipt of the prior authorization request.

|221.400 Denial of Prior Authorization Request |12-1-06 |

For denied cases, both Utilization Review and AFMC will mail a letter containing case specific rationale that explains why the request was not approved to the requesting provider and to the Medicaid beneficiary within 30 working days of receipt of the prior authorization request.

The provider may request reconsideration of the denial within thirty-five calendar days of the denial date. Requests must be made in writing and include additional documentation to substantiate the medical necessity of the requested services. Requests received after thirty-five calendar days of the denial date will not be accepted for reconsideration.

|221.500 Reconsideration of Denials |12-1-06 |

If the denial decision is reversed during the reconsideration review, an approval is forwarded to the provider specifying the approved units and services. If the denial decision is upheld, the provider and the Medicaid beneficiary will be notified in writing of the review determination.

Reconsideration is available only once per prior authorization request. However, if the denial is upheld during the reconsideration process, the provider may submit a new prior authorization request, for different dates of service, providing new supporting documentation is available. A subsequent prior authorization request will not be reviewed if it contains the same documentation submitted with the previous authorization and reconsideration requests.

|221.600 Fair Hearing Request |12-1-06 |

The Medicaid beneficiary may request a fair hearing of a denied review determination made by either Utilization Review, Department of Health and Human Services (DHHS) or the Arkansas Foundation for Medical Care (AFMC). The fair hearing request must be in writing and sent to the Appeals and Hearings Section of DHHS within thirty-five calendar days of the date on the denial letter. View or print the Department of Health and Human Services Appeals and Hearings Section contact information. Providers may refer to Section 190.000 for information regarding provider appeals through the Medicaid Fairness Act.

|230.000 REIMBURSEMENT | | |231.000 Prosthetics Service Method of Reimbursement |10-13-03 |

Reimbursement for prosthetics services is based on the lesser of the amount billed or the Title XIX (Medicaid) maximum allowable.

Providers are cautioned that an approved prior authorization does not guarantee payment. Reimbursement is contingent upon eligibility of both the beneficiary and provider at the time service is provided and upon accurate completeness of the claim filed for the service. The provider is responsible for verifying the beneficiary’s eligibility by checking the beneficiary’s eligibility through the system.

|231.010 Fee Schedule |12-1-12 |

Arkansas Medicaid provides fee schedules on the Arkansas Medicaid website. The fee schedule link is located at https://www.medicaid.state.ar.us under the provider manual section. The fees represent the fee-for-service reimbursement methodology.

Fee schedules do not address coverage limitations or special instructions applied by Arkansas Medicaid before final payment is determined.

Procedure codes and/or fee schedules do not guarantee payment, coverage or amount allowed. Information may be changed or updated at any time to correct a discrepancy and/or error. Arkansas Medicaid always reimburses the lesser of the amount billed or the Medicaid maximum.

|232.000 Specialized Wheelchair, Seating and Rehabilitative |8-1-05 | |Equipment Reimbursement for Repairs | |

Reimbursement for repairs of specialized wheelchairs will be the manufacturer’s list price for parts listed less 40% manual equipment (dealer discount), 30% power equipment (dealer discount), plus 35% (profit margin), plus labor billed by the unit (15 min. = 1 unit). A maximum of twenty (20) units (20 units = 5 hours of labor) per date of service is allowable. Any applicable pages from the manufacturer’s catalog and the manufacturer’s invoice for parts must be attached to the claim form.

Reimbursement for specialized wheelchair equipment, seating and rehab items requiring manual pricing is calculated using the manufacturer’s current published suggested retail price less 15%. Any applicable pages from the manufacturer’s catalog that reflect a description and the manufacturer’s current published suggested retail price must be attached to the claim.

Kaye Products will be reimbursed at a set rate; therefore, the Kaye Products (procedure codes E1031, modifiers EP, U1; E1031, modifiers EP, U3; and E1031, modifiers EP, U4) may be billed electronically.

|233.000 Orthotic and Prosthetic Reimbursement for Repairs |12-5-05 |

Providers must bill for the repair of orthotic appliances and prosthetic devices utilizing the procedure codes listed in the table below. One unit of service equals 15 minutes. A maximum of 20 units of service is allowed per date of service. Any applicable pages from the manufacturer’s catalog and the manufacturer’s invoice for parts must be attached to all repair claims.

|National |Required| | |Code |Modifier|Description | |L4205 |— |Repair of orthotic appliances and prosthetic | |L4210 |— |devices (non-EPSDT) | |L7510 |— | | |L7520 |— | | |L4205 |EP |Repair of orthotic appliances and prosthetic | |L4210 |EP |devices (EPSDT) | |L7510 |EP, UB | | |L7520 |— | |

Reimbursement for orthotic appliances and prosthetic devices requiring manual pricing will be calculated using the manufacturer’s invoice price plus 10%. The manufacturer invoice must be attached to all repair claims.

|234.000 Durable Medical Equipment (DME) Reimbursement for |8-1-05 | |Repairs | |

Reimbursement for repairs of durable medical equipment (DME) will be manufacturer’s invoice price for parts plus 10% and labor billed per unit (15 minutes = 1 unit of service). A maximum of twenty (20) units (20 units = 5 hours of labor) per date of service is allowable. The manufacturer’s invoice must be attached to the repair claim for all parts.

Reimbursement for unlisted DME requiring manual pricing will be calculated using the manufacturer’s invoice price plus 10%. The manufacturer’s invoice must be attached to all repair claims.

|235.000 Augmentative Communication Device Reimbursement for |10-13-03 | |Repairs | |

Reimbursement for repairs of augmentative communication device components will be manufacturer’s invoice price for parts plus 10%. Labor will be reimbursed per unit of service (1 unit = 15 minutes limited to a maximum of 20 units per date of service allowed).

|236.000 Reimbursement for Repair of the Enteral Nutrition Pump|4-1-09 |

Reimbursement for repairs to the enteral nutrition infusion pump requires prior authorization. Repairs will be approved only on equipment purchased by Medicaid. Therefore, no repairs will be reimbursable prior to the equipment becoming the property of the Medicaid beneficiary.

Requests for prior authorization for enteral pump repairs must be mailed to AFMC. (View or print AFMC contact information) on form DMS-679A titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components. (View or print form DMS- 679A and instructions for completion.)

The repair invoice and the serial number of the equipment must accompany the prior authorization request form. Total repair costs to an infusion pump may not exceed $290.93. Medicaid will not reimburse for additional repairs to an infusion pump after the provider has billed repair invoices totaling $290.93. If the equipment is still not in proper working order after the provider has billed the Medicaid maximum allowed for repairs, the provider must supply the beneficiary with a new infusion pump and may bill either procedure code B9000 or B9002 after receiving prior authorization for the new piece of equipment.

|237.000 Rate Appeal Process |8-1-05 |

A provider may request reconsideration of a program decision by writing to the Assistant Director, Division of Medial Services. The request must be received within 20 calendar days following the application of policy and/or procedure or the notification of the provider of its rate. Upon receipt of the request for review, the Assistant Director will determine the need for a program/provider conference and will contact the provider to arrange a conference if needed. Regardless of the program decision, the provider will be afforded the opportunity for a conference, if he or she so wishes, for a full explanation of the factors involved and the program decision. Following review of the matter, the Assistant Director will notify the provider of the action to be taken by the Division within 20 calendar days of receipt of the request for review or the date of the program/provider conference.

When the provider disagrees with the decision of the Assistant Director, Division of Medical Services, the provider may appeal the question to a standing rate review panel established by the Director of the Division of Medical Services. The rate review panel will include one member of the Division of Medical Services, a representative of the provider association and a member of the Department of Human Services (DHS) management staff, who will serve as chairperson.

The request for review by the rate review panel must be postmarked within 15 calendar days following the notification of the initial decision by the Assistant Director, Division of Medical Services. The rate review panel will meet to consider the question(s) within 15 calendar days after receipt of a request for such appeal. The panel will hear the question(s) and a recommendation will be submitted to the Director of the Division of Medical Services.

|240.000 billing procedures | | |241.000 Introduction to Billing |8-1-05 |

Prosthetics providers use the CMS-1500 form to bill the Arkansas Medicaid Program on paper for services provided to eligible Medicaid beneficiaries. Each claim may contain charges for only one beneficiary.

Section III of this manual contains information about Provider Electronic Solutions (PES) and other available options for electronic claim submission.

|242.000 CMS-1500 Billing Procedures | | |242.100 HCPCS Procedure Codes | | |242.105 Payment Methodology |8-1-05 |

Arkansas Medicaid has several methods of payment for all items covered by the Program. The following is a breakdown of the methods. A. Purchase items are equipment that is purchased for or purchased by an eligible Medicaid beneficiary. The equipment may be new or used. B. Rental-only items are those items paid by Arkansas Medicaid to providers for an unspecified time period on an as-needed basis. The equipment may be new or used. C. A capped rental item is equipment whose purchase price exceeds $150.00. The items may be new or used. The items are reimbursed utilizing a daily rental rate. Medicaid pays the daily rental rate not to exceed a fifteen- (15-) month rental maximum (455 days). A period of continuous use allows for periods of interruption up to 60 consecutive days. If the interruption is 60 or fewer consecutive days, a new 15-month rental period will not begin. If the interruption is more than 60 days, a new 15-month rental period will begin. D. After the total cost of a capped rental item has been reimbursed by Medicaid, the item remains the property of the DME provider. For items that have reached a 15-month rental cap, claims will be paid for maintenance and servicing fees after six months have passed from the end of the final paid rental month or from the end of the period the item is no longer covered under the supplier’s or manufacturer’s warranty, whichever is later. E. Providers may be reimbursed for capped rental and rental-only items if the equipment is used fewer than 30 consecutive days from the first day of rental. This ensure the provider of adequate reimbursement for equipment used fewer than 30 days. F. A rent-to-purchase item is an item for which Arkansas Medicaid reimburses a provider for the Medicaid-established purchase price of the item. After reimbursement has reached the maximum allowed, the equipment will become the property of the Medicaid beneficiary. Reimbursement is only approved for new equipment. G. Initial rental transactions are those for which equipment is used in a beneficiary’s home for fewer than 30 consecutive days. Initial rental transactions must not be used by the provider to bill a month in advance. Arkansas Medicaid will only pay after services are rendered. An example of an initial rental transaction is that of a hospital bed delivered on July 2 and removed from the home after 10 days. H. Manually priced items are those for which Arkansas Medicaid pays the manufacturer’s invoice price plus 10 percent. The provider must attach the invoice with their claim for services rendered. I. A used item is any item that has been rented for 90 days or longer by anyone prior to the current Medicaid “rental only” or capped rental” transaction. The provider must maintain documentation that certifies a used item is reconditioned and in good working order and has no defect in workmanship or material. J. Repair of a “rental only” item is covered in the rental fee. Repair of “purchased” items is covered separately. Total (cumulative) repair costs must not exceed 50% of the item’s total purchase cost.

|242.110 Respiratory and Diabetic Equipment, All Ages |1-15-13 |

When billed either electronically or on paper, procedure codes found in this section must be billed with certain modifiers. Modifiers in the section are indicated by the headings M1 and M2. When only the NU modifier is shown in the M1 column, the procedure code may be billed for beneficiaries of all ages. When NU and EP are listed together in the M1 column, the NU modifier must be used when billing for beneficiaries age 21 and over, and the EP modifier must be used when billing for beneficiaries under age 21. When a modifier is listed in the M2 heading, that modifier must be used in conjunction with either NU or EP.

Prior authorization requirements are shown under the heading PA. If prior authorization is needed, the information is indicated with a “Y” in the column; if not, an “N” is shown. ( Prior authorization is not required when other insurance pays at least 50% of the Medicaid maximum allowable reimbursement amount. ((…) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product. When using a procedure code with this symbol, the product must meet the indicated Arkansas Medicaid description.

|Respiratory and Diabetic Equipment, All Ages (Section 242.110) | |Procedure |M1 |M2 |Description |PA |Payment | |Code | | | | |Method | |A4230 |NU | |Infusion set for external insulin|Y( |Purchase | | | | |pump, nonneedle cannula type | | | |A4231 |NU | |Infusion set for external insulin|Y( |Purchase | | | | |pump, needle type | | | |A4232 |NU | |Syringe with needle for external |Y( |Purchase | | | | |insulin pump, sterile, 3 cc | | | |A4627 |NU |UB |((Spacer bag or reservoir without|N |Purchase | | | | |mask, for use with metered dose | | | | | | |inhaler) Spacer, bag or | | | | | | |reservoir, with or without mask, | | | | | | |for use with metered dose inhaler| | | |A4627 |NU | |((Spacer bag or reservoir with |N |Purchase | | | | |mask, for use with metered dose | | | | | | |inhaler) Spacer, bag or | | | | | | |reservoir, with or without mask, | | | | | | |for use with metered dose inhaler| | | |A7045 |NU | |Exhalation port with or without |N |Purchase | | | | |swivel used with accessories for | | | | | | |positive airway devices, | | | | | | |replacement only | | | |A7046 |NU | |Water chamber for humidifier, |N |Purchase | | | | |used with positive airway | | | | | | |pressure device, replacement, | | | | | | |each | | | |E0424 |NU | |Stationary compressed gaseous |Y( |Rental Only| | | | |oxygen system, rental; includes | | | | | | |container, contents, regulator, | | | | | | |flowmeter, humidifier, nebulizer,| | | | | | |cannula or mask, and tubing | | | |E0430 |NU | |Portable gaseous oxygen system, |Y( |Rental Only| | | | |purchase, includes regulator, | | | | | | |flowmeter, humidifier, cannula or| | | | | | |mask, and tubing | | | |E0434 |NU | |Portable liquid oxygen system, |Y( |Rental Only| | | | |rental; includes portable | | | | | | |container, supply reservoir, | | | | | | |humidifier, flowmeter, refill | | | | | | |adapter, contents gauge, cannula | | | | | | |or mask, and tubing | | | |E0435 |NU | |Portable liquid oxygen system, |Y( |Rental Only| | | | |purchase; includes portable | | | | | | |container, supply reservoir, | | | | | | |flowmeter, humidifier, contents | | | | | | |gauge, cannula or mask, tubing | | | | | | |and refill adapter | | | |E0439 |NU | |Stationary liquid oxygen system, |Y( |Rental Only| | | | |rental; includes container, | | | | | | |contents, regulator, flowmeter, | | | | | | |humidifier, nebulizer, cannula or| | | | | | |mask, and tubing | | | |E0441 |NU | |Oxygen contents, gaseous (for use|Y |Purchase | | | | |with owned gaseous stationary | | | | | | |systems or when both a stationary| | | | | | |and portable gaseous system are | | | | | | |owned), one month’s supply = I | | | | | | |unit | | | |E0442 |NU | |Oxygen contents, liquid (for use |Y |Purchase | | | | |with owned liquid stationary | | | | | | |systems or when both a stationary| | | | | | |and portable liquid system are | | | | | | |owned), one month’s supply = 1 | | | | | | |unit | | | |E0443 |NU | |Portable oxygen contents, gaseous|Y( |Purchase | | | | |(for use only with portable | | | | | | |gaseous systems when no | | | | | | |stationary gas or liquid system | | | | | | |is used), one month’s supply=1 | | | | | | |unit | | | |E0444 |NU | |Portable oxygen contents, liquid |Y( |Purchase | | | | |(for use only with portable | | | | | | |liquid systems when no stationary| | | | | | |gas or liquid system is used), | | | | | | |one month’s supply=1 unit | | | |E0470 |NU |RR |((BIPAP Device, Nasal Bi-level |Y( |Rental Only| | |EP |RR |Positive Airway support system; |Y( | | | | | |includes necessary accessory | | | | | | |items. NOTE: Complete medical | | | | | | |data pertinent to the request | | | | | | |must be submitted with the prior | | | | | | |authorization request.) | | | | | | |Respiratory assist device, | | | | | | |bi-level pressure capacity, | | | | | | |without backup rate feature, used| | | | | | |with noninvasive interface, e.g.,| | | | | | |nasal or facial mask | | | | | | |(intermittent assist device with | | | | | | |continuous positive airway | | | | | | |pressure device) | | | |E0471 |NU |RR |Respiratory assist device, |Y( |Rental Only| | |EP |RR |bi-level pressure capacity, with |Y( | | | | | |backup rate feature, used with | | | | | | |noninvasive interface, e.g., | | | | | | |nasal or facial mask | | | | | | |(intermittent assist device with | | | | | | |continuous positive airway | | | | | | |pressure device) | | | |E0472 |NU |RR |Respiratory assist device, |Y( |Rental Only| | |EP |RR |bi-level pressure capacity, with |Y( | | | | | |backup rate feature, used with | | | | | | |invasive interface, e.g., nasal | | | | | | |or facial mask (intermittent | | | | | | |assist device with continuous | | | | | | |positive airway pressure device) | | | |E0482 |NUEP| |Cough stimulating device, |Y( |Capped | | | | |alternating positive and negative| |Rental | | | | |airway pressure | | | |E0483 |NU |RR |((Bronchial Drainage System) |Y( |Capped | | | | |High-frequency chest wall | |Rental | | | | |oscillation air-pulse generator | | | | | | |system (includes hoses and vest),| | | | | | |each | | | |E0483 |NU |UB |((Pulmonary Vest. The |Y( |Purchase | | | | |manufacturer invoice must be | | | | | | |attached to the claim form.) | | | | | | |High-frequency chest wall | | | | | | |oscillation air-pulse generator | | | | | | |system (includes hoses and vest),| | | | | | |each | | | |E0560 |NU | |Humidifier, durable for |N |Purchase | | |UE | |supplemental humidification | | | | | | |during IPPB treatment or oxygen | | | | | | |delivery | | | |E0561 |NU | |Humidifier, non-heated, used |Y( |Purchase | | |EP | |w/positive airway pressure device|Y( | | |E0562 |NU | |Humidifier, heated, used |Y( |Purchase | | |EP | |w/positive airway pressure device|Y( | | |E0570 |NU | |Nebulizer, with compressor |Y( |Purchase | | |UE | | | | | |E0575 |NU | |Nebulizer, ultrasonic, large |Y( |Capped | | |UE | |volume | |Rental | |E0600 |NU | |Respiratory suction pump, home |N |Rental Only| | |UE | |model, portable or stationary, | | | | | | |electric | | | |E0601 |NU |RR |((CPAP Device Nasal Continuous |Y( |Rental Only| | | | |Positive Airway Pressure (CPAP) | | | | | | |Device; includes necessary | | | | | | |accessory items) NOTE: Complete | | | | | | |medical data pertinent to the | | | | | | |request must be submitted with | | | | | | |the prior authorization request. | | | | | | |NOTE: Bill E0601 as the global | | | | | | |daily rental service. | | | |E0784 |NU | |External ambulatory infusion |Y( |Purchase | | | | |pump, insulin | | | |E1354 |NU | |Oxygen accessory, wheeled cart |Y |Manually | | | | |for portable cylinder or portable| |priced | | | | |concentrator, any type, | | | | | | |replacement only, each | | | |E1390 |NU | |Oxygen concentrator, single |Y( |Rental Only| | | | |delivery port, capable of | | | | | | |delivering 85 % or greater oxygen| | | | | | |concentration at the prescribed | | | | | | |flow rate | | | |E1391 |NU | |O2 concentrator, dual delivery |Y( |Rental Only| | | | |port, capable of delivering 85% | | | | | | |or greater oxygen concentration | | | | | | |at the prescribed flow rate, each| | |



|242.111 Initial Rental of a DME Item for Individuals of All |12-1-12 | |Ages | |

Procedure codes found in this section may be billed either electronically or on paper.

Some procedure codes have been assigned a modifier that affects the billing process. Required modifiers are indicated in the M1 column in the list below. When a modifier is shown in the M1 column, it must be listed along with the procedure code when requesting payment by Arkansas Medicaid.

Procedure codes shown in the list below are either covered for all ages (AA), only for individuals under age 21 (U21) or only for individuals age 21 and over (21+). A column in the list below defines the differences.

( Prior authorization is not required when other insurance pays at least 50% of the Medicaid maximum allowable reimbursement amount. ((…) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product. When using a procedure code with this symbol, the product must meet the indicated Arkansas Medicaid description.

|Initial Rental of a DME Item for Individuals of All Ages (Section | |242.111) | |Procedure |M1 |Description |All | |Code | | |U21 | | | | |21+ | |E0181 | |Pressure pad, alternating with pump, |U21 | | | |heavy-duty | | |E0200 | |Heat lamp, without stand (table model), |U21 | | | |includes bulb, or infrared element | | |E0205 | |Heat lamp, with stand includes bulb, or |U21 | | | |infrared element | | |E0217 | |Water circulating heat pad with pump |U21 | |E0225 | |Hydrocollator unit, includes pad |U21 | |E0236 | |Pump for water circulating pad |U21 | |E0239 | |Hydrocollator unit, portable |U21 | |E0250( | |Hospital bed, fixed height, with any type |U21 | | | |side rails, with mattress | | |E0250( |U1 |Hospital bed, fixed height, with any type |U21 | | | |side rails, with mattress | | |E0250( |UE |Hospital bed, fixed height, with any type |21+ | | | |side rails, with mattress | | |E0255( | |Hospital bed, variable height; hi-lo, with |U21 | | | |any type side rails, with mattress | | |E0255 |KH |Hospital bed, variable height; hi-lo, with |21+ | | | |any type side rails, with mattress | | |E0260( | |Hospital bed, semi-electric (head and foot |U21 | | | |adjustment), with any type side rails with | | | | |mattress | | |E0260( |KH |Hospital bed, semi-electric (head and foot |21+ | | | |adjustment), with any type side rails with | | | | |mattress | | |E0271 | |Mattress, inner spring |U21 | |E0272 | |Mattress, foam rubber |U21 | |E0303 | |Hospital bed, heavy-duty, extra wide, with |AA | | | |weight capacity > 350 but < or = 600, any | | | | |type side rails, w/mattress | | |E0424 | |Stationary compressed gaseous oxygen system, |AA | | | |rental; includes container, contents, | | | | |regulator flowmeter, humidifier, nebulizer | | | | |cannula or mask, and tubing | | |E0430( | |Portable gaseous oxygen system, purchase, |AA | | | |includes regulator, flowmeter, humidifier, | | | | |cannula, or mask, and tubing | | |E0434 | |Portable liquid oxygen system, rental; |AA | | | |includes portable container, supply | | | | |reservoir, humidifier, flowmeter, refill | | | | |adaptor, contents gauge, cannula or mask, and| | | | |tubing | | |E0435( | |Portable liquid oxygen system, purchase; |AA | | | |includes portable container, supply | | | | |reservoir, flowmeter, humidifier, contents | | | | |gauge, cannula or mask, tubing and refill | | | | |adapter | | |E0439 | |Stationary liquid oxygen system, rental; |AA | | | |includes container, contents, regulator, | | | | |flowmeter, humidifier, nebulizer, cannula or | | | | |mask, and tubing | | |E0445( | |Oximeter for measuring blood oxygen levels |AA | | | |non-invasively. ( (Pulse oximeter, including| | | | |4 disposable probes) | | |E0480 | |Percussor, electric or pneumatic, home model |U21 | |E0565( | |Compressor, air power source for equipment |U21 | | | |which is not self-contained or cylinder | | | | |driven | | |E0575( | |Nebulizer, ultrasonic, large volume |AA | |E0585 | |Nebulizer, with compressor and heater |U21 | |E0600 | |Respiratory suction pump, home model, |AA | | | |portable or stationary, electric | | |E0606 | |Vaporizer, room type |U21 | |E0630( | |Patient lift, hydraulic, with seat or sling |U21 | |E0630 |KH |Patient lift, hydraulic, with seat or sling |21+ | |E0650( | |Pneumatic compressor, nonsegmental home model|U21 | |E0667( | |Segmental pneumatic appliance for use with |U21 | | | |pneumatic compressor, full leg | | |E0668( | |Segmental pneumatic appliance for use with |U21 | | | |pneumatic compressor, full arm | | |E0691 | |Ultraviolet light therapy system panel, |U21 | | | |includes bulbs/lamps, timer and eye | | | | |protection; treatment area two square feet or| | | | |less | | |E0692 | |Ultraviolet light therapy system panel, |U21 | | | |includes bulbs/lamps, timer and eye | | | | |protection; four foot panel | | |E0693 | |Ultraviolet light therapy system panel, |U21 | | | |includes bulbs/lamps, timer and eye | | | | |protection; six foot panel | | |E0694 | |Ultraviolet multidirectional light therapy |U21 | | | |system in six foot cabinet includes | | | | |bulbs/lamps, timer and eye protection | | |E0720( | |TENS, two lead, localized stimulation |U21 | |E0730( | |Transcutaneous electrical nerve stimulation |AA | | | |(TENS) device, four or more leads, for | | | | |multiple nerve stimulation | | |E0730( |KH |Transcutaneous electrical nerve stimulation |21+ | | | |(TENS) device, four or more leads, for | | | | |multiple nerve stimulation | | |E0745( | |Neuromuscular stimulator, electronic shock |U21 | | | |unit | | |E0779( | |((Ambulatory infusion device, payable only |AA | | | |when services are provided to patients | | | | |receiving chemotherapy, pain management or | | | | |antibiotic treatment in the home) Ambulatory| | | | |infusion device pump, mechanical, reusable, | | | | |for infusion 8 hours or greater | | |E0910 | |Trapeze bars, also known as Patient Helper, |AA | | | |attached to bed, with grab bar | | |E0910 |KH |Trapeze bars, also known as Patient Helper, |21+ | | | |attached to bed, with grab bar | | |E0911 | |Trapeze bar, heavy-duty, for patient weight |AA | | | |capacity greater than 250 pounds, attached to| | | | |bed, with grab bar | | |E0920 | |Fracture frame, attached to bed, includes |U21 | | | |weights | | |E0930 | |Fracture frame, freestanding, includes |U21 | | | |weights | | |E0935( | |Passive motion exercise device |U21 | |E0940 | |Trapeze bar, freestanding, complete with grab|U21 | | | |bar | | |E0941 | |Gravity assisted traction device, any type |U21 | |E1130( | |Standard wheelchair, fixed full-length arms, |U21 | | | |fixed or swing–away, detachable footrests | | |E1130( |KH |Standard wheelchair, fixed full-length arms, |21+ | | | |fixed or swing–away, detachable footrests | | |E1224( | |Wheelchair with detachable arms, elevating |AA | | | |legrests | | |E1224( |U1 |((Footrests wheelchair with detachable arms, |21+ | | | |elevating leg rests) Wheelchair with | | | | |detachable arms, elevating legrests | | |E1390 | |Oxygen concentrator, single delivery port, |AA | | | |capable of delivering 85% or greater oxygen | | | | |concentration at the prescribed flow rate | | |E1391 | |Oxygen concentrator, dual delivery port, |AA | | | |capable of delivering 85 percent or greater | | | | |oxygen concentration at the prescribed flow | | | | |rate, each | |

Providers will be reimbursed for a minimum of 30 days of rental when the equipment is used less than 30 days. Initial rental codes must be billed when equipment is used less than 30 days during the first month of rental.

Arkansas Medicaid will only reimburse for one initial minimum 30 days of rental per state fiscal year period per beneficiary per procedure code. The provider will not be reimbursed for the same procedure code utilizing another modifier for the same time period.

|242.112 Home Blood Glucose Monitor and Supplies – Pregnant |7-1-07 | |Women Only, All Ages | |

Procedure codes found in this section must be billed either electronically or on paper with modifier NU for individuals of all ages. When a second modifier is listed, that modifier must be used in conjunction with the NU modifier.

Modifiers in the section are indicated by the headings M1 and M2. Prior authorization is indicated by the heading PA.

|Procedure |M1 |M2 |Description |PA |Payment | |Code | | | | |Method | |E0607 |NU |U1 |Home Blood Glucose Monitor |N |Purchase| |A4253 |NU |U1 |Blood glucose test or reagent |N |Purchase| | | | |strips for home glucose monitor, | | | | | | |per 50 strips | | | |A4259 |NU |U2 |Lancets, per box of 100 |N |Purchase|

|242.120 Medical Supplies for Beneficiaries of All Ages |7-1-16 |

Procedure codes found in this section must be billed either electronically or on paper using modifier NU for beneficiaries of all ages. When a second modifier is listed, that modifier must be used in conjunction with the modifier NU.

Modifiers in this section are indicated by the headings M1 and M2 1 Not all medical supplies require prior authorization. Supplies with this symbol require prior authorization. Form DMS-679A must be used to request prior authorization. Note: Compression burn garments are manually priced. The manufacturer’s invoice must be submitted with the request for compression burn garments. View or print form DMS-679A and instructions for completion. ((…) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product. When using a procedure code with this symbol, the product must meet the indicated Arkansas Medicaid description.

|Medical Supplies, All Ages (Section 242.120) | |Procedure |M1 |M2 |Description | |Code | | | | |A4206 |NU | |Syringe with needle, sterile, 1 cc., each | |A4207 |NU | |Syringe with needle, sterile, 2 cc., each | |A4209 |NU | |Syringe with needle, sterile, 5 cc. or greater, | | | | |each | |A4213 |NU | |Syringe, sterile, 20 cc. or greater, each | |A4216 |NU | |Sterile water/saline and/or dextrose, | | | | |diluent/flush, 10 ml. | |A4217 |NU | |Sterile water/saline, 500 ml. | |A42211 |NU | |Supplies for maintenance of drug infusion | | | | |catheter, per week (list drug separately) | |A42221 |NU | |Supplies for external drug infusion pump, per | | | | |cassette or bag (list drug separately) | |A4253 |NU |UB |((Blood glucose test or reagent strips for home | | | | |blood glucose monitor, per 25 strips) | |A4253 |NU | |Blood glucose test or reagent strips for home | | | | |blood glucose monitor, per 50 strips | |A4256 |NU | |Normal, low, and high calibrator solution/chips | |A4259 |NU | |Lancets, per box of 100 | |A4265 |NU | |Paraffin, per lb. | |A4310 |NU | |Insertion tray without drainage bag and without | | | | |catheter (accessories only) | |A4311 |NU | |Insertion tray without drainage bag with | | | | |indwelling catheter, Foley type, 2-way latex with| | | | |coating (Teflon, silicone, silicone elastomer or | | | | |hydrophilic, etc.) | |A4312 |NU | |Insertion tray without drainage bag with | | | | |indwelling catheter, Foley type, 2-way, all | | | | |silicone | |A4313 |NU | |Insertion tray without drainage bag with | | | | |indwelling catheter, Foley type, 3-way, for | | | | |continuous irrigation | |A4314 |NU | |Insertion tray with drainage bag with indwelling | | | | |catheter, Foley type, 2-way latex with coating | | | | |(Teflon, silicone, silicone elastomer or | | | | |hydrophilic, etc.) | |A4315 |NU | |Insertion tray with drainage bag with indwelling | | | | |catheter, Foley type, 2-way, all silicone | |A4316 |NU | |Insertion tray with drainage bag with indwelling | | | | |catheter, Foley type, 3-way, for continuous | | | | |irrigation | |A4320 |NU | |Irrigation tray with bulb or piston syringe, any | | | | |purpose | |A4322 |NU | |Irrigation syringe, bulb or piston, each | |A4326 |NU | |Male external catheter with integral collection | | | | |chamber, any type each | |A4327 |NU | |Female external urinary collection device; metal | | | | |cup, each | |A4328 |NU | |Female external urinary collection device; pouch,| | | | |each | |A4330 |NU | |Perianal fecal collection pouch with adhesive, | | | | |each | |A4331 |NU | |Extension drainage tubing, any type, any length, | | | | |with connector/adaptor, for use with urinary leg | | | | |bag or urostomy pouch, each | |A4338 |NU | |Indwelling catheter, Foley type, 2-way latex with| | | | |coating (Teflon, silicone, silicone elastomer or | | | | |hydrophilic, etc.), each | |A4340 |NU | |Indwelling catheter; specialty type (e.g., Coude,| | | | |mushroom, wing, etc.), each | |A4344 |NU | |Indwelling catheter, Foley type, 2-way, all | | | | |silicone, each | |A4346 |NU | |Indwelling catheter, Foley type, 3-way for | | | | |continuous irrigation, each | |A4349 |NU | |Male external catheter with or without adhesive, | | | | |disposable, each | |A4351 |NU | |Intermittent urinary catheter; straight tip, with| | | | |or without coating (Teflon, silicone, silicone | | | | |elastomer or hydrophilic, etc.), each | |A4351 |NU |U1 |Intermittent urinary catheter; disposable | | | | |straight tip, with or without coating (Teflon, | | | | |silicone, silicone elastomer or hydrophilic, | | | | |etc.), each | |A4352 |NU | |Intermittent urinary catheter; Coude (curved) | | | | |tip, with or without coating (Teflon, silicone, | | | | |silicone elastomeric or hydrophilic, etc.), each | |A4352 |NU |U1 |Intermittent urinary catheter; Coude (curved) | | | | |tip, with or without coating (Teflon, silicone, | | | | |silicone elastomeric or hydrophilic, etc.), each | |A4353 |NU | |Intermittent urinary catheter, with insertion | | | | |supplies | |A4353 |NU |U2 |Intermittent urinary catheter, with insertion | | | | |supplies | |A4354 |NU | |Insertion tray with drainage bag but without | | | | |catheter | |A4355 |NU | |Irrigation tubing set for continuous bladder | | | | |irrigation through a 3-way indwelling Foley | | | | |catheter, each | |A4356 |NU | |External urethral clamp or compression device | | | | |(not to be used for catheter clamp), each | |A4357 |NU | |Bedside drainage bag, day or night, with or | | | | |without anti reflux device, with or without tube,| | | | |each | |A4358 |NU | |Urinary drainage bag, leg or abdomen, vinyl, with| | | | |or without tube, with straps, each | |A4361 |NU | |Ostomy faceplate, each | |A4362 |NU | |Skin barrier; solid, four by four or equivalent; | | | | |each | |A4364 |NU | |Adhesive, liquid, or equal, any type, per oz. | |A4367 |NU | |Ostomy belt, each | |A4368 |NU | |Ostomy filter, any type, each | |A4369 |NU | |Ostomy skin barrier, liquid, (spray, brush, | | | | |etc.), per oz. | |A4371 |NU | |Ostomy skin barrier, powder, per oz. | |A4394 |NU | |Ostomy deodorant, with or without lubricant, for | | | | |use in ostomy pouch, per fl. oz. | |A4397 |NU | |Irrigation supply; sleeve, each | |A4398 |NU | |Ostomy irrigation supply; bag, each | |A4399 |NU | |Ostomy irrigation supply; cone/catheter, | | | | |including brush | |A4400 |NU | |Ostomy irrigation set | |A4402 |NU | |Lubricant, per oz. | |A4404 |NU | |Ostomy ring, each | |A4405 |NU | |Ostomy skin barrier, nonpectin-based, paste, per | | | | |oz. | |A4406 |NU | |Ostomy skin barrier, pectin-based, paste, per oz.| |A4407 |NU | |Ostomy skin barrier, with flange (solid, | | | | |flexible, or accordion), extended wear, with | | | | |built-in convexity, 4 x 4 in. or smaller, each | |A4414 |NU | |Ostomy skin barrier, with flange (solid, flexible| | | | |or accordion), without built-in convexity, 4 x 4 | | | | |in. or smaller, each | |A4425 |NU | |Ostomy pouch, drainable; for use on barrier with | | | | |non-locking flange, with filter (2 piece system),| | | | |each | |A4435 |NU | |Ostomy pouch, drainable, high output, with | | | | |extended wear barrier (one piece system), with or| | | | |without filter, each | |A4450 |NU |U1 |Tape, nonwaterproof, per 18 sq. in. | |A4452 |NU | |Tape, waterproof, per 18 sq. in. | |A4455 |NU | |Adhesive remover or solvent (for tape, cement or | | | | |other adhesive), per oz. | |A4456 |NU | |Adhesive remover; any type | |A4483 |NU |U1 |((non-vent, trach nose) Moisture exchanger, | | | | |disposable, for use with invasive mechanical | | | | |ventilation | |A4558 |NU | |Conductive gel or paste, for use with electrical | | | | |device (e.g., TENS, NMES), per oz. | |A4561 |NU |U1 |Pessary, rubber, any type | |A4562 |NU | |Pessary, non rubber, any type | |A4623 |NU | |Tracheostomy, inner cannula | |A4624 |NU | |Tracheal suction catheter, any type other than | | | | |closed system, each | |A4625 |NU | |Tracheostomy care kit for new tracheostomy | |A4626 |NU | |Tracheostomy cleaning brush, each | |A4628 |NU | |Oropharyngeal suction catheter, each | |A4629 |NU | |Tracheostomy care kit for established | | | | |tracheostomy | |A4772 |NU | |Blood glucose test strips, for dialysis, per 50 | |A4927 |NU | |Gloves, non-sterile, per 100 | |A5051 |NU | |Ostomy pouch, closed; with barrier attached (1 | | | | |piece), each | |A5052 |NU | |Ostomy pouch, closed; without barrier attached (1| | | | |piece), each | |A5053 |NU | |Ostomy pouch, closed; for use on faceplate, each | |A5054 |NU | |Ostomy pouch, closed; for use on barrier with | | | | |flange (2 piece), each | |A5055 |NU | |Stoma cap | |A5056 |NU | |Ostomy pouch, drainable; with extended wear | | | | |barrier attached, with filter, 1 piece, each | |A5057 |NU | |Ostomy pouch, drainable; with extended wear | | | | |barrier attached, with built in convexity, with | | | | |filter, 1 piece, each | |A5061 |NU |U1 |Ostomy pouch, drainable; with barrier attached (1| | | | |piece), each | |A5062 |NU | |Ostomy pouch, drainable; without barrier attached| | | | |(1 piece), each | |A5063 |NU | |Ostomy pouch, drainable; for use on barrier with | | | | |flange (2-piece system), each | |A5071 |NU | |Ostomy pouch, urinary; with barrier attached (1 | | | | |piece), each | |A5072 |NU | |Ostomy pouch, urinary; without barrier attached | | | | |(1 piece), each | |A5073 |NU | |Ostomy pouch, urinary; for use on barrier with | | | | |flange (2 piece), each | |A5081 |NU | |Continent device; plug for continent stoma | |A5082 |NU | |Continent device; catheter for continent stoma | |A5093 |NU | |Ostomy accessory; convex insert | |A5102 |NU | |Bedside drainage bottle, with or without tubing, | | | | |rigid or expandable, each | |A5105 |NU | |Urinary suspensory with leg bag, with or without | | | | |tube, each | |A5112 |NU | |Urinary leg bag; latex | |A5113 |NU | |Leg strap; latex, replacement only, per set | |A5114 |NU | |Leg strap; foam or fabric, replacement only, per | | | | |set | |A5120 |NU | |Skin barrier, wipes or swabs, each | |A5121 |NU | |Skin barrier; solid, 6 x 6 or equivalent, each | |A5122 |NU | |Skin barrier; solid, 8 x 8 or equivalent, each | |A5126 |NU | |Adhesive or non-adhesive; disk or foam pad | |A5131 |NU | |Appliance cleaner, incontinence and ostomy | | | | |appliances, per 16 oz. | |A6021 |NU | |Collagen dressing, sterile, size 16 sq. in. or | | | | |less, each | |A6022 |NU | |Collagen dressing, sterile, size more than 16 sq.| | | | |in. but less than or equal to 48 sq. in., each | |A6023 |NU | |Collagen dressing, sterile, size more than 48 sq.| | | | |in., each | |A6024 |NU | |Collagen dressing wound filler, sterile, per 6 | | | | |in. | |A6154 |NU | |Wound pouch, each | |A6196 |NU | |Alginate or other fiber gelling dressing, wound | | | | |cover, pad size 16 sq. in. or less, each dressing| |A6197 |NU | |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 | |A6197 |NU |UB |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 | | | | |((1 linear yard) | |A6198 |NU | |Alginate or other fiber gelling dressing, wound | | | | |cover, sterile, pad size more than 48 sq. in., | | | | |each dressing | |A6203 |NU | |Composite dressing, sterile, pad size 16 sq. in. | | | | |or less, with any size adhesive border, each | | | | |dressing | |A6204 |NU | |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 | |A6205 |NU | |Composite dressing, sterile, pad size more than | | | | |48 sq. in., with any size adhesive border, each | | | | |dressing | |A6209 |NU | |Foam dressing, wound cover, pad size 16 sq. in. | | | | |or less, without adhesive border, each dressing | |A6210 |NU | |Foam dressing, wound cover, pad size more than 16| | | | |sq. in., but less than or equal to 48 sq. in., | | | | |without adhesive border, each dressing | |A6211 |NU | |Foam dressing, wound cover, sterile, pad size | | | | |more than 48 sq. in., without adhesive border, | | | | |each dressing | |A6212 |NU | |Foam dressing, wound cover, sterile, pad size 16 | | | | |sq. in. or less, with any size adhesive border, | | | | |each dressing | |A6213 |NU | |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 | |A6216 |NU | |Gauze, nonimpregnated, non-sterile, pad size 16 | | | | |sq. in. or less, without adhesive border, each | | | | |dressing | |A6219 |NU | |Gauze, nonimpregnated, sterile, 16 sq. in. or | | | | |less with any size adhesive border, each dressing| |A6220 |NU | |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| |A6221 |NU | |Gauze, non-impregnated, sterile, pad size more | | | | |than 48 sq. in., with any size adhesive border, | | | | |each dressing | |A6228 |NU | |Gauze, impregnated, water or normal saline, | | | | |sterile, pad, size 16 sq. in. or less, without | | | | |adhesive border, each dressing | |A6229 |NU | |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 | |A6230 |NU | |Gauze, impregnated, water or normal saline, | | | | |sterile, pad size more than 48 sq. in., without | | | | |adhesive border, each dressing | |A6234 |NU | |Hydrocolloid dressing, wound cover, sterile, pad | | | | |size 16 sq. in. or less, without adhesive border,| | | | |each dressing | |A6234 |NU |U1 |((Hydrocolloid dressing, wound cover, sterile, | | | | |pad size greater than 16 sq. in. , without | | | | |adhesive border, each dressing) | |A6235 |NU | |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 | |A6236 |NU | |Hydrocolloid dressing, wound cover, sterile, pad | | | | |size more than 48 sq. in., without adhesive | | | | |border, each dressing | |A6237 |NU | |Hydrocolloid dressing, wound cover, sterile, pad | | | | |size 16 sq. in. or less, with any size adhesive | | | | |border, each dressing | |A6237 |NU |U1 |((Hydrocolloid dressing, wound cover, sterile, | | | | |pad size greater than 16 sq. in., with any size | | | | |adhesive border, each dressing) | |A6238 |NU | |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 | |A6238 |NU |U1 |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 | |A6239 |NU | |Hydrocolloid dressing, wound cover, sterile, pad | | | | |size more than 48 sq. in., with any size adhesive| | | | |border, each dressing | |A6241 |NU | |Hydrocolloid dressing, wound filler, dry form, | | | | |sterile, per gram | |A6242 |NU | |Hydrogel dressing, wound cover, sterile, pad size| | | | |16 sq. in. or less, without adhesive border, each| | | | |dressing | |A6242 |NU |U1 |((Hydrogel dressing, wound cover, sterile, pad | | | | |size greater than 16 sq. in., without adhesive | | | | |border, each dressing) | |A6243 |NU | |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 | |A6244 |NU | |Hydrogel dressing, wound cover, sterile, pad size| | | | |more than 48 sq. in. without adhesive border, | | | | |each dressing | |A6245 |NU | |Hydrogel dressing, wound cover, sterile, pad size| | | | |16 sq. in. or less, with any size adhesive | | | | |border, each dressing | |A6246 |NU | |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 | |A6247 |NU | |Hydrogel dressing, wound cover, sterile, pad size| | | | |more than 48 sq. in. with any size adhesive | | | | |border, each dressing | |A6248 |NU | |Hydrogel dressing, wound filler, gel, sterile, | | | | |per fl. oz. | |A6248 |NU |U1 |Hydrogel dressing, wound filler, gel, sterile, | | | | |per fl. oz. | |A6257 |NU | |Transparent film, sterile, 16 sq. in. or less, | | | | |each dressing | |A6258 |NU | |Transparent film, sterile, more than 16 sq. in., | | | | |but less than or equal to 48 sq. in., each | | | | |dressing | |A6259 |NU | |Transparent film, sterile, more than 48 sq. in., | | | | |each dressing | |A6403 |NU | |Gauze, nonimpregnated, sterile, pad size more | | | | |than 16 sq. in. less than 48 sq. in., without | | | | |adhesive border, each dressing | |A6404 |NU | |Gauze, nonimpregnated, sterile, pad size more | | | | |than 48 sq. in., without adhesive border, each | | | | |dressing | |A6441 |NU | |Padding bandage, nonelastic, nonwoven/nonknitted,| | | | |width greater than or equal to 3 in. and less | | | | |than 5 in., per yd. | |A6442 |NU | |Conforming bandage, nonelastic, knitted/woven, | | | | |nonsterile, width less than 3 in., per yd. | |A6443 |NU | |Conforming bandage, nonelastic, knitted/woven, | | | | |nonsterile, width greater than or equal to 3 in. | | | | |and less than 5 in., per yd. | |A6444 |NU | |Conforming bandage, nonelastic, knitted/woven, | | | | |nonsterile, width greater than or equal to 5 in.,| | | | |per yd. | |A6445 |NU | |Conforming bandage, nonelastic, knitted/woven | | | | |sterile, width less than 3 in., per yd. | |A6446 |NU | |Conforming bandage, nonelastic, knitted/woven, | | | | |sterile, width greater than or equal to 3 in. and| | | | |less than 5 in., per yd. | |A6447 |NU | |Conforming bandage, nonelastic, knitted/woven, | | | | |sterile, width greater than or equal to 5 in., | | | | |per yd. | |A6448 |NU | |Light compression bandage, elastic, knitted/woven| | | | |width less than 3in., per yd. | |A6449 |NU | |Light compression bandage, elastic, | | | | |knitted/woven, width greater than or equal to 3 | | | | |in. and less than 5 in., per yd. | |A6450 |NU | |Light compression bandage, elastic, | | | | |knitted/woven, width greater than or equal to 5 | | | | |in., per yd. | |A6451 |NU | |Moderate compress bandage, elastic, knitted/woven| | | | |load resistance of 1.25 to 1.34 ft. lbs. at 50% | | | | |maximum stretch, width greater than or equal to 3| | | | |in. and less than 5 in., per yd. | |A6452 |NU | |High compress bandage, elastic, knitted/woven, | | | | |load resistance greater than or equal to 1.35 ft.| | | | |lbs. at 50 % maximum stretch, width greater than | | | | |or equal to 3 in. and less than 5 in., per yd. | |A6453 |NU | |Self-adherent bandage, elastic, | | | | |nonknitted/nonwoven, width less than 3 in., per | | | | |yd. | |A6454 |NU | |Self-adherent bandage, elastic, | | | | |nonknitted/nonwoven, width greater than or equal | | | | |to 3 in and less than 5 in., per yd. | |A6455 |NU | |Self-adherent bandage, elastic, | | | | |nonknitted/nonwoven, width greater than or equal | | | | |to 5 in., per yd. | |A65011 |NU | |Compression burn garment, bodysuit (head to | | | | |foot), custom fabricated | |A65021 |NU | |Compression burn garment, chin strap, custom | | | | |fabricated | |A65031 |NU | |Compression burn garment, facial hood, custom | | | | |fabricated | |A65041 |NU | |Compression burn garment, glove to wrist, custom | | | | |fabricated | |A65051 |NU | |Compression burn garment, glove to elbow, custom | | | | |fabricated | |A65061 |NU | |Compression burn garment, glove to axilla, custom| | | | |fabricated | |A65071 |NU | |Compression burn garment, foot to knee length, | | | | |custom fabricated | |A65081 |NU | |Compression burn garment, foot to thigh length, | | | | |custom fabricated | |A65091 |NU | |Compression burn garment, upper trunk to waist | | | | |including arm openings (vest), custom fabricated | |A65101 |NU | |Compression burn garment, trunk including arms | | | | |down to leg openings (leotard), custom fabricated| |A65111 |NU | |Compression burn garment, lower trunk including | | | | |leg openings (panty), custom fabricated | |A65121 |NU | |Compression burn garment, not otherwise | | | | |classified | |A65131 |NU | |Compression burn mask, face and/or neck, plastic | | | | |or equal, custom fabricated | |A7520 |NU | |Tracheostomy/laryngectomy tube, noncuffed, | | | | |polyvinylchloride (PVC), silicone or equal, each | |A7521 | | |Tracheostomy/laryngectomy tube, cuffed, | | | | |polyvinylchloride (PVC), silicone or equal, each | |A7522 | | |Tracheostomy/laryngectomy tube, stainless steel | | | | |or equal, (sterilizable and reusable), each | |A7524 | | |Tracheostoma stent/stud/button, each | |A7525 | | |Tracheostomy mask, each | |B4087 |NU | |Gastrostomy/jejunostomy tube, standard, any | | | | |material, any type, each | |E0776 |NU | |IV pole | |E0779 |NU |RR |((Ambulatory infusion device, payable only when | | | | |services are provided to patients receiving | | | | |chemotherapy, pain management or antibiotic | | | | |treatment in the home) Ambulatory infusion pump, | | | | |mechanical, reusable, for infusion 8 hours or | | | | |greater | |J1642 |NU | |Injection, heparin sodium, (heparin lock flush), | | | | |per 10 units |

|242.121 Food Thickeners, All Ages |7-1-07 |

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

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

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

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

|Procedure |M1 |M2 |Description | |Code | | | | |B4100 |NU | |Food thickener, administered orally, per oz. | |B4100 |NU |BA |Food thickener, administered enterally, per oz.|

|242.122 Jobst Stocking for Beneficiaries of All Ages |8-15-09 |

The gradient compression stocking (Jobst) is payable for beneficiaries of all ages. However, before supplying the item, the Jobst stocking must be prior authorized by AFMC. View or print form DMS-679A and instructions for completion. Documentation accompanying form DMS-679A must indicate that the beneficiary has severe varicose veins with edema, or a venous statis ulcer, unresponsive to conventional therapy such as wrappings, over-the-counter stockings and Unna boots. The documentation must include clinical medical records from a physician detailing the failure of conventional therapy.

|Procedure |M1 |M2 |Description |Maximum Units | |Code | | | | | |A6530 |NU | |Gradient compression |Maximum 4 units | | |EP | |stocking, below knee, 18-30mm|per date of | | | | |Hg, each |service | |A6549 |NU | |Gradient compression |Maximum 4 units | | | | |stocking, NOS (Jobst); 1 unit|per date of | | | | |= 1 stocking |service |

|242.123 Negative Pressure Wound Therapy Pump Accessories and |9-1-12 | |Supplies for Beneficiaries Ages 2 Years and Older | |

Effective for dates of service on or after May 11, 2012, procedure codes found in this section must be billed either electronically or on paper with modifier EP for beneficiaries aged 2-20 years or modifier NU for beneficiaries aged 21 and over.

Modifiers in this section are indicated by the heading M1. Prior authorization is indicated by the heading PA. If prior authorization is required, that information is indicated with a “Y” in the column, or if not, an “N” is shown.

|Negative Pressure Wound Therapy Pump Accessories and Supplies for | |Beneficiaries Ages 2 Years and Older (Section 242.123) | |Procedure |M1 | |Description |PA |Age | |Code | | | | |Restriction| |A6550 |NU | |Wound care set, for negative |Y |21 years | | | | |pressure wound therapy | |and over | | | | |electrical pump, includes all | | | | | | |supplies and accessories | | | |A6550 |EP | |Wound care set, for negative |Y |2-20 years | | | | |pressure wound therapy | | | | | | |electrical pump, includes all | | | | | | |supplies and accessories | | | |A7000 |NU | |Disposable canister, used with |Y |21 years | | | | |suction pump, each | |and over | |A7000 |EP | |Disposable canister, used with |Y |2-20 years | | | | |suction pump, each | | | |E2402 |NU | |Negative pressure wound therapy|Y |21 years | | | | |electrical pump, stationary or | |and over | | | | |portable | | | |E2402 |EP | |Negative pressure wound therapy|Y |2-20 years | | | | |electrical pump, stationary or | | | | | | |portable | | |

|242.130 Diapers and Underpads for Beneficiaries Ages 3 Years |4-20-15 | |and Older | |

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

Modifiers in this section are indicated by the headings M1 and M2. Prior authorization is indicated by the heading PA. If prior authorization is required, that information is indicated with a “Y” in the column, or if not, an “N” is shown. ((…) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product. When using a procedure code with this symbol, the product must meet the indicated Arkansas Medicaid description.

|Diapers and Underpads, 3 Years Old and Older (Section 242.130) | |Procedure |M1 |M2 |Description |PA |Payment | |Code | | | | |Method | |A4335 |NU |UB |Incontinence supply; |N |Purchase | | | | |miscellaneous | | | |A4554 |NU | |Disposable underpads, all sizes|N |Purchase | | | | |(e.g., Chux’s) | | | |T4521 |NU | |Adult-sized disposable |N |Purchase | | | | |incontinence product, | | | | | | |brief/diaper, small, each | | | |T4522 |NU | |Adult-sized disposable |N |Purchase | | | | |incontinence product, | | | | | | |brief/diaper, medium, each | | | |T4523 |NU | |Adult-sized disposable |N |Purchase | | | | |incontinence product, | | | | | | |brief/diaper, large, each | | | |T4524 |NU | |Adult-sized disposable |N |Purchase | | | | |incontinence product, | | | | | | |brief/diaper, extra large, each| | | |T4526 |NU | |Adult-sized disposable |N |Purchase | | |EP | |incontinence product, | | | | | | |protective underwear/pull-on, | | | | | | |medium size, each | | | |T4527 |NU | |Adult-sized disposable |N |Purchase | | |EP | |incontinence product, | | | | | | |protective underwear/pull-on, | | | | | | |large size, each | | | |T4528 |NU | |Adult-sized disposable |N |Purchase | | |EP | |incontinence product, | | | | | | |protective underwear/pull-on, | | | | | | |extra large size, each | | | |T4529 |EP | |((Small diaper) Pediatric-sized|N |Purchase | | | | |disposable incontinence | | | | | | |product, brief/diaper, | | | | | | |small/medium size, each | | | |T4529 |EP |U1 |((Medium diaper) |N |Purchase | | | | |Pediatric-sized disposable | | | | | | |incontinence product, | | | | | | |brief/diaper, small/medium | | | | | | |size, each | | | |T4530 |NU | |Pediatric-sized disposable |N |Purchase | | |EP | |incontinence product, | | | | | | |brief/diaper, large size, each | | | |T4531 |EP | |((Small diaper) Pediatric-sized|N |Purchase | | | | |disposable incontinence | | | | | | |product, protective | | | | | | |underwear/pull-on, | | | | | | |small/medium size, each | | | |T4531 |EP |U1 |((Medium diaper) |N |Purchase | | | | |Pediatric-sized disposable | | | | | | |incontinence product, | | | | | | |protective underwear/pull-on, | | | | | | |small/medium size, each | | | |T4532 |NU | |((Large diaper) Pediatric-sized|N |Purchase | | |EP | |disposable incontinence | | | | | | |product, protective | | | | | | |underwear/pull-on, large size, | | | | | | |each | | | |T4532 |NU |U1 |((Extra large diaper) |N |Purchase | | |EP |U1 |Pediatric-sized disposable | | | | | | |incontinence product, | | | | | | |protective underwear/pull-on, | | | | | | |large size, each | | | |T4533 |NU | |Youth-sized disposable |N |Purchase | | |EP | |incontinence product, | | | | | | |brief/diaper, each | | | |T4535 |NU | |((Pantyliners/Bladder |N |Purchase | | |EP | |Pads/Diaper Doubles) Disposable| | | | | | |liner/shield/guard/pad/ | | | | | | |undergarment for incontinence, | | | | | | |each | | | |T4535 |NU |U1 |((Under Garment One Size Fits |N |Purchase | | |EP |U1 |All) Disposable | | | | | | |liner/shield/guard/pad/ | | | | | | |undergarment for incontinence, | | | | | | |each | | | |T4543 |NU | |Disposable incontinence |N |Purchase | | | | |product, brief/diaper, | | | | | | |bariatric, each | | | |T4544 |NU | |Adult-sized disposable | | | | | | |incontinence product, | | | | | | |protective underwear/pull-on, | | | | | | |above extra large each | | |

Reimbursement is based on a per unit basis with one unit equaling one item (diaper, underpad). When billing for these services that are benefit limited to a dollar amount per month, providers must bill according to the calendar month.

Providers must not span calendar months when billing for diapers and/or underpads. The date of delivery is the date of service. Providers should not bill “from” and “through” dates of service.

Refer to Section 212.100 of this manual for coverage information on diapers and underpads.

|242.140 Electronic Blood Pressure Monitor and Cuff, All Ages |7-1-07 |

The procedure code found in this section must be billed either electronically or on paper using modifier NU for individuals of all ages.

Modifiers in this section are indicated by the headings M1 and M2. Prior authorization requirements are shown under the heading PA. If prior authorization is needed, that information is indicated with a “Y” in the column; if not, an “N” is shown. (Prior authorization is not required when other insurance pays at least 50% of the Medicaid maximum allowable reimbursement amount.

|Procedure |M1 |M2 |Description |PA |Payment | |Code | | | | |Method | |A4670 |NU | |Automatic blood pressure |Y( |Rental Only| | | | |monitor | | |

Included with the rental of this monitor, the provider will need to supply one (1) disposable blood pressure cuff each month.

|242.150 Nutritional Formulae for Child Health Services (EPSDT)|2-1-17 | |Beneficiaries Under 21 Years of Age | |

The following list provides the enteral formula HCPCS procedure codes, any associated modifiers, code descriptions and the formula covered for each HCPCS code. The code description lists the formula included in the category of nutrients.

The coverage listed is payable only if the service is prescribed as a result of a Child Health Services (EPSDT) screening/referral.

There is no prior authorization required for nutritional formulae for EPSDT beneficiaries from age five years through twenty years.

Prior authorization is required for beneficiaries from birth through four years. Use of modifier U7 in the following list will be necessary, as indicated.

To request prior authorization, providers should complete the Arkansas Foundation for Medical Care, Inc. Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components (DMS-679A), attaching a copy of the EPSDT screening/referral as well as a prescription signed by the beneficiary’s PCP. View or print form DMS-679A.

NOTE: The Women, Infant and Children program (WIC) must be accessed first for children from birth to their fifth birthday.

The Arkansas Medicaid program mirrors coverage of approved WIC nutritional formulae. As stated in current policy, the WIC Program must be accessed first for Arkansas Medicaid beneficiaries aged zero (0) to five (5) years, prior to requesting supplemental amounts of WIC-approved nutritional formula. The Medicaid nutritional formula list will be updated accordingly to continue compliance with the WIC Program in Arkansas. Changes will be reflected in the appropriate Medicaid provider manual.

For beneficiaries from birth through four years of age, the use of modifier U8, as well as additional documentation, will be required when a non-WIC formula is prescribed or WIC guidelines are not followed when prescribing special formula.

An EPSDT screening, which documents the PCP’s medical rationale for prescribing a formula, as well as medical records documenting the beneficiary’s failed trials of WIC formula, must be submitted for review. Flavor preferences for formulae will not be considered for medical necessity.

Exceptions to Use of Formulae

The following exceptions must be followed in order to use formulae listed in this section. A. Nutramigen LIPIL – Sensitivity or allergy to milk and/or soy protein; chronic diarrhea, food allergies, GI bleeds. Similac Advance must first have been tried. B. Nutramigen Enflora LGG – Sensitivity or allergy to milk and/or soy protein; chronic diarrhea, food allergies, GI bleeds. Similac Advance must first have been tried. C. Pregestimil – Allergy to milk and/or soy protein; chronic diarrhea, short gut; cystic fibrosis; fat malabsorption due to GI or liver disease. D. Gerber Extensive HA – Allergy to milk and/or soy protein; severe malnutrition; chronic diarrhea; short bowel syndrome; known or suspected corn allergy. Similac Advance must first have been tried. E. Alfamino Junior – Allergy to cow’s milk, multiple food protein intolerance, and food allergy associated conditions: short bowel syndrome, gastroesophageal reflux disease (GERD), eosinophilic esophagitis, malabsorption and other GI disorders. Neocate Junior with Prebiotics is intended for children over the age of one year. F. Alfamino Infant – Allergy to cow’s milk, multiple food protein intolerance, and food allergy associated conditions: short bowel syndrome, gastroesophageal reflux disease (GERD), eosinophilic esophagitis, malabsorption and other GI disorders. Similac Expert Care Alimentum, Nutramigen, or Pregestimil must first have been tried. G. Portagen – Pancreatic insufficiency, bile acid deficiency or lymphatic anomalies; biliary atresia; liver disease; chylothorax. H. Similac PM 60/40 – Renal, cardiac or other condition that requires lowered minerals. I. Periflex Infant – PKU; Hyperphenylalaninemia; for infants and toddlers. J. PKU Periflex Junior Plus – Hyperphenylalaninemia; for children and adults. K. Gerber Good Start Premature 24– Preterm, low birth weight. Not intended for feeding low birth weight infants after they reach a weight of 3600 g (approximately 8 lbs.). Not approved for an infant previously on term formula or a term infant for increased calories. L. Enfamil EnfaCare – Preterm infant transitional formula for use between premature formula and term formula. Not approved for an infant previously on term formula or a term infant for increased calories.

Procedure codes found in this section must be billed either electronically or on paper with modifier EP for beneficiaries under 21 years of age. Modifier BO is used to bill for oral usage. When a second or third modifier is listed, that modifier must be used in conjunction with EP.

For beneficiaries from birth through four years of age, the use of modifier U7, as well as additional documentation will be required when a non-WIC formula is prescribed or WIC guidelines are not followed when prescribing special formula.

Modifiers in this section are indicated by the headings M1, M2, M3 and M4.

** – These covered formulae are substitutions for PediaSure.

|Nutritional Formulae for Child Health Services (EPSDT) Beneficiaries| |Under 21 Years of Age (Section 242.150) | |HCPCS Code|M1 |M2 |M3 |M4 |Description |Covered Formulae | |B4149 |EP | | | |Enteral formula, |Compleat | |B4149 |EP |BO | | |blenderized natural | | | | | | | |foods with intact | | |B4149 |EP |U7 | | |nutrients, includes | | |B4149 |EP |U7 |BO | |proteins, fats, | | |Ages 0 – 4| | | | |carbohydrates, | | |Years | | | | |vitamins and | | |requires | | | | |minerals, may | | |PA | | | | |include fiber, | | | | | | | |administered through| | | | | | | |an enteral feeding | | | | | | | |tube, 100 calories =| | | | | | | |1 unit | | |B4150 |EP | | | |Enteral formula, |See list below | |B4150 |EP |BO | | |nutritionally | | | | | | | |complete with intact| | |B4150 |EP |U7 | | |nutrients, includes | | |B4150 |EP |U7 |BO | |proteins, fats, | | |Ages 0 – 4| | | | |carbohydrates, | | |Years | | | | |vitamins and | | |requires | | | | |minerals, may | | |PA | | | | |include fiber, | | | | | | | |administered through| | | | | | | |an enteral feeding | | | | | | | |tube, 100 calories =| | | | | | | |1 unit | | |Covered Formulae: | | | |Boost |Fibersource HN |Nutren Junior 1.0| |Carnation Instant Breakfast –|IsoSource HN |Fiber | |Lactose Free |Jevity 1.0 CAL |Osmolite 1.0 CAL | |Ensure |Nutren 1.0 |Promote | |Ensure Fiber with FOS | |Promote with | |Ensure High Protein | |Fiber | |Ensure Powder | | | |B4150 |EP |U1 |BO | |Enteral formula, |Boost Pudding | | | | | | |nutritionally |Ensure Pudding | |B4150 |EP |U1 |U7 |BO |complete with intact| | |Ages 0 – 4| | | | |nutrients, includes | | |Years | | | | |proteins, fats, | | |requires | | | | |carbohydrates, | | |PA | | | | |vitamins and | | | | | | | |minerals, may | | | | | | | |include fiber, | | | | | | | |administered through| | | | | | | |an enteral feeding | | | | | | | |tube, 100 calories =| | | | | | | |1 unit | | |B4152 |EP | | | |Enteral formula, |Boost Plus | |B4152 |EP |BO | | |nutritionally |Carnation Instant| | | | | | |complete, |Breakfast – | |B4152 |EP |U7 | | |calorically dense |Lactose Free Plus| |B4152 |EP |U7 |BO | |(equal to or greater|Ensure Plus | |Ages 0 – 4| | | | |than 1.5 Kcal/ml), |Nutren Junior 1.5| |Years | | | | |with intact |Nutren Junior 2.0| |requires | | | | |nutrients, includes |Osmolite 1.5 Cal | |PA | | | | |proteins, fats, |Resource 2.0 | | | | | | |carbohydrates, |Scandishake | | | | | | |vitamins and |Two-Cal HN | | | | | | |minerals, may | | | | | | | |include fiber, | | | | | | | |administered through| | | | | | | |an enteral feeding | | | | | | | |tube, 100 calories =| | | | | | | |1 unit | | |B4153 |EP | | | |Enteral formula, |Peptamen | |B4153 |EP |BO | | |nutritionally |Peptamen 1.5 | | | | | | |complete, hydrolyzed|Peptamen with | |B4153 |EP |U7 | | |proteins (amino |Prebio 1 | |B4153 |EP |U7 |BO | |acids and peptide |Perative | |Ages 0 – 4| | | | |chain), includes |Tolerex | |Years | | | | |fats, carbohydrates,|Vital HN | |requires | | | | |vitamins and |Vivonex Plus | |PA | | | | |minerals, may |Vivonex TEN | | | | | | |include fiber, | | | | | | | |administered through| | | | | | | |an enteral feeding | | | | | | | |tube, 100 calories =| | | | | | | |1 unit | | |B4154 |EP | | | |Enteral formula, |See list below | |B4154 |EP |BO | | |nutritionally | | | | | | | |complete, for | | |B4154 |EP |U7 | | |special metabolic | | |B4154 |EP |U7 |BO | |needs, includes | | |Ages 0 – 4| | | | |inherited disease of| | |Years | | | | |metabolism, includes| | |requires | | | | |altered composition | | |PA | | | | |of proteins, fats, | | | | | | | |carbohydrates, | | | | | | | |vitamins and/or | | | | | | | |minerals, may | | | | | | | |include fiber, | | | | | | | |administered through| | | | | | | |an enteral feeding | | | | | | | |tube, 100 calories =| | | | | | | |1 unit | | |Covered formulae: | | | |Boost Glucose Control |Impact with Fiber |Pulmocare | |Glucerna 1.0 cal |Ketocal 4:1 |Similac PM 60/40 | |Nutren Glytrol |Ketocal 3:1 |Suplena with Carb| |Hepatic Aid II |Nepro with Carb |Steady | |Impact |Steady | | | |NutriHep | | |B4155 |EP | | | |Enteral formula, |MCT Oil | |B4155 |EP |BO | | |nutritionally |Procel Protein | | | | | | |incomplete/modular |Supplement | | | | | | |nutrients, includes |Provimin | | | | | | |specific nutrients, | | | | | | | |carbohydrates (e.g.,| | | | | | | |glucose polymers), | | | | | | | |proteins/amino acids| | | | | | | |(e.g., glutamine, | | | | | | | |arganine), fat | | | | | | | |(e.g., medium chain | | | | | | | |triglycerides) or | | | | | | | |combination, | | | | | | | |administered through| | | | | | | |an enteral feeding | | | | | | | |tube, 100 calories =| | | | | | | |1 unit | | |B4155 |EP | | | |Enteral formula, |MCT Oil | |B4155 |EP |U7 |BO | |nutritionally |Procel Protein | |Ages 0 – 4| | | | |incomplete/modular |Supplement | |Years | | | | |nutrients, includes |Provimin | |requires | | | | |specific nutrients, | | |PA | | | | |carbohydrates (e.g.,| | | | | | | |glucose polymers), | | | | | | | |proteins/amino acids| | | | | | | |(e.g., glutamine, | | | | | | | |arganine), fat | | | | | | | |(e.g., medium chain | | | | | | | |triglycerides) or | | | | | | | |combination, | | | | | | | |administered through| | | | | | | |an enteral feeding | | | | | | | |tube, 100 calories =| | | | | | | |1 unit | | |B4155 |EP |U1 | | |Enteral formula, |SolCarb | |B4155 |EP |U1 |BO | |nutritionally |Scandical | | | | | | |incomplete/modular | | |B4155 |EP |U1 |U7 | |nutrients, includes | | |B4155 |EP |U1 |U7 |BO |specific nutrients, | | |Ages 0 – 4| | | | |carbohydrates (e.g.,| | |Years | | | | |glucose polymers), | | |requires | | | | |proteins/amino acids| | |PA | | | | |(e.g., glutamine, | | | | | | | |arganine), fat | | | | | | | |(e.g., medium chain | | | | | | | |triglycerides) or | | | | | | | |combination, | | | | | | | |administered through| | | | | | | |an enteral feeding | | | | | | | |tube, 100 calories =| | | | | | | |1 unit | | |B4155 |EP |U2 | | |Enteral formula, |Microlipid | |B4155 |EP |U2 |BO | |nutritionally | | | | | | | |incomplete/modular | | |B4155 |EP |U2 |U7 | |nutrients, includes | | |B4155 |EP |U2 |U7 |BO |specific nutrients, | | |Ages 0 – 4| | | | |carbohydrates (e.g.,| | |Years | | | | |glucose polymers), | | |requires | | | | |proteins/amino acids| | |PA | | | | |(e.g., glutamine, | | | | | | | |arganine), fat | | | | | | | |(e.g., medium chain | | | | | | | |triglycerides) or | | | | | | | |combination, | | | | | | | |administered through| | | | | | | |an enteral feeding | | | | | | | |tube, 100 calories =| | | | | | | |1 unit | | |B4155 |EP |U3 | | |Enteral formula, |MSUD 1 | |B4155 |EP |U3 |BO | |nutritionally |MSUD 2 | | | | | | |incomplete/modular |Periflex Infant | |B4155 |EP |U3 |U7 | |nutrients, includes |Periflex Junior | |B4155 |EP |U3 |U7 |BO |specific nutrients, |Plus | |Ages 0 – 4| | | | |carbohydrates (e.g.,|RCF | |Years | | | | |glucose polymers), |TYR 1 | |requires | | | | |proteins/amino acids|TYR 2 | |PA | | | | |(e.g., glutamine, | | | | | | | |arganine), fat | | | | | | | |(e.g., medium chain | | | | | | | |triglycerides) or | | | | | | | |combination, | | | | | | | |administered through| | | | | | | |an enteral feeding | | | | | | | |tube, 100 calories =| | | | | | | |1 unit | | |B4158 |EP | | | |Enteral formula, for|Portagen | |B4158 |EP |BO | | |pediatrics, |Similac Advance | | | | | | |nutritionally |Similac Advance | |B4158 |EP |U7 | | |complete with intact| | |B4158 |EP |U7 |BO | |nutrients, includes | | |Ages 0 – 4| | | | |proteins, fats, | | |Years | | | | |carbohydrates, | | |requires | | | | |vitamins and | | |PA | | | | |minerals, may | | | | | | | |include fiber and/or| | | | | | | |iron, administered | | | | | | | |through an enteral | | | | | | | |feeding tube, 100 | | | | | | | |calories = 1 unit | | |B4159 |EP | | | |Enteral formula, for|Similac Soy | |B4159 |EP |BO | | |pediatrics, |Isomil | | | | | | |nutritionally | | |B4159 |EP |U7 | | |complete soy base | | |B4159 |EP |U7 |BO | |with intact | | |Ages 0 – 4| | | | |nutrients, includes | | |Years | | | | |proteins, fats, | | |requires | | | | |carbohydrates, | | |PA | | | | |vitamins and | | | | | | | |minerals, may | | | | | | | |include fiber and/or| | | | | | | |iron, administered | | | | | | | |through an enteral | | | | | | | |feeding tube, 100 | | | | | | | |calories = 1 unit | | |B4159 |EP | | | |Enteral formula, for|Similac Advance | |B4159 |EP |BO | | |pediatrics, |(20 calorie – | | | | | | |nutritionally |milk-based) | |B4159 |EP |U8 |U7 | |complete soy base |Similac Soy | |B4159 |EP |U8 |U7 |BO |with intact |Isomil (20 | |Ages 0 – 4| | | | |nutrients, includes |calorie – | |Years | | | | |proteins, fats, |soy-based) | |requires | | | | |carbohydrates, | | |PA | | | | |vitamins and | | | | | | | |minerals, may | | | | | | | |include fiber and/or| | | | | | | |iron, administered | | | | | | | |through an enteral | | | | | | | |feeding tube, 100 | | | | | | | |calories = 1 unit | | |B4160 |EP | | | |Enteral formula, for|Boost Kids | |B4160 |EP |BO | | |pediatrics, |Essentials Nutren| | | | | | |nutritionally |Junior | |B4160 |EP |U7 | | |complete calorically|Nutren Junior | |B4160 |EP |U7 |BO | |dense (equal to or |with Fiber | |Ages 0 – 4| | | | |greater than | | |Years | | | | |0.7Kcal/ml) with | | |requires | | | | |intact nutrients, | | |PA | | | | |includes proteins, | | | | | | | |fats, carbohydrates,| | | | | | | |vitamins and | | | | | | | |minerals, may | | | | | | | |include fiber, | | | | | | | |administered through| | | | | | | |an enteral feeding | | | | | | | |tube, 100 calories =| | | | | | | |1 unit | | |B4160 |EP | | | |Enteral formula, for|Boost Kids | |B4160 |EP |BO | | |pediatrics, |Essentials Nutren| | | | | | |nutritionally |Junior | |B4160 |EP |U8 |U7 | |complete calorically|Nutren Junior | |B4160 |EP |U8 |U7 |BO |dense (equal to or |with Fiber | |Ages 0 – 4| | | | |greater than 0.7 | | |Years | | | | |Kcal/ml) with intact| | |requires | | | | |nutrients, includes | | |PA | | | | |proteins, fats, | | | | | | | |carbohydrates, | | | | | | | |vitamins and | | | | | | | |minerals, may | | | | | | | |include fiber, | | | | | | | |administered through| | | | | | | |an enteral feeding | | | | | | | |tube, 100 calories =| | | | | | | |1 unit | | |B4160 |EP |U1 | | |Enteral formula, for|Gerber Good Start| |B4160 |EP |U1 |BO | |pediatrics, |Premature 24 | | | | | | |nutritionally | | |B4160 |EP |U1 |U7 | |complete calorically| | |B4160 |EP |U1 |U7 |BO |dense (equal to or | | |Ages 0 – 4| | | | |greater than 0.7 | | |Years | | | | |Kcal/ml) with intact| | |requires | | | | |nutrients, includes | | |PA | | | | |proteins, fats, | | | | | | | |carbohydrates, | | | | | | | |vitamins and | | | | | | | |minerals, may | | | | | | | |include fiber, | | | | | | | |administered through| | | | | | | |an enteral feeding | | | | | | | |tube, 100 calories =| | | | | | | |1 unit | | |B4160 |EP |U1 |U8 | |Enteral formula, for|Enfamil EnfaCare | |B4160 |EP |U1 |U8 |BO |pediatrics, | | |Ages 0 – 4| | | | |nutritionally | | |Years | | | | |complete calorically| | |requires | | | | |dense (equal to or | | |PA | | | | |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 | | |B4161 |EP | | | |Enteral formula, for|Alfamino Junior | |B4161 |EP |BO | | |pediatrics, |Alfamino Infant | | | | | | |hydrolyzed/amino |Nutramigen | |B4161 |EP |U7 | | |acids and peptide |Enflora LGG | |B4161 |EP |U7 |BO | |chain proteins, |Nutramigen LIPIL | |Ages 0 – 4| | | | |includes fats, |Pregestimil | |Years | | | | |carbohydrates, |Gerber Extensive | |requires | | | | |vitamins and |HA | |PA | | | | |minerals, may | | | | | | | |include fiber, | | | | | | | |administered through| | | | | | | |an enteral feeding | | | | | | | |tube, 100 calories =| | | | | | | |1 unit | | |B4161 |EP | | | |Enteral formula, for|Neocate Splash | |B4161 |EP |BO | | |pediatrics, |Peptamen Junior | | | | | | |hydrolyzed/amino |Vivonex Pediatric| |B4161 |EP |U7 |U8U8|BO |acids and peptide | | |B4161 |EP |U7 | | |chain proteins, | | |Ages 0 – 4| | | | |includes fats, | | |Years | | | | |carbohydrates, | | |requires | | | | |vitamins and | | |PA | | | | |minerals, may | | | | | | | |include fiber, | | | | | | | |administered through| | | | | | | |an enteral feeding | | | | | | | |tube, 100 calories =| | | | | | | |1 unit | | |B4162 |EP | | | |Enteral formula, for|See list below | |B4162 |EP |BO | | |pediatrics, special | | | | | | | |metabolic needs for | | |B4162 |EP |U7 | | |inherited disease of| | |B4162 |EP |U7 |BO | |metabolism, includes| | |Ages 0 – 4| | | | |fats, carbohydrates,| | |Years | | | | |vitamins and | | |requires | | | | |minerals, may | | |PA | | | | |include fiber, | | | | | | | |administered through| | | | | | | |an enteral feeding | | | | | | | |tube, 100 calories =| | | | | | | |1 unit | | |Covered Formulae: | |Propimex-1 | |Calcilo XD |MSUD Maxamaid |Propimex-2 | |Cyclinex-1 |MSUD Maxamum |XLys, XTrp | |Cyclinex-2 |MSUD Analog |Maxamaid | |Glutarex-1 |Periflex Infant |Xphe Maxamaid | |Glutarex-2 |Periflex Junior Plus|Xphe Maxamum | |Hominex-1 |Phenex-1 |Xphe, XTyr | |Hominex-2 |Phenex-2 |Maxamaid | |I-Valex-1 | | | |I-Valex-2 | | | |Ketonex-1 | | | |Ketonex-2 | | | |B4162 |EP |U1 | | |Enteral formula, for|XMTVI Maxamaid | |B4162 |EP |U1 |BO | |pediatrics, special | | | | | | | |metabolic needs for | | |B4162 |EP |U1 |U7 | |inherited disease of| | |B4162 |EP |U1 |U7 |BO |metabolism, includes| | |Ages 0 – 4| | | | |fats, carbohydrates,| | |Years | | | | |vitamins and | | |requires | | | | |minerals, may | | |PA | | | | |include fiber, | | | | | | | |administered through| | | | | | | |an enteral feeding | | | | | | | |tube, 100 calories =| | | | | | | |1 unit | |

One unit of service equals 100 calories with a reimbursable maximum of 30 units per day. Supplies furnished by prosthetics providers in conjunction with the nutritional formula must be billed to Medicaid with the prosthetics medical supply codes. These formulae are covered as nutritional supplements rather than as the sole source of nutrition.

NOTE: Beneficiaries who require enteral nutrition as the sole source of nutrition with the formulae being administered through a nasogastric, jejunostomy or gastrostomy tube should be referred to a hyperalimentation provider enrolled in the Medicaid Program.

Each claim should reflect a “from” and “through” date of service. The claims must not be filed until after the “through” date has elapsed. Claims may be submitted on either a weekly or a monthly basis.

NOTE: If a specific formula is not listed but is prescribed as the result of the EPSDT screening of an Arkansas Medicaid beneficiary, the provider may forward a copy of the screening and prescription, along with product information, to Utilization Review for consideration.

|242.151 Pedia-Pop |7-1-07 |

The procedure code found in this section must be billed with modifier EP. Pedia-Pop is only for oral consumption, and is only in frozen form.

Modifiers in this section are indicated by the headings M1 and M2.

|Procedure |M1 |M2 |Description |Maximum Units | |Code | | | | | |Z2487 |EP | |Pedia-Pop; 1 unit = 1 |2 units per date of | | | | |box |service |

|242.152 Enteral Nutrition Infusion Pump and Enteral Feeding |4-15-11 | |Pump Supply Kit | |

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

The procedure codes require prior authorization from AFMC.

Modifiers in this section are indicated by the headings M1 and M2. Prior authorization requirements are shown under the heading PA. If prior authorization is needed, that information is indicated with a “Y” in the column; if not, an “N” is shown. ((…) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product.

|Procedure |M1 |M2 |Description |Maximum |PA |Payment | |Code | | | |Units | |Method | |B4035 |EP | |Enteral feeding |1 per day|Y |Purchase | | | | |supply kit, pump fed,| | | | | | | |per day | | | | | | | |(1 unit = 1 day) | | | | |B9000 |EP | |Enteral nutrition |1 per day|Y |Rent to | | | | |infusion pump – | | |Purchase | | | | |without alarm | | | | | | | |(1 day = 1 unit) | | | | |B9002 |EP | |Enteral nutrition |1 per day|Y |Rent to | | | | |infusion pump – with | | |Purchase | | | | |alarm | | | | | | | |(1 day = 1 unit) | | | | |K0739 |EP |U2 |((Repair or | |Y | | | | | |non-routine service | | | | | | | |for enteral nutrition| | | | | | | |infusion pump, | | | | | | | |requiring the skill | | | | | | | |of a technician, | | | | | | | |parts and labor) | | | |

Enteral Nutrition Infusion Pump

Reimbursement for the enteral nutrition infusion pump is based on a rent- to-purchase methodology. Each unit reimbursed by Medicaid will apply towards the purchase price established by Medicaid.

Reimbursement will only be approved for new equipment. Used equipment will not be prior authorized. Procedure codes B9000 and B9002 represent a new piece of equipment being reimbursed by Medicaid on the rent-to- purchase plan.

Codes B9000 and B9002 are reimbursed on a per unit basis with 1 day equaling 1 unit of service per day.

Medicaid will reimburse on the rent-to-purchase plan for a total of 304 units of service. After reimbursement has been made for 304 units, the equipment will become the property of the Medicaid beneficiary.

Prior authorization is required for codes B9000 and B9002. The prior authorization request must include the serial number of the infusion pump being provided to the beneficiary.

See Section 236.000 for reimbursement when the Medicaid Program is billed for repairs made to the enteral infusion pump.

|242.153 MIC-KEY Skin Level Gastrostomy Tube (MIC-KEY Button) |7-1-14 | |and MIC-KEY Percutaneous Cecostomy Tube and Supplies for | | |Beneficiaries of All Ages | |

NOTE: When billing for the MIC-KEY Percutaneous Cecostomy Tube and/or supplies, an additional third modifier UA will be required.

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

|Procedure |M1 |M2 |PA |Description |Payment | |Code | | | | |Method | |B9998 | | |Y |MIC-KEY Kit |Purchase | |B9998 |NU |U1 |Y |SECUR-LOK Extension Set with 2 |Purchase | | | | | |Port ‘Y’ and Clamp 12” Length | | |B9998 |NU |U2 |Y |SECUR-LOK Extension Set with 2 |Purchase | | | | | |Port ‘Y’ and Clamp 24” Length | | |B9998 |NU |U3 |Y |Bolus Extension Set with Single |Purchase | | | | | |Port Clamp 12” Length | | |B9998 |NU |U4 |Y |Bolus Extension Set with Single |Purchase | | | | | |Port Clamp 24” Length | | |B9998 |NU |U5 |Y |Bolus SECUR-LOK Extension Set |Purchase | | | | | |Single Port w/Clamp 12” Length | | |B9998 |NU |U6 |Y |Bolus SECUR-LOK Extension Set |Purchase | | | | | |Single Port w/Clamp 24” Length | | |B9998 |NU |U7 |Y |Microvasive Adapter |Purchase | |B9998 |NU |U8 |Y |Microvasive Decompression Tube |Purchase |

|242.154 Nasogastric Tubing for Individuals Under Age 21 |7-1-07 |

The procedure code found in this section must be billed with modifier EP for beneficiaries under 21 years of age. The code is payable only for beneficiaries under age 21.

|Procedure |M1 |M2 |PA |Description |Payment | |Code | | | | |Method | |B4082 |EP | |N |Nasogastric tubing without |Purchase | | | | | |stylet | |

|242.155 Billing and Reimbursement Protocol for FM (Frequency |12-1-12 | |Modulation) System and Replacement Cochlear Implant Parts | |

Procedure codes L8621, L8622 and L8624 in the table below require paper claim submission with a manufacturer’s invoice attached that demonstrates the specific cost per item. The invoice must clearly indicate the specific item(s) supplied to the beneficiary for whom the claim is billed. Procedure codes L8615, L8616, L8617, L8618, L8619, L8623, L8627, L8628 and L8629 may be submitted electronically or on a paper claim form. Procedure code V5273 may be submitted electronically or on a paper claim form. For provider charges for an FM system that is meant to be used with a cochlear implant, V5273 should reflect the retail price. For reimbursement of an FM system to be used with a cochlear implant, V5273 will be at 68 percent of the retail price.

|Procedure |M1 |Description |PA |PA |Units | |Code | | | |Criteria |Allowed | | | | | | |per Date | | | | | | |of | | | | | | |Service | |L8615* |EP |Headset/headpiece for|Y |1 per 3 |2 | | | |use with cochlear | |years | | | | |implant device, | | | | | | |replacement | | | | |L8616* |EP |Microphone for use |Y |1 per |2 | | | |with cochlear implant| |year | | | | |device, replacement | | | | |L8617* |EP |Transmitting coil for|Y |1 per |2 | | | |use with cochlear | |year | | | | |implant device, | | | | | | |replacement | | | | |L8618* |EP |Transmitter cable for|Y |4 per 6 |8 | | | |use with cochlear | |months | | | | |implant device, | | | | | | |replacement | | | | |L8619* |EP |Cochlear implant |Y |5 years |2 | | | |external speech | | | | | | |processor, and | | | | | | |controller, | | | | | | |integrated system, | | | | | | |replacement | | | | |L8621* |EP |Zinc air battery for |Y |180 units|360 | | | |use with cochlear | |per 6 | | | | |implant device | |months | | | | |replacement, each | | | | |L8622* |EP |Alkaline battery for |Y |180 units|360 | | | |use with cochlear | |per 6 | | | | |implant device, any | |months | | | | |size, replacement, | | | | | | |each | | | | |L8623* |EP |Lithium ion battery |Y |1 (set of|2 | | | |for use with cochlear| |2) per | | | | |implant device speech| |year | | | | |processor, other than| |Unilatera| | | | |ear level, | |l | | | | |replacement, each | | | | |L8624* |EP |Lithium ion battery |Y |1 (set of|2 | | | |for use with cochlear| |2) per | | | | |implant device speech| |year | | | | |processor, ear level,| |Unilatera| | | | |replacement, each | |l | | |L8627* |EP |Cochlear implant, |Y |Prior |2 | | | |external speech | |authorize| | | | |processor, component,| |d when | | | | |replacement | |not under| | | | | | |warranty | | |L8628* |EP |Cochlear implant, |Y |Prior |2 | | | |external controller | |authorize| | | | |component, | |d when | | | | |replacement | |not under| | | | | | |warranty | | |L8629* |EP |Transmitting coil and|Y |1 per |2 | | | |cable, integrated, | |year | | | | |for use with cochlear| | | | | | |implant device, | | | | | | |replacement | | | | |V5273 |EP |Assistive listening |Y |Prior |1 | | | |device, for use with | |authorize| | | | |cochlear implant | |d when | | | | | | |not | | | | | | |covered | | | | | | |through | | | | | | |IDEA | |

*Denotes paper claim

|242.160 Durable Medical Equipment, All Ages |9-1-13 |

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

Modifiers in this section are indicated by the headings M1 and M2. Prior authorization requirements are shown under the heading PA. If prior authorization is needed, that information is indicated with a “Y” in the column; if not, an “N” is shown. * The purchase of wheelchairs for individuals age 21 and older is limited to one per five-year period. *** This procedure code may not be billed for used equipment. ( Prior authorization is not required when other insurance pays at least 50% of the Medicaid maximum allowable reimbursement amount. ((…) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product. When using a procedure code with this symbol, the product must meet the indicated Arkansas Medicaid description. 3 This item is a capped rental for 90 days only, and requires PA and a review.

|Durable Medical Equipment, All Ages (Section 242.160) | |Procedure |M1 |M2 |M3 |PA |Description |Payment | |Code | | | | | |Method | |A4566 |NU | | |N |Shoulder sling or vest |Manually | | |EP | | | |design, abduction restrainer,|Priced | | | | | | |with or without swathe | | | | | | | |control, prefabricated, | | | | | | | |includes fitting and | | | | | | | |adjustment | | |A4635 |NU | | |N |Underarm pad, crutch, |Purchase | | |EP | | | |replacement, each | | | |UE | | | | | | |A4636 |NU | | |N |Replacement, handgrip, cane, |Purchase | | |EP | | | |crutch, or walker, each | | | |UE | | | | | | |A4637 |NU | | |N |Replacement, tip, cane, |Purchase | | |EP | | | |crutch, walker, each | | | |UE | | | | | | |A7020 |NU | | |Y |Interface for cough |Manually | | |EP | | | |stimulating device, includes |Priced | | | | | | |all components, replacement | | | | | | | |only | | |A9999 |NU | | |Y |((Unlisted Durable Medical |Purchase | | | | | | |Equipment. The | | | | | | | |manufacturer’s invoice must | | | | | | | |be attached to the claim | | | | | | | |form.) Misc. DME supply or | | | | | | | |accessory, not otherwise | | | | | | | |specified | | |E0100 |NU | | |N |Cane, includes canes of all |Purchase | | |EP | | | |materials, adjustable or | | | |UE | | | |fixed, with tip | | |E0105 |NU | | |N |Cane, quad or three-prong, |Purchase | | |EP | | | |includes canes of all | | | |UE | | | |materials, adjustable or | | | | | | | |fixed, with tips | | |E0110 |NU | | |N |Crutches, forearm, includes |Purchase | | |EP | | | |crutches of various | | | |UE | | | |materials, adjustable or | | | | | | | |fixed, pair, complete with | | | | | | | |tips and handgrips | | |E0111 |NU | | |N |Crutch, forearm, includes |Purchase | | |EP | | | |crutches of various | | | |UE | | | |materials, adjustable or | | | | | | | |fixed, each, with tip and | | | | | | | |handgrip | | |E0111 |NU |U1 | |N |Crutch, forearm, includes |Purchase | | | | | | |crutches of various | | | | | | | |materials, adjustable or | | | | | | | |fixed, each, with tip and | | | | | | | |handgrip | | |E0112 |NU | | |N |Crutches, underarm, wood, |Purchase | | |EP | | | |adjustable or fixed, pair, | | | |UE | | | |with pads, tips and handgrips| | |E0113 |NU | | |N |Crutch, underarm, wood, |Purchase | | |EP | | | |adjustable or fixed, each, | | | |UE | | | |with pad, tip and handgrip | | |E0114 |NU | | |N |Crutches, underarm, other |Purchase | | |EP | | | |than wood, adjustable or | | | |UE | | | |fixed, pair, with pads, tips | | | | | | | |and handgrips | | |E0116 |NU | | |N |Crutch, underarm, other than |Purchase | | |EP | | | |wood, adjustable or fixed, | | | |UE | | | |each, with pad, tip and | | | | | | | |handgrip | | |E0130 |NU | | |N |Walker, rigid (pickup), |Purchase | | |EP | | | |adjustable or fixed height | | | |UE | | | | | | |E0135 |NU | | |N |Walker, folding (pickup), |Purchase | | |EP | | | |adjustable or fixed height | | | |UE | | | | | | |E0140 |NU | | |N |Walker, w/trunk support, |Purchase | | |EP | | | |adjustable or fixed height, | | | | | | | |any type | | |E0141 |NU | | |N |Walker, rigid, wheeled, |Purchase | | |EP | | | |adjustable or fixed height | | | |UE | | | | | | |E0143 |NU | | |N |Walker, folding, wheeled, |Purchase | | |EP | | | |adjustable or fixed height | | | |UE | | | | | | |E0147 |NU | | |N |Walker, heavy-duty, multiple |Purchase | | |EP | | | |braking system, variable | | | |UE | | | |wheel resistance | | |E0153 |NU | | |N |Platform attachment, forearm |Purchase | | |EP | | | |crutch, each | | | |UE | | | | | | |E0154 |NU | | |N |Platform attachment, walker, |Purchase | | |EP | | | |each | | | |UE | | | | | | |E0155 |NU | | |N |Wheel attachment, rigid |Purchase | | |EP | | | |pick-up walker, per pair seat| | | |UE | | | |attachment, walker | | |E0156 |NU | | |N |Seat attachment, walker |Purchase | | |EP | | | | | | |E0157 |NU | | |N |Crutch attachment, walker, |Purchase | | |EP | | | |each | | | |UE | | | | | | |E0158 |NU | | |N |Leg extensions for walker, |Purchase | | |EP | | | |per set of four (4) | | | |UE | | | | | | |E0159 |NU | | |N |Brake attachment for wheeled |Purchase | | |EP | | | |walker, replacement, each | | |E0160 |NU | | |N |Sitz type bath or equipment, |Purchase | | |EP | | | |portable, used with or | | | |UE | | | |without commode | | |E0161 |NU | | |N |Sitz type bath or equipment, |Purchase | | |EP | | | |portable, used with or | | | |UE | | | |without commode, with faucet | | | | | | | |attachment(s) | | |E0163 |NU | | |N |Commode chair, stationary, |Purchase | | |EP | | | |with fixed arms | | | |UE | | | | | | |E0167 |NU | | |N |Pail or pan for use with |Purchase | | |EP | | | |commode chair | | | |UE | | | | | | |E0175 |NU | | |N |Foot rest, for use with |Purchase | | |EP | | | |commode chair, each | | | |UE | | | | | | |E0181 |NU | | |N |Pressure pad, alternating |Capped | | |EP | | | |with pump, heavy-duty |Rental | | |UE | | | | | | |E0182 |NU | | |N |Pump for alternating pressure|Purchase | | |EP | | | |pad | | | |UE | | | | | | |E0184 |NU | | |N |Dry pressure mattress |Purchase | | |EP | | | | | | | |UE | | | | | | |E0185 |NU | | |N |Gel or gel-like pressure pad |Purchase | | |EP | | | |for mattress, standard | | | |UE | | | |mattress length and width | | |E0186 |NU | | |Y |Air pressure mattress |Purchase | | |EP | | | | | | |E0187 |NU | | |Y |Water pressure mattress |Purchase | | |EP | | | | | | |E0189 |NU | | |N |Lamb’s wool sheepskin pad, |Purchase | | |EP | | | |any size | | | |UE | | | | | | |E0190 |NU | | |N |Positioning |Purchase | | |UE | | | |cushion/pillow/wedge, any | | | | | | | |shape or size | | |E0190 |EP | | |N |( (Tumble Form Therapy Roll |Purchase | | | | | | |4“) Positioning | | | | | | | |cushion/pillow/wedge, any | | | | | | | |shape or size | | |E0190 |EP |U1 | |N |( (Tumble Form Therapy Roll |Purchase | | | | | | |6”) Positioning | | | | | | | |cushion/pillow/wedge, any | | | | | | | |shape or size | | |E0190 |EP |U2 | |N |( (Tumble Form Therapy Wedge |Purchase | | | | | | |4”) Positioning | | | | | | | |cushion/pillow/wedge, any | | | | | | | |shape or size | | |E0190 |EP |U3 | |N |( (Tumble Form Therapy Roll |Purchase | | | | | | |8”) Positioning | | | | | | | |cushion/pillow/wedge, any | | | | | | | |shape or size | | |E0190 |EP |U4 | |N |( (Tumble Form Therapy Wedge |Purchase | | | | | | |6”) Positioning | | | | | | | |cushion/pillow/wedge, any | | | | | | | |shape or size | | |E0190 |EP |U5 | |N |( (Floor Sitter Wedge 4”) |Purchase | | | | | | |Positioning | | | | | | | |cushion/pillow/wedge, any | | | | | | | |shape or size | | |E0190 |EP |U6 | |N |( (Tumble Form Therapy Roll |Purchase | | | | | | |12”) Positioning | | | | | | | |cushion/pillow/wedge, any | | | | | | | |shape or size | | |E0190 |EP |U7 | |N |( (Deluxe Wedge with strap |Purchase | | | | | | |4”) Positioning | | | | | | | |cushion/pillow/wedge, any | | | | | | | |shape or size | | |E0190 |EP |U8 | |N |( (Deluxe Wedge with strap |Purchase | | | | | | |6”) Positioning | | | | | | | |cushion/pillow/wedge, any | | | | | | | |shape or size | | |E0190 |EP |U9 | |N |( (Tumble Form Therapy Wedge |Purchase | | | | | | |10”) Positioning | | | | | | | |cushion/pillow/wedge, any | | | | | | | |shape or size | | |E0190 |EP |KA |U1 |N |( (Tumble Form Therapy Roll |Purchase | | | | | | |14”) Positioning | | | | | | | |cushion/pillow/wedge, any | | | | | | | |shape or size | | |E0190 |EP |KA |U2 |N |(Tumble Form Therapy Roll |Purchase | | | | | | |16”) Positioning | | | | | | | |cushion/pillow/wedge, any | | | | | | | |shape or size ( | | |E0190 |EP |KA |U3 |N |( (Tumble Form Therapy Wedge |Purchase | | | | | | |8”) Positioning | | | | | | | |cushion/pillow/wedge, any | | | | | | | |shape or size | | |E0191 |NU | | |N |Heel or elbow protector, each|Purchase | | |EP | | | | | | | |UE | | | | | | |E01943 |NU | | |Y |((Clinitron Bed) Air |Capped | | |EP | | | |fluidized bed |Rental | |E0196 |NU | | |N |Gel pressure mattress |Purchase | | |EP | | | | | | |E0197 |NU | | |N |Air pressure pad for |Purchase | | |EP | | | |mattress, standard mattress | | | |UE | | | |length and width | | |E0198 |NU | | |Y |Water pressure pad for |Purchase | | |EP | | | |mattress, standard mattress | | | | | | | |length and width | | |E0200 |NU | | |N |Heat lamp, without stand |Capped | | |EP | | | |(table model), includes bulb,|Rental | | |UE | | | |or infrared element | | |E0202 |NU | | |N |Phototherapy (bilirubin) |Rental | | |EP | | | |light with photometer |Only | | |UE | | | | | | |E0202 |UE |U1 | |N |Phototherapy (bilirubin) |Capped | | | | | | |light with photometer |Rental | |E0205 |NU | | |N |Heat lamp, with stand |Capped | | |EP | | | |includes bulb, or infrared |Rental | | |UE | | | |element | | |E0217 |NU | | |N |Water circulating heat pad |Capped | | |EP | | | |with pump |Rental | | |UE | | | | | | |E0225 |NU | | |N |Hydrocollator unit, includes |Capped | | |EP | | | |pad |Rental | | |UE | | | | | | |E0235 |NU | | |N |Paraffin bath unit, portable |Purchase | | |EP | | | |(see medical supply code | | | |UE | | | |A4265 for paraffin) | | |E0236 |NU | | |N |Pump for water circulating |Capped | | |EP | | | |pad |Rental | | |UE | | | | | | |E0239 |NU | | |N |Hydrocollator unit, portable |Capped | | |EP | | | | |Rental | | |UE | | | | | | |E0240 |NU | | |N |Bath/shower chair w/wo |Purchase | | |EP | | | |wheels, any size | | |E0240 |NU |U1 | |N |Bath/shower chair w/wo |Purchase | | |EP |U1 | | |wheels, any size | | |E0240 |NU |U2 | |N |Bath/shower chair w/wo |Purchase | | |EP |U2 | | |wheels, any size | | |E0240 |NU |U3 | |N |Bath/shower chair w/wo |Purchase | | |EP |U3 | | |wheels, any size | | |E0244 |NU | | |N |Raised toilet seat |Purchase | | |EP | | | | | | |E0245*** |NU |U1 | |N |((Bath Frame Support, Large) |Purchase | | |EP |U1 | | |Tub stool or bench | | |E0247 |NU | | |N |Transfer bench, tub/toilet, |Purchase | | |EP | | | |w/wo commode opening | | |E0247 |NU |U1 | |N |Transfer bench, tub/toilet, |Purchase | | |EP |U1 | | |w/wo commode opening | | |E0248 |NU | | |N |Transfer bench, heavy-duty, |Purchase | | |EP | | | |tub/toilet w/wo commode | | | | | | | |opening | | |E0248 |NU |U1 | |N |Transfer bench, heavy-duty, |Purchase | | |EP |U1 | | |tub/toilet w/wo commode | | | | | | | |opening | | |E0249 |NU | | |N |Pad for water circulating |Purchase | | |EP | | | |heat unit | | | |UE | | | | | | |E0250 |NU | | |Y( |((Hospital bed, with side |Purchase | | |EP | | | |rails, fixed height, with | | | | | | | |mattress, purchase) Hospital| | | | | | | |bed, fixed height, with any | | | | | | | |type side rails, with | | | | | | | |mattress | | |E0250 |NU |RR | |Y( |Hospital bed, fixed height, |Capped | | |EP |RR | | |with any type side rails, |Rental | | | | | | |with mattress | | |E0255 |NU | | |Y( |Hospital bed, variable |Purchase | | |EP | | | |height; hi-lo, with any type | | | | | | | |side rails, with mattress | | |E0255 |NU |RR | |Y( |Hospital bed, variable |Capped | | |EP |RR | | |height; hi-lo, with any type |Rental | | | | | | |side rails, with mattress | | |E0255 |NU |U1 | |Y( |((Hospital bed, with side |Purchase | | | | | | |rails, variable height; | | | | | | | |hi-lo, with mattress, | | | | | | | |purchase) Hospital bed, | | | | | | | |variable height; hi-lo, with | | | | | | | |any type side rails, with | | | | | | | |mattress | | |E0255 |UE | | |Y( |Hospital bed, variable |Capped | | | | | | |height; hi-lo, with any type |Rental | | | | | | |side rails, with mattress | | |E0260 |NU | | |Y( |((Hospital bed, with side |Purchase | | |EP | | | |rails, semi-electric, head | | | |UE | | | |and foot adjustments, with | | | | | | | |mattress, purchase) Hospital| | | | | | | |bed, semi-electric, head and | | | | | | | |foot adjustment, with any | | | | | | | |type side rails with mattress| | |E0260 |NU |RR | |Y( |Hospital bed, semi-electric, |Capped | | |EP |RR | | |head and foot adjustment, |Rental | | | | | | |with any type side rails with| | | | | | | |mattress | | |E0271 |NU | | |N |Mattress, inner spring |Capped | | |EP | | | | |Rental | | |UE | | | | | | |E0272 |NU | | |N |Mattress, foam rubber |Capped | | |EP | | | | |Rental | | |UE | | | | | | |E0273 |NU | | |N |Bed board |Purchase | | |EP | | | | | | | |UE | | | | | | |E0275 |NU | | |N |Bed pan, standard, metal or |Purchase | | |EP | | | |plastic | | | |UE | | | | | | |E0276 |NU | | |N |Bed pan, fracture, metal or |Purchase | | |EP | | | |plastic | | | |UE | | | | | | |E02773 |NU | | |Y |((Low Air Loss Mattress) |Capped | | |EP | | | |Powered pressure-reducing air|Rental | | | | | | |mattress | | |E0280 |NU | | |N |Bed cradle, any type |Purchase | | |EP | | | | | | | |UE | | | | | | |E0300 |EP | | |Y |Pediatric crib, hospital |Purchase | | | | | | |grade, fully enclosed | | |E0480 |NU | | |N |Percussor, electric or |Capped | | |EP | | | |pneumatic, home model |Rental | | |UE | | | | | | |E0570 |NU | | |Y |Nebulizer, with compressor |Purchase | | |UE | | | | | | |E0585 |NU | | |N |Nebulizer, with compressor |Capped | | |EP | | | |and heater |Rental | | |UE | | | | | | |E0630 |NU | | |Y( |Patient lift, hydraulic, with|Capped | | |EP | | | |seat or sling |Rental | | |UE | | | | | | |E0650 |NU | | |Y( |Pneumatic compressor, |Capped | | |EP | | | |nonsegmental home model |Rental | | |UE | | | | | | |E0667 |NU | | |Y( |Segmental pneumatic appliance|Capped | | |EP | | | |for use with pneumatic |Rental | | | | | | |compressor, full leg | | |E0668 |NU | | |Y( |Segmental pneumatic appliance|Capped | | |EP | | | |for use with pneumatic |Rental | | | | | | |compressor, full arm | | |E0670 |NU | | |N |Segmental pneumatic appliance|Purchase | | |EP | | | |for use with pneumatic | | | | | | | |compressor, integrated, 2 | | | | | | | |full legs and trunk | | |E0691 |NU | | |N |Ultraviolet light therapy |Rental | | |EP | | | |system panel, includes |Only | | | | | | |bulbs/lamps, timer and eye | | | | | | | |protection; treatment area | | | | | | | |two square feet or less | | |E0692 |NU | | |N |Ultraviolet light therapy |Rental | | |EP | | | |system panel, includes |Only | | | | | | |bulbs/lamps, timer and eye | | | | | | | |protection; four foot panel | | |E0730 |NU | | |Y( |Transcutaneous electrical |Capped | | |EP | | | |nerve stimulation (TENS) |Rental | | |UE | | | |device, four or more leads, | | | | | | | |for multiple nerve | | | | | | | |stimulation | | |E0740 |NU | | |N |Incontinence treatment |Purchase | | |EP | | | |system, pelvic floor | | | |UE | | | |stimulator, monitor, sensor | | | | | | | |and/or trainer | | |E0745 |NU | | |Y( |Neuromuscular stimulator, |Capped | | |EP | | | |electronic shock unit |Rental | | |UE | | | | | | |E0747 |NU | | |Y( |Osteogenesis stimulator, |Rental | | |EP | | | |electrical noninvasive, other|Only | | |UE | | | |than spinal applications | | |E0748 |NU | | |Y |Osteogenesis stimulator, |Rental | | |EP | | | |electrical noninvasive, |Only | | | | | | |spinal applications | | |E0760 |NU | | |Y |Osteogenesis stimulator, low |Rental | | |EP | | | |intensity ultrasound, |Only | | | | | | |noninvasive | | |E0779 |NU |RR | |Y( |((Ambulatory infusion device,|Rental | | | | | | |payable only when services |Only | | | | | | |are provided to patients | | | | | | | |receiving chemotherapy, pain | | | | | | | |management or antibiotic | | | | | | | |treatment in the home) | | | | | | | |Ambulatory infusion pump, | | | | | | | |mechanical, reusable, for | | | | | | | |infusion 8 hours or greater | | |E0840 |NU | | |N |Traction frame, attached to |Purchase | | |EP | | | |headboard, cervical traction | | | |UE | | | | | | |E0850 |NU | | |N |Traction stand, freestanding,|Purchase | | |EP | | | |cervical traction | | | |UE | | | | | | |E0860 |NU | | |N |Traction equipment, overdoor,|Purchase | | |EP | | | |cervical | | | |UE | | | | | | |E0870 |NU | | |N |Traction frame, attached to |Purchase | | |EP | | | |footboard, extremity traction| | | |UE | | | |(e.g., Buck’s) | | |E0880 |NU | | |N |Traction stand, freestanding,|Purchase | | |EP | | | |extremity traction (e.g., | | | |UE | | | |Buck’s) | | |E0890 |NU | | |N |Traction frame, attached to |Purchase | | |EP | | | |footboard, pelvic traction | | | |UE | | | | | | |E0900 |NU | | |N |Traction stand, freestanding,|Purchase | | |EP | | | |pelvic traction (e.g., | | | |UE | | | |Buck’s) | | |E0910 |NU | | |N |Trapeze bars, also known as |Capped | | |EP | | | |Patient Helper, attached to |Rental | | |UE | | | |bed, with grab bar | | |E0910 |NU |RR | |N |Trapeze bars, also known as |Capped | | | | | | |Patient Helper, attached to |Rental | | | | | | |bed, with grab bar | | |E0920 |NU | | |N |Fracture frame, attached to |Capped | | |EP | | | |bed, includes weights |Rental | | |UE | | | | | | |E0930 |NU | | |N |Fracture frame, freestanding,|Capped | | |EP | | | |includes weights |Rental | | |UE | | | | | | |E0935 |NU | | |Y( |Continuous passive motion |Capped | | |EP | | | |exercise device for use on |Rental | | |UE | | | |knee only | | |E0940 |NU | | |N |Trapeze bar, freestanding, |Capped | | |EP | | | |complete with grab bar |Rental | | |UE | | | | | | |E0941 |NU | | |N |Gravity assisted traction |Capped | | |EP | | | |device, any type |Rental | | |UE | | | | | | |E0942 |NU | | |N |Cervical head harness/halter |Purchase | | |EP | | | | | | | |UE | | | | | | |E0944 |NU | | |N |Pelvic belt/harness/boot |Purchase | | |EP | | | | | | | |UE | | | | | | |E0945 |NU | | |N |Extremity belt/harness |Purchase | | |EP | | | | | | | |UE | | | | | | |E0946 |NU | | |N |Fracture frame, dual with |Purchase | | |EP | | | |cross bars, attached to bed | | | |UE | | | |(e.g., Balken, Four Poster) | | |E0947 |NU | | |N |Fracture frame, attachments |Purchase | | |EP | | | |for complex pelvic traction | | | |UE | | | | | | |E0948 |NU | | |N |Fracture frame, attachments |Purchase | | |EP | | | |for complex cervical traction| | | |UE | | | | | | |E0950 |NU | | |N |Wheelchair accessory, tray, |Purchase | | |EP | | | |each | | | |UE | | | | | | |E1036 |NU | | |Y |Multi-positional patient |Purchase | | |EP | | | |transfer system, with | | | | | | | |integrated seat, operated by | | | | | | | |care giver; patient weight | | | | | | | |capacity up to and including | | | | | | | |300 lbs | | |E1130* |NU | | |Y( |Standard wheelchair, fixed |Capped | | |EP | | | |full-length arms, fixed or |Rental | | |UE | | | |swing–away, detachable | | | | | | | |footrests | | |E1130* |NU |U1 | |Y( |Standard wheelchair, fixed |Rental | | | | | | |full-length arms, fixed or |Only | | | | | | |swing–away, detachable | | | | | | | |footrests | | |E1140* |NU | | |Y( |Wheelchair, detachable arms, |Capped | | |EP | | | |desk or full-length, |Rental | | | | | | |swing–away, detachable | | | | | | | |footrests | | |E1150* |NU | | |Y( |Wheelchair; detachable arms, |Capped | | |EP | | | |desk or |Rental | | | | | | |full-length, swing–away, | | | | | | | |detachable, elevating leg | | | | | | | |rests | | |E1160* |NU | | |Y( |Wheelchair; fixed full-length|Capped | | |EP | | | |arms, |Rental | | | | | | |swing–away, detachable, | | | | | | | |elevating leg rests | | |E1224* |NU | | |Y( |Wheelchair with detachable |Capped | | |EP | | | |arms, elevating leg rests |Rental | | |UE | | | | | | |E1224* |NU |U1 | |Y( |((Footrests wheelchair with |Rental | | | | | | |detachable arms, elevating |Only | | | | | | |leg rests) Wheelchair with | | | | | | | |detachable arms, elevating | | | | | | | |leg rests | | |E1399 |NU | | |N |Durable medical equipment, |Manually | | | | | | |miscellaneous |Priced | |K0105 |NU | | |N |IV hanger, each |Purchase | | |EP | | | | | | |K0606 |NU | | |Y |Automatic external |Capped | | |EP | | | |defibrillator, with |Rental | | | | | | |integrated electrocardiogram | | | | | | | |analysis, garment type | | | | | | | |(covered only for | | | | | | | |beneficiaries ages 18 and | | | | | | | |over) | | |K0739 |NU | | |N |((DME Repair, Parts only. |Manually | | | | | | |Repairs will not be approved |Priced | | | | | | |for more than the allowed | | | | | | | |purchase price of new | | | | | | | |equipment. The | | | | | | | |manufacturer’s invoice must | | | | | | | |be attached to the repair | | | | | | | |claim for all parts.) | | |K0739 |NU |U4 | |N |((Maintenance for Capped |Manually | | | | | | |Rental items) Repair or |Priced | | | | | | |non-routine service for | | | | | | | |durable medical equipment | | | | | | | |requiring the skill of a | | | | | | | |technician, labor component, | | | | | | | |per 15 minutes | | |K0739 |NU |U1 | |N |((Labor only, Repair or |Manually | | |EP |U1 | | |non-routine service for |Priced | | | | | | |durable medical equipment | | | | | | | |requiring the skill of a | | | | | | | |technician, labor component, | | | | | | | |per 15 minutes. A maximum of| | | | | | | |twenty units per date of | | | | | | | |service is allowable, 20 | | | | | | | |units=5 hours of labor) | | |K0739 |NU |U3 | |N |((Unlisted Repairs/Parts Only|Manually | | |EP |U3 | | |wheelchairs; applicable pages|Priced | | | | | | |from the manufacturer’s | | | | | | | |catalog must be attached to | | | | | | | |the claim form. Repair or | | | | | | | |non-routine service for | | | | | | | |durable medical equipment | | | | | | | |requiring the skill of a | | | | | | | |technician, labor component, | | | | | | | |per 15 minutes.) | | |S8096*** |NU | | |N |((Peak flow meter used by |Purchase | | |EP | | | |asthmatic patients) Portable| | | | | | | |peak flow meter | | |Z2211 |NU | | |Y |Power Kit/Batteries |Purchase | |(Bill on |EP | | | | | | |Paper) | | | | | | |

Procedure codes E0250(, E0255( and E0260( must be billed when hospital beds are purchased for Medicaid beneficiaries of all ages. Providers must only provide these purchase-only services to beneficiaries who are expected to require the bed for a long period of time. Each procedure code for hospital beds listed above may only be billed once every 10 years.

Procedure codes E0250(, E0255( and E0260( must also be used to bill for equipment that does not meet the purchase-only criteria. They are reimbursed on a capped rental basis. The capped rental items must be used until the equipment is no longer repairable or until it is no longer appropriate for the beneficiary as verified by the physician.

|242.161 Reserved |1-1-10 | |242.170 Apnea Monitors for Beneficiaries Under 1 Year of Age |8-9-10 |

Procedure codes found in this section must be billed either electronically or on paper with modifier EP for beneficiaries under 21 years of age. Modifier UE must be used to bill for used equipment.

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

Sections 212.300 and 222.200 contain information regarding specific coverage and restrictions. ( Prior authorization is not required when other insurance pays at least 50% of the Medicaid maximum allowable reimbursement amount. ((…) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product. When using a procedure code with this symbol, the product must meet the indicated Arkansas Medicaid description.

|National|M1 |M2 |Local |Description |PA |Payment | |Code | | |Code | | |Method | |E0619 | | | |((Initial setup of |N |First 60 | | | | | |Apnea monitor, | |Days Rental | | | | | |includes 60 days | | | | | | | |rental) Apnea | | | | | | | |monitor, with | | | | | | | |recording feature | | | |E0619 |EP | | |Apnea monitor, with |Y (on |Rental Only | | | | | |recording feature |61st |(Daily | | | | | | |day)( |Rental) | |Bill on |EP | |Z1684 |Technical and lab |N |Purchase | |paper | | | |services for setting| | | | | | | |up pneumogram or | | | | | | | |event recording (not| | | | | | | |including | | | | | | | |professional | | | | | | | |services) | | |

|242.180 Orthotic Appliances for Beneficiaries of All Ages |10-1-15 |

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

Modifiers in this section are indicated by the headings M1 and M2. Prior authorization requirements are shown under the heading PA. If prior authorization is needed for individuals age 21 and older, that information is indicated with a “Y” in the column; if not, an “N” is shown. When prior authorization is not applicable (for U21) that information is shown with an “N/A” in the column.

When codes are payable for all ages, “All” is indicated in the column, “U21” is shown when the code is payable only for individuals under age 21 and “21+” is shown when the code is payable only for those individuals age 21 and older. ** This item is not a covered service for the diagnosis of Carpal Tunnel Syndrome prior to surgery. ((…) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product. When using a procedure code with this symbol, the product must meet the indicated Arkansas Medicaid description. ■ This procedure code does not require prior authorization; however, the beneficiary’s medical condition must fall within the following diagnosis codes. (View ICD codes.) + This item is limited to one every twelve months for beneficiaries age 21 and over.

|Orthotic Appliances, All Ages (Section 242.180) | |Procedure |M1 |M2 |Description |All |PA |Payment | |Code | | | |U21 |21+ |Method | | | | | |21+ | | | |A5500ν |NU | |For diabetics only, fitting |21+ |N |Purchase | | | | |(including follow-up) custom | | | | | | | |preparation and supply of | | | | | | | |off-the-shelf depth-inlay | | | | | | | |shoe manufactured to | | | | | | | |accommodate multi-density | | | | | | | |insert(s), per shoe | | | | |A5501ν |NU | |For diabetics only, fitting |21+ |N |Purchase | | | | |(including follow-up) custom | | | | | | | |preparation and supply of | | | | | | | |molded from cast(s) of | | | | | | | |patient’s foot (custom molded| | | | | | | |shoe), per shoe | | | | |A5503ν |NU | |For diabetics only, |21+ |N |Purchase | | | | |modification (including | | | | | | | |fitting) of off-the-shelf | | | | | | | |depth-inlay shoe or custom | | | | | | | |molded shoe with roller or | | | | | | | |rigid rocker bottom, per shoe| | | | |A5504ν |NU | |For diabetics only, |21+ |N |Purchase | | | | |modification (including | | | | | | | |fitting) of off-the-shelf | | | | | | | |depth-inlay shoe or custom | | | | | | | |molded shoe with wedge(s), | | | | | | | |per shoe | | | | |A5505ν |NU | |For diabetics only, |21+ |N |Purchase | | | | |modification (including | | | | | | | |fitting) of off-the-shelf | | | | | | | |depth-inlay shoe or custom | | | | | | | |molded shoe with metatarsal | | | | | | | |bar, per shoe | | | | |A5506ν |NU | |For diabetics only, |21+ |N |Purchase | | | | |modification (including | | | | | | | |fitting) of off-the-shelf | | | | | | | |depth-inlay shoe or custom | | | | | | | |molded shoe with off-set | | | | | | | |heel(s), per shoe | | | | |A5507 |NU | |For diabetics only, not |21+ |Y |Purchase | | | | |otherwise specified | | | | | | | |modification (including | | | | | | | |fitting) of off-the-shelf | | | | | | | |depth-inlay shoe or custom | | | | | | | |molded shoe, per shoe | | | | |A5510ν |NU | |For diabetics only, direct |21+ |N |Purchase | | | | |formed, compression molded to| | | | | | | |patient’s foot without | | | | | | | |external heat source, | | | | | | | |multiple-density insert(s) | | | | | | | |prefabricated, per shoe | | | | |A5512ν |NU | |For diabetics only, multiple |21+ |N |Purchase | | | | |density insert, direct | | | | | | | |formed, molded to foot after | | | | | | | |external heat source of 230 | | | | | | | |degrees Fahrenheit or higher,| | | | | | | |total contact with patient’s | | | | | | | |foot, including arch, base | | | | | | | |layer minimum of ¼ inch | | | | | | | |material of shore a 35 | | | | | | | |durometer of 3/16 inch | | | | | | | |material of shore a 40 | | | | | | | |durometer (or higher), | | | | | | | |prefabricated, each | | | | |A5513ν |NU | |For diabetics only, multiple |21+ |N |Purchase | | | | |density insert, custom molded| | | | | | | |from model of patient’s foot,| | | | | | | |total contact with patient’s | | | | | | | |foot, including arch, base | | | | | | | |layer minimum of 3/16 inch | | | | | | | |material of shore a 35 | | | | | | | |durometer or higher, includes| | | | | | | |arch filler and other shaping| | | | | | | |material custom fabricated, | | | | | | | |each | | | | |E1810 |NU | |Dynamic adjustable knee |All |N |Purchase | | |EP | |extension/flexion device, | | | | | | | |includes soft interface | | | | | | | |material | | | | |K0672 |NU | |Addition to lower extremity |All |N |Purchase | | |EP | |orthotic, removable soft | | | | | | | |interface, all components, | | | | | | | |replacement only, each. | | | | |L0120 |NU | |Cervical, flexible, |All |N |Purchase | | |EP | |nonadjustable (foam collar) | | | | |L0130 |NU | |Cervical, flexible, |All |N |Purchase | | |EP | |thermoplastic collar, molded | | | | | | | |to patient | | | | |L0140 |NU | |Cervical, semi-rigid, |All |N |Purchase | | |EP | |adjustable (plastic collar) | | | | |L0150 |NU | |Cervical, semi-rigid, |All |N |Purchase | | |EP | |adjustable molded chin cup | | | | | | | |(plastic collar with | | | | | | | |mandibular/occipital piece) | | | | |L0160 |NU | |Cervical, semi-rigid, wire |All |N |Purchase | | |EP | |frame occipital/mandibular | | | | | | | |support | | | | |L0170 |NU | |Cervical, collar, molded to |All |N |Purchase | | |EP | |patient model | | | | |L0172 |NU | |Cervical, collar, semi-rigid |All |N |Purchase | | |EP | |thermoplastic foam, two piece| | | | |L0174 |NU | |Cervical, collar, semi-rigid |All |N |Purchase | | |EP | |thermoplastic foam, two piece| | | | | | | |with thoracic extension | | | | |L0180 |NU | |Cervical, multiple post |All |N |Purchase | | |EP | |collar, occipital/mandibular | | | | | | | |supports, adjustable | | | | |L0190 |NU | |Cervical, multiple post |All |N |Purchase | | |EP | |collar, occipital/mandibular | | | | | | | |supports, adjustable cervical| | | | | | | |bars (SOMI, Guilford, Taylor | | | | | | | |types) | | | | |L0200 |NU | |Cervical, multiple post |All |N |Purchase | | |EP | |collar, occipital/mandibular | | | | | | | |supports, adjustable cervical| | | | | | | |bars, and thoracic extension | | | | |L0220 |NU | |Thoracic, rib belt, custom |All |N |Purchase | | |EP | |fabricated | | | | |L0450 |NU | |TLSO, flexible, provides |All |N |Purchase | | |EP | |trunk support, upper thoracic| | | | | | | |region, produces | | | | | | | |intracavitary pressure to | | | | | | | |reduce load on the | | | | | | | |intervertebral disks with | | | | | | | |rigid stays or panel(s), | | | | | | | |includes shoulder straps and | | | | | | | |closures, prefabricated, | | | | | | | |includes fitting and | | | | | | | |adjustment | | | | |L0452 |NU | |TLSO, flexible, provides |All |N |Purchase | | |EP | |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 | | | | |L0454 |NU | |TLSO, flexible, provides |All |N |Purchase | | |EP | |trunk support, extends from | | | | | | | |sacrococcygeal junction to | | | | | | | |above T-9 vertebra, restricts| | | | | | | |gross trunk motion in the | | | | | | | |sagittal plane, produces | | | | | | | |intracavitary pressure to | | | | | | | |reduce load on the | | | | | | | |intervertebral disks with | | | | | | | |rigid stays or panel(s), | | | | | | | |includes shoulder straps and | | | | | | | |closures, prefabricated, | | | | | | | |includes fitting and | | | | | | | |adjustment | | | | |L0456 |NU | |TLSO, flexible, provides |All |N |Purchase | | |EP | |trunk support, thoracic | | | | | | | |region, rigid posterior panel| | | | | | | |and soft anterior apron, | | | | | | | |extends from sacrococcygeal | | | | | | | |junction and terminates just | | | | | | | |inferior to the scapular | | | | | | | |spine, restricts gross trunk | | | | | | | |motion in the sagittal plane,| | | | | | | |produces intracavitary | | | | | | | |pressure to reduce load on | | | | | | | |the intervertebral disks, | | | | | | | |includes straps and closures,| | | | | | | |prefabricated, includes | | | | | | | |fitting and adjustment | | | | |L0458 |NU | |TLSO, triplanar control, |All |Y |Purchase | | |EP | |modular segmented spinal | | | | | | | |system, two rigid plastic | | | | | | | |shells, posterior extends | | | | | | | |from sacrococcygeal junction | | | | | | | |and terminates just inferior | | | | | | | |to the scapular spine, | | | | | | | |anterior extends from the | | | | | | | |symphysis pubis to the | | | | | | | |xiphoid, soft liner, | | | | | | | |restricts gross trunk motion | | | | | | | |in the sagittal, coronal and | | | | | | | |transverse planes, lateral | | | | | | | |strength is provided by | | | | | | | |overlapping plastic and | | | | | | | |stabilizing closures, | | | | | | | |includes straps and closures,| | | | | | | |prefabricated, includes | | | | | | | |fitting and adjustment | | | | |L0460 |NU | |TLSO, triplanar control |All |Y |Purchase | | |EP | |modular segmented spinal | | | | | | | |system, two rigid plastic | | | | | | | |shells, posterior extends | | | | | | | |from the sacrococcygeal | | | | | | | |junction and terminates just | | | | | | | |inferior to the scapular | | | | | | | |spine, anterior extends from | | | | | | | |the symphysis pubis to the | | | | | | | |sternal notch, soft liner, | | | | | | | |restricts gross trunk motion | | | | | | | |in the sagittal, coronal and | | | | | | | |transverse planes, lateral | | | | | | | |strength is provided by | | | | | | | |overlapping plastic and | | | | | | | |stabilizing closures, | | | | | | | |including straps and | | | | | | | |closures, prefabricated, | | | | | | | |includes fitting and | | | | | | | |adjustment | | | | |L0462 |NU | |TLSO, triplanar control |All |Y |Purchase | | |EP | |modular segmented spinal | | | | | | | |system, three rigid plastic | | | | | | | |shells, posterior extends | | | | | | | |from sacrococcygeal junction | | | | | | | |and terminates just inferior | | | | | | | |to the scapular spine, | | | | | | | |anterior extends from the | | | | | | | |symphysis pubis to the | | | | | | | |sternal notch, soft liner, | | | | | | | |restricts gross trunk motion | | | | | | | |in the sagittal, coronal and | | | | | | | |transverse planes, lateral | | | | | | | |strength is provided by | | | | | | | |overlapping plastic and | | | | | | | |stabilizing closures, | | | | | | | |including straps and | | | | | | | |closures, prefabricated, | | | | | | | |includes fitting and | | | | | | | |adjustment | | | | |L0464 |NU | |TLSO, triplanar control |All |Y |Purchase | | |EP | |modular segmented spinal | | | | | | | |system, four rigid plastic | | | | | | | |shells, posterior extends | | | | | | | |from sacrococcygeal junction | | | | | | | |and terminates just inferior | | | | | | | |to the scapular spine, | | | | | | | |anterior extends from the | | | | | | | |symphysis pubis to the | | | | | | | |sternal notch, soft liner, | | | | | | | |restricts gross trunk motion | | | | | | | |in sagittal, coronal and | | | | | | | |transverse planes, lateral | | | | | | | |strength is provided by | | | | | | | |overlapping plastic and | | | | | | | |stabilizing closures, | | | | | | | |including straps and | | | | | | | |closures, prefabricated, | | | | | | | |includes fitting and | | | | | | | |adjustment | | | | |L0466 |NU | |TLSO, sagittal control, rigid|All |N |Purchase | | |EP | |posterior frame and flexible | | | | | | | |soft anterior apron with | | | | | | | |straps, closures and padding,| | | | | | | |restricts gross trunk motion | | | | | | | |in sagittal plane, produces | | | | | | | |intracavitary pressure to | | | | | | | |reduce load on intervertebral| | | | | | | |disks, includes fitting and | | | | | | | |shaping the frame, | | | | | | | |prefabricated, includes | | | | | | | |fitting and adjustment | | | | |L0468 |NU | |TLSO, sagittal-coronal |All |N |Purchase | | |EP | |control, rigid posterior | | | | | | | |frame and flexible soft | | | | | | | |anterior apron with straps, | | | | | | | |closures and padding, extends| | | | | | | |from sacrococcygeal junction | | | | | | | |over scapulae, lateral | | | | | | | |strength provided by pelvic, | | | | | | | |thoracic, and lateral frame | | | | | | | |pieces, restricts gross trunk| | | | | | | |motion in sagittal and | | | | | | | |coronal planes, produces | | | | | | | |intracavitary pressure to | | | | | | | |reduce load on intervertebral| | | | | | | |disks, includes fitting and | | | | | | | |shaping the frame, | | | | | | | |prefabricated, includes | | | | | | | |fitting and adjustment | | | | |L0470 |NU | |TLSO, triplanar control, |All |N |Purchase | | |EP | |rigid posterior frame and | | | | | | | |flexible soft anterior apron | | | | | | | |with straps, closures and | | | | | | | |padding, extends from | | | | | | | |sacrococcygeal junction to | | | | | | | |scapula, lateral strength | | | | | | | |provided by pelvic, thoracic,| | | | | | | |and lateral frame pieces, | | | | | | | |rotational strength provided | | | | | | | |by subclavicular extensions, | | | | | | | |restricts gross trunk motion | | | | | | | |in sagittal, coronal and | | | | | | | |transverse planes, produces | | | | | | | |intracavitary pressure to | | | | | | | |reduce load on intervertebral| | | | | | | |disks, includes fitting and | | | | | | | |shaping the frame, | | | | | | | |prefabricated, includes | | | | | | | |fitting and adjustment | | | | |L0472 |NU | |TLSO, triplanar control, |All |N |Purchase | | |EP | |hyperextension, rigid | | | | | | | |anterior and lateral frame | | | | | | | |extends from symphysis pubis | | | | | | | |to sternal notch with two | | | | | | | |anterior components (one | | | | | | | |pubic and one sternal) | | | | | | | |posterior and lateral pads | | | | | | | |with straps and closures, | | | | | | | |limits spinal flexion, | | | | | | | |restricts gross trunk motion | | | | | | | |in sagittal, coronal and | | | | | | | |transverse planes, includes | | | | | | | |fitting and shaping the | | | | | | | |frame, prefabricated, | | | | | | | |includes fitting and | | | | | | | |adjustment | | | | |L0480 |NU | |TLSO, triplanar control, |All |Y |Purchase | | |EP | |one-piece rigid plastic shell| | | | | | | |without interface liner, with| | | | | | | |multiple straps and closures,| | | | | | | |posterior extends from | | | | | | | |sacrococcygeal junction and | | | | | | | |terminates just inferior to | | | | | | | |scapular spine, anterior | | | | | | | |extends from symphysis pubis | | | | | | | |to sternal notch, anterior or| | | | | | | |posterior opening, restricts | | | | | | | |gross trunk motion in | | | | | | | |sagittal, coronal and | | | | | | | |transverse planes, includes a| | | | | | | |carved plaster or CAD-CAM | | | | | | | |model, custom fabricated | | | | |L0482 |NU | |TLSO, triplanar control, |All |Y |Purchase | | |EP | |one-piece rigid plastic shell| | | | | | | |with interface liner, | | | | | | | |multiple straps and closures,| | | | | | | |posterior extends from | | | | | | | |sacrococcygeal junction and | | | | | | | |terminates just inferior to | | | | | | | |scapular spine, anterior | | | | | | | |extends from symphysis pubis | | | | | | | |to sternal notch, anterior or| | | | | | | |posterior opening, restricts | | | | | | | |gross trunk motion in | | | | | | | |sagittal, coronal and | | | | | | | |transverse planes, includes a| | | | | | | |carved plaster or CAD-CAM | | | | | | | |model, custom fabricated | | | | |L0484 |NU | |TLSO, triplanar control, |All |Y |Purchase | | |EP | |two-piece rigid plastic shell| | | | | | | |without interface liner, with| | | | | | | |multiple straps and closures,| | | | | | | |posterior extends from | | | | | | | |sacrococcygeal junction and | | | | | | | |terminates just inferior to | | | | | | | |scapular spine, anterior | | | | | | | |extends from symphysis pubis | | | | | | | |to sternal notch, lateral | | | | | | | |strength is enhanced by | | | | | | | |overlapping plastic, | | | | | | | |restricts gross trunk motion | | | | | | | |in the sagittal, coronal and | | | | | | | |transverse planes, includes a| | | | | | | |carved plaster or CAD-CAM | | | | | | | |model, custom fabricated | | | | |L0486 |NU | |TLSO, triplanar control, |All |Y |Purchase | | |EP | |two-piece rigid plastic shell| | | | | | | |with interface liner, | | | | | | | |multiple straps and closures,| | | | | | | |posterior extends from | | | | | | | |sacrococcygeal junction and | | | | | | | |terminates just inferior to | | | | | | | |scapular spine, anterior | | | | | | | |extends from symphysis pubis | | | | | | | |to sternal notch, lateral | | | | | | | |strength is enhanced by | | | | | | | |overlapping plastic, | | | | | | | |restricts gross trunk motion | | | | | | | |in the sagittal, coronal and | | | | | | | |transverse planes, includes a| | | | | | | |carved plaster or CAD-CAM | | | | | | | |model, custom fabricated | | | | |L0488 |NU | |TLSO, triplanar control, |All |Y |Purchase | | |EP | |one-piece rigid plastic shell| | | | | | | |with interface liner, | | | | | | | |multiple straps and closures,| | | | | | | |posterior extends from | | | | | | | |sacrococcygeal junction and | | | | | | | |terminates just inferior to | | | | | | | |scapular spine, anterior | | | | | | | |extends from symphysis pubis | | | | | | | |to sternal notch, anterior or| | | | | | | |posterior opening, restricts | | | | | | | |gross trunk motion in | | | | | | | |sagittal, coronal and | | | | | | | |transverse planes, | | | | | | | |prefabricated, includes | | | | | | | |fitting and adjustment | | | | |L0490 |NU | |TLSO, sagittal-coronal |All |Y |Purchase | | |EP | |control, one-piece rigid | | | | | | | |plastic shell with | | | | | | | |overlapping reinforced | | | | | | | |anterior, with multiple | | | | | | | |straps and closures, | | | | | | | |posterior extends from | | | | | | | |sacrococcygeal junction and | | | | | | | |terminates at or before the | | | | | | | |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 | | | | |L0621 |NU | |Sacroiliac orthosis, |All |N |Purchase | | |EP | |flexible, provides | | | | | | | |pelvic-sacral support, | | | | | | | |reduces motion about the | | | | | | | |sacroiliac joint, includes | | | | | | | |straps, closures, may include| | | | | | | |pendulous abdomen design, | | | | | | | |prefabricated, includes | | | | | | | |fitting and adjustment | | | | |L0622 |NU | |Sacroiliac orthosis, |All |N |Purchase | | |EP | |flexible, provides | | | | | | | |pelvic-sacral support, | | | | | | | |reduces motion about the | | | | | | | |sacroiliac joint, includes | | | | | | | |straps, closures, may include| | | | | | | |pendulous abdomen design, | | | | | | | |custom fabricated | | | | |L0623 |NU | |Sacroiliac orthosis, |All |N |Purchase | | |EP | |provides pelvic-sacral | | | | | | | |support, with rigid or | | | | | | | |semi-rigid panels over the | | | | | | | |sacrum and abdomen, reduces | | | | | | | |motion about the sacroiliac | | | | | | | |joint, includes straps, | | | | | | | |closures, may include | | | | | | | |pendulous abdomen design, | | | | | | | |prefabricated, includes | | | | | | | |fitting and adjustment | | | | |L0624 |NU | |Sacroiliac orthosis, provides|All |N |Manually | | |EP | |pelvic-sacral support, with | | |Priced | | | | |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 | | | | |L0625 |NU | |Lumbar orthosis, flexible, |All |N |Purchase | | |EP | |provides lumbar support, | | | | | | | |posterior extends from L-1 to| | | | | | | |below L-5 vertebra, produces | | | | | | | |intracavitary pressure to | | | | | | | |reduce load on the | | | | | | | |intervertebral discs, | | | | | | | |includes straps, closures, | | | | | | | |may include pendulous abdomen| | | | | | | |design, shoulder straps, | | | | | | | |stays, prefabricated, | | | | | | | |includes fitting and | | | | | | | |adjustment | | | | |L0626 |NU | |Lumbar orthosis, sagittal |All |N |Purchase | | |EP | |control, with rigid posterior| | | | | | | |panel(s), posterior extends | | | | | | | |from L-1 to below L-5 | | | | | | | |vertebra, produces | | | | | | | |intracavitary pressure to | | | | | | | |reduce load on the | | | | | | | |intervertebral discs, | | | | | | | |includes straps, closures, | | | | | | | |may include padding, stays, | | | | | | | |shoulder straps, pendulous | | | | | | | |abdomen design, | | | | | | | |prefabricated, includes | | | | | | | |fitting and adjustment | | | | |L0627 |NU | |Lumbar orthosis, sagittal |All |N |Purchase | | |EP | |control, with rigid anterior | | | | | | | |and posterior panel(s), | | | | | | | |posterior extends from L-1 to| | | | | | | |below L-5 vertebra, produces | | | | | | | |intracavitary pressure to | | | | | | | |reduce load on the | | | | | | | |intervertebral discs, | | | | | | | |includes straps, closures, | | | | | | | |may include padding, shoulder| | | | | | | |straps, pendulous abdomen | | | | | | | |design, prefabricated, | | | | | | | |includes fitting and | | | | | | | |adjustment | | | | |L0628 |NU | |Lumbar-sacral orthosis, |All |N |Purchase | | |EP | |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, | | | | | | | |includes fitting and | | | | | | | |adjustment | | | | |L0629 |NU | |Lumbar-sacral orthosis, |All |N |Manually | | |EP | |flexible, provides | | |Priced | | | | |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 | | | | |L0630 |NU | |Lumbar-sacral orthosis, |All |N |Purchase | | |EP | |sagittal control, with rigid | | | | | | | |posterior panel(s), posterior| | | | | | | |extends from sacrococcygeal | | | | | | | |junction to T-9 vertebra, | | | | | | | |produces intracavitary | | | | | | | |pressure to reduce load on | | | | | | | |the intervertebral discs, | | | | | | | |includes straps, closures, | | | | | | | |may include padding, stays, | | | | | | | |shoulder straps, pendulous | | | | | | | |abdomen design, | | | | | | | |prefabricated, includes | | | | | | | |fitting and adjustment | | | | |L0631 |NU | |Lumbar-sacral orthosis, |All |N |Purchase | | |EP | |sagittal control, with rigid | | | | | | | |anterior and posterior | | | | | | | |panel(s), posterior extends | | | | | | | |from sacrococcygeal junction | | | | | | | |to T-9 vertebra, produces | | | | | | | |intracavitary pressure to | | | | | | | |reduce load on the | | | | | | | |intervertebral discs, | | | | | | | |includes straps, closures, | | | | | | | |may include padding, shoulder| | | | | | | |straps, pendulous abdomen | | | | | | | |design, prefabricated, | | | | | | | |includes fitting and | | | | | | | |adjustment | | | | |L0632 |NU | |Lumbar-sacral orthosis, |All |N |Manually | | |EP | |sagittal control, with rigid | | |Priced | | | | |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 | | | | |L0633 |NU | |Lumbar-sacral orthosis, |All |N |Purchase | | |EP | |sagittal-coronal control, | | | | | | | |with rigid posterior | | | | | | | |frame/panel(s), posterior | | | | | | | |extends from sacrococcygeal | | | | | | | |junction to T-9 vertebra, | | | | | | | |lateral strength provided by | | | | | | | |rigid lateral frame/panels, | | | | | | | |produces intracavitary | | | | | | | |pressure to reduce load on | | | | | | | |the intervertebral discs, | | | | | | | |includes straps, closures, | | | | | | | |may include padding, stays, | | | | | | | |shoulder straps, pendulous | | | | | | | |abdomen design, | | | | | | | |prefabricated, includes | | | | | | | |fitting and adjustment | | | | |L0634 |NU | |Lumbar-sacral orthosis, |All |N |Manually | | |EP | |sagittal-coronal control, | | |Priced | | | | |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 | | | | |L0635 |NU | |Lumbar-sacral orthosis, |All |N |Purchase | | |EP | |sagittal-coronal control, | | | | | | | |lumbar flexion, rigid | | | | | | | |posterior frame/panel(s), | | | | | | | |lateral articulating design | | | | | | | |to flex the lumbar spine, | | | | | | | |posterior extends from | | | | | | | |sacrococcygeal junction to | | | | | | | |T-9 vertebra, lateral | | | | | | | |strength provided by rigid | | | | | | | |lateral frame/panel(s), | | | | | | | |produces intracavitary | | | | | | | |pressure to reduce load on | | | | | | | |the intervertebral discs, | | | | | | | |includes straps, closures, | | | | | | | |may include padding, anterior| | | | | | | |panel, pendulous abdomen | | | | | | | |design, prefabricated, | | | | | | | |includes fitting and | | | | | | | |adjustment | | | | |L0636 |NU | |Lumbar-sacral orthosis, |All |N |Purchase | | |EP | |sagittal-coronal control, | | | | | | | |lumbar flexion, rigid | | | | | | | |posterior frame/panel(s), | | | | | | | |lateral articulating design | | | | | | | |to flex the lumbar spine, | | | | | | | |posterior extends from | | | | | | | |sacrococcygeal junction to | | | | | | | |T-9 vertebra, lateral | | | | | | | |strength provided by rigid | | | | | | | |lateral frame/panels, | | | | | | | |produces intracavitary | | | | | | | |pressure to reduce load on | | | | | | | |the intervertebral discs, | | | | | | | |includes straps, closures, | | | | | | | |may include padding, anterior| | | | | | | |panel, pendulous abdomen | | | | | | | |design, custom fabricated | | | | |L0637 |NU | |Lumbar-sacral orthosis, |All |N |Purchase | | |EP | |sagittal-coronal control, | | | | | | | |with rigid anterior and | | | | | | | |posterior frame/panels, | | | | | | | |posterior extends from | | | | | | | |sacrococcygeal junction to | | | | | | | |T-9 vertebra, lateral | | | | | | | |strength provided by rigid | | | | | | | |lateral frame/panels, | | | | | | | |produces intracavitary | | | | | | | |pressure to reduce load on | | | | | | | |the intervertebral discs, | | | | | | | |includes straps, closures, | | | | | | | |may include padding, shoulder| | | | | | | |straps, pendulous abdomen | | | | | | | |design, prefabricated, | | | | | | | |includes fitting and | | | | | | | |adjustment | | | | |L0638 |NU | |Lumbar-sacral orthosis, |All |N |Purchase | | |EP | |sagittal-coronal control, | | | | | | | |with rigid anterior and | | | | | | | |posterior frame/‌panels, | | | | | | | |posterior extends from | | | | | | | |sacrococcygeal junction to | | | | | | | |T-9 vertebra, lateral | | | | | | | |strength provided by rigid | | | | | | | |lateral frame/panels, | | | | | | | |produces intracavitary | | | | | | | |pressure to reduce load on | | | | | | | |the intervertebral discs, | | | | | | | |includes straps, closures, | | | | | | | |may include padding, shoulder| | | | | | | |straps, pendulous abdomen | | | | | | | |design, custom fabricated | | | | |L0639 |NU | |Lumbar-sacral orthosis, |All |N |Purchase | | |EP | |sagittal-coronal control, | | | | | | | |rigid shell(s)/panel(s), | | | | | | | |posterior extends from | | | | | | | |sacrococcygeal junction to | | | | | | | |T-9 vertebra, anterior | | | | | | | |extends from symphysis pubis | | | | | | | |to xiphoid, produces | | | | | | | |intracavitary pressure to | | | | | | | |reduce load on the | | | | | | | |intervertebral discs, overall| | | | | | | |strength provided by | | | | | | | |overlapping rigid material | | | | | | | |and stabilizing closures, | | | | | | | |includes straps, closures, | | | | | | | |may include soft interface, | | | | | | | |pendulous abdomen design, | | | | | | | |prefabricated, includes | | | | | | | |fitting and adjustment | | | | |L0640 |NU | |Lumbar-sacral orthosis, |All |N |Purchase | | |EP | |sagittal-coronal control, | | | | | | | |rigid shell(s)/panel(s), | | | | | | | |posterior extends from | | | | | | | |sacrococcygeal junction to | | | | | | | |T-9 vertebra, anterior | | | | | | | |extends from symphysis pubis | | | | | | | |to xiphoid, produces | | | | | | | |intracavitary pressure to | | | | | | | |reduce load on the | | | | | | | |intervertebral discs, overall| | | | | | | |strength provided by | | | | | | | |overlapping rigid material | | | | | | | |and stabilizing closures, | | | | | | | |includes straps, closures, | | | | | | | |may include soft interface, | | | | | | | |pendulous abdomen design, | | | | | | | |custom fabricated | | | | |L0700 |NU | |Cervical-thoracic-lumbar-sacr|All |Y |Purchase | | |EP | |al orthoses (CTLSO), | | | | | | | |anterior-posterior-lateral | | | | | | | |control, molded to patient | | | | | | | |model (Minerva type) | | | | |L0710 |NU | |CTLSO, |All |Y |Purchase | | |EP | |anterior-posterior-lateral | | | | | | | |control, molded to patient | | | | | | | |model, with interface | | | | | | | |material (Minerva type) | | | | |L0810 |NU | |Halo procedure, cervical halo|All |Y |Purchase | | |EP | |incorporated into jacket vest| | | | |L0820 |NU | |Halo procedure, cervical halo|All |Y |Purchase | | |EP | |incorporated into plaster | | | | | | | |body jacket | | | | |L0830 |NU | |Halo procedure, cervical halo|All |Y |Purchase | | |EP | |incorporated into Milwaukee | | | | | | | |type orthosis | | | | |L0859 |NU | |Addition to halo procedure, |All |Y |Purchase | | |EP | |magnetic resonance image | | | | | | | |compatible system, rings and | | | | | | | |pins, any material | | | | |L0970 |NU | |TLSO, corset front |All |N |Purchase | | |EP | | | | | | |L0972 |NU | |LSO, corset front |All |N |Purchase | | |EP | | | | | | |L0974 |NU | |TLSO, full corset |All |N |Purchase | | |EP | | | | | | |L0976 |NU | |LSO, full corset |All |N |Purchase | | |EP | | | | | | |L0978 |NU | |Axillary crutch extension |All |N |Purchase | | |EP | | | | | | |L0980 |NU | |Peroneal straps, pair |All |N |Purchase | | |EP | | | | | | |L0982 |NU | |Stocking supporter grips, set|All |N |Purchase | | |EP | |of four (4) | | | | |L0984 |NU | |Protective body sock, each |21+ |N |Purchase | |L1000 |NU | |CTLSO (Milwaukee), inclusive |All |Y |Purchase | | |EP | |of furnishing initial | | | | | | | |orthosis, including model | | | | |L1010 |NU | |Addition to CTLSO or |All |N |Purchase | | |EP | |scoliosis orthosis, axilla | | | | | | | |sling | | | | |L1020 |NU | |Addition to CTLSO or |All |N |Purchase | | |EP | |scoliosis orthosis, kyphosis | | | | | | | |pad | | | | |L1025 |NU | |Addition to CTLSO or |All |N |Purchase | | |EP | |scoliosis orthosis, kyphosis | | | | | | | |pad, floating | | | | |L1030 |NU | |Addition to CTLSO or |All |N |Purchase | | |EP | |scoliosis orthosis, lumbar | | | | | | | |bolster pad | | | | |L1040 |NU | |Addition to CTLSO or |All |N |Purchase | | |EP | |scoliosis orthosis, lumbar or| | | | | | | |lumbar rib pad | | | | |L1050 |NU | |Addition to CTLSO or |All |N |Purchase | | |EP | |scoliosis orthosis, sternal | | | | | | | |pad | | | | |L1060 |NU | |Addition to CTLSO or |All |N |Purchase | | |EP | |scoliosis orthosis, thoracic | | | | | | | |pad | | | | |L1070 |NU | |Addition to CTLSO or |All |N |Purchase | | |EP | |scoliosis orthosis, trapezius| | | | | | | |sling | | | | |L1080 |NU | |Addition to CTLSO or |All |N |Purchase | | |EP | |scoliosis orthosis, outrigger| | | | |L1085 |NU | |Addition to CTLSO or |All |N |Purchase | | |EP | |scoliosis orthosis, | | | | | | | |outrigger, bilateral with | | | | | | | |vertical extensions | | | | |L1090 |NU | |Addition to CTLSO or |All |N |Purchase | | |EP | |scoliosis orthosis, lumbar | | | | | | | |sling | | | | |L1100 |NU | |Addition to CTLSO or |All |N |Purchase | | |EP | |scoliosis orthosis, ring | | | | | | | |flange, plastic or leather | | | | |L1110 |NU | |Addition to CTLSO or |All |N |Purchase | | |EP | |scoliosis orthosis, ring | | | | | | | |flange, plastic or leather, | | | | | | | |molded to patient model | | | | |L1120 |NU | |Addition to CTLSO, scoliosis |All |N |Purchase | | |EP | |orthosis, cover for upright, | | | | | | | |each | | | | |L1200 |NU | |Thoracic-lumbar-sacral-orthos|All |Y |Purchase | | |EP | |is (TLSO), inclusive of | | | | | | | |furnishing initial orthosis | | | | | | | |only | | | | |L1210 |NU | |Addition to TLSO (low |All |N |Purchase | | |EP | |profile), lateral thoracic | | | | | | | |extension | | | | |L1220 |NU | |Addition to TLSO (low |All |N |Purchase | | |EP | |profile), anterior thoracic | | | | | | | |extension | | | | |L1230 |NU | |Addition to TLSO (low |All |N |Purchase | | |EP | |profile), Milwaukee type | | | | | | | |superstructure | | | | |L1240 |NU | |Addition to TLSO (low |All |N |Purchase | | |EP | |profile), lumbar derotation | | | | | | | |pad | | | | |L1250 |NU | |Addition to TLSO (low |All |N |Purchase | | |EP | |profile), anterior ASIS pad | | | | |L1260 |NU | |Addition to TLSO (low |All |N |Purchase | | |EP | |profile), anterior thoracic | | | | | | | |derotation pad | | | | |L1270 |NU | |Addition to TLSO (low |All |N |Purchase | | |EP | |profile), abdominal pad | | | | |L1280 |NU | |Addition to TLSO (low |All |N |Purchase | | |EP | |profile), rib gusset | | | | | | | |(elastic), each | | | | |L1290 |NU | |Addition to TLSO (low |All |N |Purchase | | |EP | |profile), lateral | | | | | | | |trochanteric pad | | | | |L1300 |NU | |Other scoliosis procedure, |All |Y |Purchase | | |EP | |body jacket molded to patient| | | | | | | |model | | | | |L1310 |NU | |Other scoliosis procedure, |All |Y |Purchase | | |EP | |post-operative body jacket | | | | |L1499 |NU | |Spinal orthosis, not |All |Y |Manually | | |EP | |otherwise specified. ((The | | |Priced | | | | |manufacturer’s invoice must | | | | | | | |be attached to all claims.) | | | | |L1600 |NU | |HO, abduction control of hip |All |N |Purchase | | |EP | |joints, flexible, Frejka type| | | | | | | |with cover, prefabricated, | | | | | | | |includes fitting and | | | | | | | |adjustment | | | | |L1610 |NU | |HO, abduction control of hip |All |N |Purchase | | |EP | |joints, flexible (Frejka | | | | | | | |cover only), prefabricated, | | | | | | | |includes fitting and | | | | | | | |adjustment | | | | |L1620 |NU | |HO, abduction control of hip |All |N |Purchase | | |EP | |joints, flexible (Pavlik | | | | | | | |harness), prefabricated, | | | | | | | |includes fitting and | | | | | | | |adjustment | | | | |L1630 |NU | |HO, abduction control of hip |All |N |Purchase | | |EP | |joints, semi-flexible (Von | | | | | | | |Rosen type), custom | | | | | | | |fabricated | | | | |L1640 |NU | |HO, abduction control of hip |All |N |Purchase | | |EP | |joints, static, pelvic band | | | | | | | |or spreader bar, thigh cuffs,| | | | | | | |custom fabricated | | | | |L1650 |NU | |HO, abduction control of hip |All |N |Purchase | | |EP | |joints, static, adjustable, | | | | | | | |custom fitted (Ilfled type), | | | | | | | |prefabricated, includes | | | | | | | |fitting and adjustment | | | | |L1660 |NU | |HO, abduction control of hip |All |N |Purchase | | |EP | |joints, static, plastic, | | | | | | | |prefabricated, includes | | | | | | | |fitting and adjustment | | | | |L1680 |NU | |HO; abduction control of hip |All |Y |Purchase | | |EP | |joints, dynamic, pelvic | | | | | | | |control, adjustable hip | | | | | | | |motion control, thigh cuffs | | | | | | | |(Rancho hip action type), | | | | | | | |custom fabricated | | | | |L1685 |NU | |HO, abduction control of hip |All |Y |Purchase | | |EP | |joint, post operative hip | | | | | | | |abduction type, custom | | | | | | | |fabricated | | | | |L1686 |NU | |HO, abduction control of hip |All |Y |Purchase | | |EP | |joint, post operative hip | | | | | | | |abduction type, | | | | | | | |prefabricated, includes | | | | | | | |fitting and adjustments | | | | |L1690 |NU | |Combination, bilateral, |All |Y |Purchase | | |EP | |lumbo-sacral, hip, femur | | | | | | | |orthosis providing adduction | | | | | | | |and internal rotation | | | | | | | |control, prefabricated, | | | | | | | |includes fitting and | | | | | | | |adjustment | | | | |L1700 |NU | |Legg Perthes orthosis |All |Y |Purchase | | |EP | |(Toronto type), custom | | | | | | | |fabricated | | | | |L1710 |NU | |Legg Perthes orthosis |All |Y |Purchase | | |EP | |(Newington type), custom | | | | | | | |fabricated | | | | |L1720 |NU | |Legg Perthes orthosis, |All |Y |Purchase | | |EP | |trilateral (Tachdijan type), | | | | | | | |custom fabricated | | | | |L1730 |NU | |Legg Perthes orthosis |All |Y |Purchase | | |EP | |(Scottish Rite type) custom | | | | | | | |fabricated | | | | |L1755 |NU | |Legg Perthes orthosis (Patten|All |Y |Purchase | | |EP | |bottom type), custom | | | | | | | |fabricated | | | | |L1810 |NU | |KO, elastic with joints, |All |N |Purchase | | |EP | |prefabricated, includes | | | | | | | |fitting and adjustment | | | | |L1820 |NU | |KO, elastic with condylar |All |N |Purchase | | |EP | |pads and joints, | | | | | | | |prefabricated, includes | | | | | | | |fitting and adjustment | | | | |L1830 |NU | |KO, immobilizer, canvas |All |N |Purchase | | |EP | |longitudinal, prefabricated, | | | | | | | |includes fitting and | | | | | | | |adjustment | | | | |L1832 |NU | |Knee orthosis, adjustable |All |N |Purchase | | |EP | |knee joints (unicentric or | | | | | | | |polycentric), positional | | | | | | | |orthosis, rigid support, | | | | | | | |prefabricated, includes | | | | | | | |fitting and adjustment | | | | |L1834 |NU | |KO, without knee joint, |All |N |Purchase | | |EP | |rigid, custom fabricated | | | | |L1840 |NU | |KO, derotation, |All |Y |Purchase | | |EP | |medial-lateral, anterior | | | | | | | |cruciate ligament, custom | | | | | | | |fabricated | | | | |L1843 |NU | |Knee orthosis, single |21+ |Y |Purchase | | | | |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, includes | | | | | | | |fitting and adjustment | | | | |L1844 |NU | |Knee orthosis, single |21+ |Y |Purchase | | | | |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 | | | | |L1845 |NU | |Knee orthosis, double |All |Y |Purchase | | |EP | |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, includes | | | | | | | |fitting and adjustment | | | | |L1846 |NU | | Knee orthosis, double |All |Y |Purchase | | |EP | |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 | | | | |L1847 |NU | |Knee orthosis, double upright|21+ |N |Purchase | | | | |with adjustable joint, with | | | | | | | |inflatable air support | | | | | | | |chamber(s) prefabricated, | | | | | | | |includes fitting and | | | | | | | |adjustment | | | | |L1850 |NU | |KO, Swedish type, |All |N |Purchase | | |EP | |prefabricated, includes | | | | | | | |fitting and adjustment | | | | |L1860 |NU | |KO, modification of |All |Y |Purchase | | |EP | |supracondylar prosthetic | | | | | | | |socket, custom fabricated | | | | | | | |(SK) | | | | |L1900 |NU | |AFO, spring wire, |All |N |Purchase | | |EP | |dorsiflexion assist calf | | | | | | | |band, custom fabricated | | | | |L1902 |NU | |AFO, ankle gauntlet, |All |N |Purchase | | |EP | |prefabricated, includes | | | | | | | |fitting and adjustment | | | | |L1904 |NU | |AFO, molded ankle gauntlet, |All |N |Purchase | | |EP | |custom fabricated | | | | |L1906 |NU | |AFO, multiligamentus ankle |All |N |Purchase | | |EP | |support, prefabricated, | | | | | | | |includes fitting and | | | | | | | |adjustment | | | | |L1907 |NU | |AFO, supramalleolar with |All |N |Purchase | | |EP | |straps, with or without | | | | | | | |interface/pads, custom | | | | | | | |fabricated | | | | |L1910 |NU | |AFO, posterior, single bar, |All |N |Purchase | | |EP | |clasp attachment to shoe | | | | | | | |counter prefabricated, | | | | | | | |includes fitting and | | | | | | | |adjustment | | | | |L1920 |NU | |((Custom night “A” |All |N |Purchase | | |EP | |frame-KAFO, torsion control, | | | | | | | |bilateral night “A” frame) | | | | | | | |AFO, single upright with | | | | | | | |static or adjustable stop | | | | | | | |(Phelps or Perlstein type), | | | | | | | |custom fabricated | | | | |L1930 |NU | |AFO, plastic or other |All |N |Purchase | | |EP | |material, prefabricated, | | | | | | | |includes fitting and | | | | | | | |adjustment | | | | |L1932 |NU | |AFO, rigid anterior tibial |All |N |Purchase | | |EP | |section, total carbon fiber | | | | | | | |or equal material, | | | | | | | |prefabricated, includes | | | | | | | |fitting and adjustment | | | | |L1940 |NU | |AFO, plastic or other |All |N |Purchase | | |EP | |material, custom-fabricated | | | | |L1945 |NU | |AFO, molded to patient model,|All |Y |Purchase | | |EP | |plastic, rigid anterior | | | | | | | |tibial section (floor | | | | | | | |reaction), custom fabricated | | | | |L1950 |NU | |AFO, spiral (Institute of |All |N |Purchase | | |EP | |Rehabilitative Medicine | | | | | | | |type), plastic, custom | | | | | | | |fabricated | | | | |L1951 |NU | |Ankle foot orthosis, spiral |All |N |Purchase | | |EP | |(Institute of Rehabilitative | | | | | | | |Medicine type), plastic, or | | | | | | | |other material, | | | | | | | |prefabricated, includes | | | | | | | |fitting and adjustment | | | | |L1960 |NU | |AFO, posterior solid ankle, |All |N |Purchase | | |EP | |plastic, custom fabricated | | | | |L1970 |NU | |AFO, plastic, with ankle |All |N |Purchase | | |EP | |joint, custom fabricated | | | | |L1980 |NU | |AFO, single upright free |All |N |Purchase | | |EP | |plantar dorsiflexion, solid | | | | | | | |stirrup, calf band/cuff | | | | | | | |(single bar BK orthosis), | | | | | | | |custom fabricated | | | | |L1990 |NU | |AFO, double upright free |All |N |Purchase | | |EP | |plantar dorsiflexion, solid | | | | | | | |stirrup, calf band/cuff | | | | | | | |(double bar BK orthosis), | | | | | | | |custom fabricated | | | | |L2000 |NU | |KAFO, single upright, free |All |Y |Purchase | | |EP | |knee, free ankle, solid | | | | | | | |stirrup, thigh and calf | | | | | | | |bands/cuffs (single bar AK | | | | | | | |orthosis), custom fabricated | | | | |L2005 |NU | |KAFO, any material, single or|All |N |Purchase | | |EP | |double upright, stance | | | | | | | |control, automatic lock and | | | | | | | |swing phase release, | | | | | | | |mechanical activation, | | | | | | | |includes ankle joint, any | | | | | | | |type, custom fabricated | | | | |L2010 |NU | |KAFO, single upright, free |All |Y |Purchase | | |EP | |knee, free ankle, solid | | | | | | | |stirrup, thigh and calf | | | | | | | |bands/cuffs (single bar AK | | | | | | | |orthosis), without knee | | | | | | | |joint, custom fabricated | | | | |L2020 |NU | |KAFO, double upright, free |All |Y |Purchase | | |EP | |knee, free ankle, solid | | | | | | | |stirrup, thigh and calf | | | | | | | |bands/cuffs (double bar AK | | | | | | | |orthosis), custom fabricated | | | | |L2030 |NU | |KAFO, double upright, free |All |Y |Purchase | | |EP | |knee, free ankle, solid | | | | | | | |stirrup, thigh and calf | | | | | | | |bands/cuffs, (double bar AK | | | | | | | |orthosis), without knee | | | | | | | |joint, custom fabricated | | | | |L2035 |NU | |Knee ankle foot orthosis, |21+ |N |Purchase | | | | |full plastic, static | | | | | | | |(pediatric size) without free| | | | | | | |motion ankle, prefabricated, | | | | | | | |includes fitting and | | | | | | | |adjustment | | | | |L2036 |NU | |Knee ankle foot orthosis, |All |Y |Purchase | | |EP | |full plastic, double upright,| | | | | | | |with or without free motion | | | | | | | |knee, with or without free | | | | | | | |motion ankle, custom | | | | | | | |fabricated | | | | |L2037 |NU | |Knee ankle foot orthosis, |All |Y |Purchase | | |EP | |full plastic, single upright,| | | | | | | |with or without free motion | | | | | | | |knee, with or without free | | | | | | | |motion ankle, custom | | | | | | | |fabricated | | | | |L2038 |NU | |Knee ankle foot orthosis, |All |Y |Purchase | | |EP | |full plastic, with or without| | | | | | | |free motion knee , multi-axis| | | | | | | |ankle, custom fabricated | | | | |L2040 |NU | |HKAFO, torsion control, |All |N |Purchase | | |EP | |bilateral rotation straps, | | | | | | | |pelvic band/belt, custom | | | | | | | |fabricated | | | | |L2040 |NU |U1 |((Night “A” frame-KAFO, |All |N |Manually | | | | |torsion control, bilateral | | |Priced | | |EP |U1 |night “A” frame) HKAFO, | | |Purchase | | | | |torsion control, bilateral | | | | | | | |rotation straps, pelvic | | | | | | | |band/belt, custom fabricated | | | | |L2050 |NU | |HKAFO, torsion control, |All |N |Purchase | | |EP | |bilateral torsion cables, hip| | | | | | | |joint, pelvic band/belt, | | | | | | | |custom fabricated | | | | |L2060 |NU | |HKAFO, torsion control, |All |N |Purchase | | |EP | |bilateral torsion cables, | | | | | | | |ball bearing hip joint, | | | | | | | |pelvic band/belt, custom | | | | | | | |fabricated | | | | |L2070 |NU | |HKAFO, torsion control, |All |N |Purchase | | |EP | |unilateral rotation straps, | | | | | | | |pelvic band/belt, custom | | | | | | | |fabricated | | | | |L2080 |NU | |HKAFO, torsion control, |All |N |Purchase | | |EP | |unilateral torsion cable, hip| | | | | | | |joint, pelvic band/belt, | | | | | | | |custom fabricated | | | | |L2090 |NU | |HKAFO, torsion control, |All |N |Purchase | | |EP | |unilateral torsion cable, | | | | | | | |ball bearing hip joint, | | | | | | | |pelvic band/belt, custom | | | | | | | |fabricated | | | | |L2106 |NU | |AFO, fracture orthosis, |All |N |Purchase | | |EP | |tibial fracture cast | | | | | | | |orthosis, thermoplastic type | | | | | | | |casting material, custom | | | | | | | |fabricated | | | | |L2108 |NU | |AFO, fracture orthosis, |All |Y |Purchase | | |EP | |tibial fracture cast | | | | | | | |orthosis, custom fabricated | | | | |L2112 |NU | |AFO, fracture orthosis, |All |N |Purchase | | |EP | |tibial fracture orthosis, | | | | | | | |soft, prefabricated, includes| | | | | | | |fitting and adjustment | | | | |L2114 |NU | |AFO, fracture orthosis, |All |N |Purchase | | |EP | |tibial fracture orthosis, | | | | | | | |semi-rigid, prefabricated, | | | | | | | |includes fitting and | | | | | | | |adjustment | | | | |L2116 |NU | |AFO, fracture orthosis, |All |N |Purchase | | |EP | |tibial fracture orthosis, | | | | | | | |rigid, prefabricated, | | | | | | | |includes fitting and | | | | | | | |adjustment | | | | |L2126 |NU | |KAFO, fracture orthosis, |All |Y |Purchase | | |EP | |femoral fracture cast | | | | | | | |orthosis, thermoplastic type | | | | | | | |casting material, custom | | | | | | | |fabricated | | | | |L2128 |NU | |KAFO, fracture orthosis, |All |Y |Purchase | | |EP | |femoral fracture cast | | | | | | | |orthosis, custom fabricated | | | | |L2132 |NU | |KAFO, fracture orthosis, |All |Y |Purchase | | |EP | |femoral fracture cast | | | | | | | |orthosis, soft, | | | | | | | |prefabricated, includes | | | | | | | |fitting and adjustment | | | | |L2134 |NU | |KAFO, fracture orthosis, |All |Y |Purchase | | |EP | |femoral fracture cast | | | | | | | |orthosis, semi-rigid | | | | | | | |prefabricated, includes | | | | | | | |fitting and adjustment | | | | |L2136 |NU | |KAFO, fracture orthosis, |All |Y |Purchase | | |EP | |femoral fracture cast | | | | | | | |orthosis, rigid, | | | | | | | |prefabricated, includes | | | | | | | |fitting and adjustment | | | | |L2180 |NU | |Addition to lower extremity |All |N |Purchase | | |EP | |fracture orthosis, plastic | | | | | | | |shoe insert with ankle joints| | | | |L2182 |NU | |Addition to lower extremity |All |N |Purchase | | |EP | |fracture orthosis, drop lock | | | | | | | |knee joint | | | | |L2184 |NU | |Addition to lower extremity |All |N |Purchase | | |EP | |fracture orthosis, limited | | | | | | | |motion knee joint | | | | |L2186 |NU | |Addition to lower extremity |All |N |Purchase | | |EP | |fracture orthosis, adjustable| | | | | | | |motion knee joint, Lerman | | | | | | | |type | | | | |L2188 |NU | |Addition to lower extremity |All |N |Purchase | | |EP | |fracture orthosis, | | | | | | | |quadrilateral brim | | | | |L2190 |NU | |Addition to lower extremity |All |N |Purchase | | |EP | |fracture orthosis, waist belt| | | | |L2192 |NU | |Addition to lower extremity |All |N |Purchase | | |EP | |fracture orthosis, hip joint,| | | | | | | |pelvic band, thigh flange, | | | | | | | |and pelvic belt | | | | |L2200 |NU | |Additions to lower extremity,|All |N |Purchase | | |EP | |limited ankle motion, each | | | | | | | |joint | | | | |L2210 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |dorsiflexion assist (plantar | | | | | | | |flexion resist), each joint | | | | |L2220 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |dorsiflexion and plantar | | | | | | | |flexion assist/resist, each | | | | | | | |joint | | | | |L2230 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |split flat caliper stirrups | | | | | | | |and plate attachment | | | | |L2232 |NU | |Addition to lower extremity |All |N |Manually | | |EP | |orthosis, rocker bottom for | | |Priced | | | | |total contact ankle foot | | | | | | | |orthosis, for custom | | | | | | | |fabricated orthosis only | | | | |L2240 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |round caliper and plate | | | | | | | |attachment | | | | |L2250 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |foot plate, molded to patient| | | | | | | |model, stirrup attachment | | | | |L2260 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |reinforced solid stirrup | | | | | | | |(Scott-Craig type) | | | | |L2265 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |long tongue stirrup | | | | |L2270 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |varus/valgus correction (T) | | | | | | | |strap, padded/lined or | | | | | | | |malleolus pad | | | | |L2275 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |varus/valgus correction, | | | | | | | |plastic modification, | | | | | | | |padded/lined | | | | |L2280 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |molded inner boot | | | | |L2300 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |abduction bar (bilateral hip | | | | | | | |involvement), jointed, | | | | | | | |adjustable | | | | |L2310 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |abduction bar straight | | | | |L2320 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |nonmolded lacer, for custom | | | | | | | |fabricated orthosis only | | | | |L2330 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |lacer molded to patient | | | | | | | |model, for custom fabricated | | | | | | | |orthosis only | | | | |L2335 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |anterior swing band | | | | |L2340 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |pretibial shell, molded to | | | | | | | |patient model | | | | |L2350 |NU | |Addition to lower extremity, |All |Y |Purchase | | |EP | |prosthetic type, (BK) socket,| | | | | | | |molded to patient model, | | | | | | | |(used for PTB, AFO orthoses) | | | | |L2360 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |extended steel shank | | | | |L2370 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |Patten bottom | | | | |L2375 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |torsion control, ankle joint | | | | | | | |and half solid stirrup | | | | |L2380 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |torsion control, straight | | | | | | | |knee joint, each joint | | | | |L2385 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |straight knee joint, | | | | | | | |heavy-duty, each joint | | | | |L2390 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |offset knee joint, each joint| | | | |L2395 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |offset knee joint, | | | | | | | |heavy-duty, each joint | | | | |L2397 |NU | |Addition to lower extremity |21+ |N |Purchase | | | | |orthosis, suspension sleeve | | | | |L2405 |NU | |Addition to knee joint, drop |All |N |Purchase | | |EP | |lock, each | | | | |L2415 |NU | |Addition to knee lock with |All |N |Purchase | | |EP | |integrated release mechanism | | | | | | | |, (bail, cable or equal, any | | | | | | | |material, each joint | | | | |L2425 |NU | |Addition to knee joint, disc |All |N |Purchase | | |EP | |or dial lock for adjustable | | | | | | | |knee flexion, each joint | | | | |L2430 |NU | |Addition to knee joint, |All |N |Purchase | | |EP | |ratchet lock for active and | | | | | | | |progressive knee extension, | | | | | | | |each joint | | | | |L2492 |NU | |Addition to knee joint, lift |All |N |Purchase | | |EP | |loop for drop lock ring | | | | |L2500 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |thigh/weight bearing, | | | | | | | |gluteal/ischial weight | | | | | | | |bearing, ring | | | | |L2510 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |thigh/weight bearing, | | | | | | | |quadri-lateral brim, molded | | | | | | | |to patient model | | | | |L2520 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |thigh/weight bearing, | | | | | | | |quadri-lateral brim, custom | | | | | | | |fitted | | | | |L2525 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |thigh/weight bearing, ischial| | | | | | | |containment/narrow M-L brim | | | | | | | |molded to patient model | | | | |L2526 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |thigh/weight bearing, ischial| | | | | | | |containment/narrow M-L brim, | | | | | | | |custom fitted | | | | |L2530 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |thigh/weight bearing, lacer, | | | | | | | |non-molded | | | | |L2540 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |thigh/weight bearing, lacer, | | | | | | | |molded to patient model | | | | |L2550 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |thigh/weight bearing, high | | | | | | | |roll cuff | | | | |L2570 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |pelvic control, hip joint, | | | | | | | |Clevis type two position | | | | | | | |joint, each | | | | |L2580 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |pelvic control, pelvic sling | | | | |L2600 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |pelvic control, hip joint, | | | | | | | |Clevis type, or thrust | | | | | | | |bearing, free, each | | | | |L2610 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |pelvic control, hip joint, | | | | | | | |Clevis or thrust bearing, | | | | | | | |lock, each | | | | |L2620 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |pelvic control, hip joint, | | | | | | | |heavy-duty, each | | | | |L2622 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |pelvic control, hip joint, | | | | | | | |adjustable flexion, each | | | | |L2624 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |pelvic control, hip joint, | | | | | | | |adjustable flexion, | | | | | | | |extension, abduction control,| | | | | | | |each | | | | |L2627 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |pelvic control, plastic, | | | | | | | |molded to patient model, | | | | | | | |reciprocating hip joint and | | | | | | | |cables | | | | |L2628 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |pelvic control, metal frame, | | | | | | | |reciprocating hip joint and | | | | | | | |cables | | | | |L2630 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |pelvic control, band and belt| | | | | | | |unilateral | | | | |L2640 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |pelvic control, band and belt| | | | | | | |bilateral | | | | |L2650 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |pelvic and thoracic control, | | | | | | | |gluteal pad, each | | | | |L2660 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |thoracic control, thoracic | | | | | | | |band | | | | |L2670 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |thoracic control, paraspinal | | | | | | | |uprights | | | | |L2680 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |thoracic control, lateral | | | | | | | |support uprights | | | | |L2750 |NU | |Addition to lower extremity |All |N |Purchase | | |EP | |orthosis, plating chrome or | | | | | | | |nickel, per bar | | | | |L2755 |NU | |((Carbon composite ankles; |All |N |Purchase | | |EP | |addition to AFO) Addition to| | | | | | | |lower extremity orthosis, | | | | | | | |high strength, lightweight | | | | | | | |material, all hybrid | | | | | | | |lamination/prepreg composite,| | | | | | | |per segment, for custom | | | | | | | |fabricated orthosis only | | | | |L2760 |NU | |Addition to lower extremity |All |N |Purchase | | |EP | |orthosis, extension, per | | | | | | | |extension, per bar (for | | | | | | | |linear adjustment for growth)| | | | |L2780 |NU | |Addition to lower extremity |All |N |Purchase | | |EP | |orthosis, non-corrosive | | | | | | | |finish, per bar | | | | |L2785 |NU | |Addition to lower extremity |All |N |Purchase | | |EP | |orthosis, drop lock retainer,| | | | | | | |each | | | | |L2795 |NU | |Addition to lower extremity |All |N |Purchase | | |EP | |orthosis, knee control, full | | | | | | | |kneecap | | | | |L2800 |NU | |Addition to lower extremity |All |N |Purchase | | |EP | |orthosis, knee control, | | | | | | | |kneecap, medial or lateral | | | | | | | |pull, for use with custom | | | | | | | |fabricated orthosis only | | | | |L2810 |NU | |Addition to lower extremity |All |N |Purchase | | |EP | |orthosis, knee control, | | | | | | | |condylar pad | | | | |L2810 |EP | |((Custom night “A” |U21 |N/A |Purchase | | | | |frame-KAFO, torsion control, | | | | | | | |bilateral night “A” frame) | | | | | | | |Addition to lower extremity | | | | | | | |orthosis, knee control, | | | | | | | |condylar pad | | | | |L2820 |NU | |Addition to lower extremity |All |N |Purchase | | |EP | |orthosis, soft interface for | | | | | | | |molded plastic, below knee | | | | | | | |section | | | | |L2830 |NU | |Addition to lower extremity |All |N |Purchase | | |EP | |orthosis, soft interface for | | | | | | | |molded plastic, above knee | | | | | | | |section | | | | |L2840 |NU | |Addition to lower extremity |All |N |Purchase | | |EP | |orthosis, tibial length sock,| | | | | | | |fracture or equal, each | | | | |L2850 |NU | |Addition to lower extremity |All |N |Purchase | | |EP | |orthosis, femoral length | | | | | | | |sock, fracture or equal, each| | | | |L2861 |EP | |Addition to lower extremity |U21 |Y |Manually | | | | |joint, knee or ankle, | | |Priced | | | | |concentric adjustable torsion| | | | | | | |style mechanism for custom | | | | | | | |fabricated orthotics only, | | | | | | | |each | | | | |L2999 |EP | |Lower extremity orthoses, NOS|All |N |Manually | | | | | | | |Priced | |L2999 |NU | |((Unlisted prosthetic devices|All |Y |Manually | | |EP | |or orthotic appliances; the | | |Priced | | | | |manufacturer’s invoice must | | | | | | | |be attached to all claims.) | | | | | | | |Lower extremity orthoses, NOS| | | | |L3000 |NU | |Foot insert, removable, |All |N |Purchase | | |EP | |molded to patient model, UCB | | | | | | | |type, Berkeley shell, each | | | | |L3002 |NU | |Foot insert, removable, |All |N |Manually | | |EP | |molded to patient model, | | |Priced | | | | |Plastazote or equal, each | | | | |L3010 |NU | |Foot insert, removable, |All |N |Purchase | | |EP | |molded to patient model, | | | | | | | |longitudinal arch support, | | | | | | | |each | | | | |L3020 |NU | |Foot insert, removable, |All |N |Purchase | | |EP | |molded to patient model, | | | | | | | |longitudinal/metatarsal | | | | | | | |support, each | | | | |L3030 |NU | |Foot insert, removable, |All |N |Purchase | | |EP | |formed to patient foot, each | | | | |L3040 |NU | |Foot, arch support, |All |N |Purchase | | |EP | |removable, premolded, | | | | | | | |longitudinal, each | | | | |L3050 |NU | |Foot, arch support, |All |N |Purchase | | |EP | |removable, premolded, | | | | | | | |metatarsal, each | | | | |L3060 |NU | |Foot, arch support, |All |N |Purchase | | |EP | |removable, premolded, | | | | | | | |longitudinal/metatarsal, each| | | | |L3070 |NU | |Foot, arch support, |All |N |Purchase | | |EP | |non-removable, attached to | | | | | | | |shoe, longitudinal, each | | | | |L3080 |NU | |Foot, arch support, |All |N |Purchase | | |EP | |non-removable, attached to | | | | | | | |shoe, metatarsal, each | | | | |L3090 |NU | |Foot, arch support, |All |N |Purchase | | |EP | |non-removable, attached to | | | | | | | |shoe, | | | | | | | |longitudinal/metatarsal, each| | | | |L3100 |NU | |Hallus–valgus night dynamic |All |N |Purchase | | |EP | |splint | | | | |L3140 |NU | |((Bebox foot orthosis club |All |Y |Purchase | | |EP |UB |foot abduction orthosis) | | | | | | | |Foot, abduction rotation bar,| | | | | | | |including shoes | | | | |L3140 |NU | |((Don Joy knee orthosis) |21+ |Y |Purchase | | | | |Foot, abduction rotation bar,| | | | | | | |including shoes | | | | |L3150 |NU | |Foot, abduction rotation bar,|All |N |Purchase | | |EP | |without shoes | | | | |L3150 |EP |UB |((Custom night “A” |U21 |N |Purchase | | | | |frame-KAFO, torsion control, | | | | | | | |bilateral night “A” frame) | | | | | | | |Foot, abduction rotation bar,| | | | | | | |without shoes | | | | |L3170 |NU | |Foot, plastic, silicone or |All |N |Purchase | | |EP | |equal, heel stabilizer, each | | | | |L3202 |EP | |Orthopedic shoe, Oxford with |U21 |N/A |Purchase | | | | |supinator or pronator, child | | | | |L3204 |NU | |((Straight last hightop shoe,|All |N |Purchase | | |EP | |each, size 2-8) Orthopedic | | | | | | | |shoe, hightop with supinator | | | | | | | |or pronator, infant | | | | |L3204 |NU | |((Straight last hightop shoe,|All |N |Purchase | | |EP |U1 |each, size 8½-12) Orthopedic| | | | | | | |shoe, hightop with supinator | | | | | | | |or pronator, infant | | | | |L3204 |NU | |((Regular last hightop shoe, |All |N |Purchase | | |EP |U1 |each, size 3-6) Orthopedic | | | | | | | |shoe, hightop with supinator | | | | | | | |or pronator, infant | | | | |L3204 |NU | |((Regular last hightop shoe, |All |N |Purchase | | |EP |U1 |each, size 8½-12) Orthopedic| | | | | | | |shoe, hightop with supinator | | | | | | | |or pronator, infant | | | | |L3204 |NU | |((Reverse last closed toe) |All |N |Purchase | | |EP |U1 |Orthopedic shoe, hightop with| | | | | | | |supinator or pronator, infant| | | | |L3204 |NU | |((Orthopedic shoe, hightop, |21+ |N |Purchase | | | | |normal last, each, size 3-8) | | | | | | | |Orthopedic shoe, hightop with| | | | | | | |supinator or pronator, infant| | | | |L3204 |NU | |((Orthopedic shoe, hightop, |All |N |Purchase | | |EP |U1 |normal last, each, size | | | | | | | |8½-12) Orthopedic shoe, | | | | | | | |hightop with supinator or | | | | | | | |pronator, infant | | | | |L3206 |NU | |((Straight last hightop shoe,|All |N |Purchase | | |EP | |each, size 2-8) Orthopedic | | | | | | | |shoe, hightop with supinator | | | | | | | |or pronator, child | | | | |L3206 |NU | |((Straight last hightop shoe,|All |N |Purchase | | |EP |U1 |each, size 8½-12) Orthopedic| | | | | | | |shoe, hightop with supinator | | | | | | | |or pronator, child | | | | |L3206 |NU | |((Regular last hightop shoe, |All |N |Purchase | | |EP |U1 |each, size 3-6) Orthopedic | | | | | | | |shoe, hightop with supinator | | | | | | | |or pronator, child | | | | |L3206 |NU | |((Regular last hightop shoe, |All |N |Purchase | | |EP |U1 |each, size 8½-12) Orthopedic| | | | | | | |shoe, hightop with supinator | | | | | | | |or pronator, child | | | | |L3206 |NU | |((Reverse last closed toe) |All |N |Purchase | | |EP |U1 |Orthopedic shoe, hightop with| | | | | | | |supinator or pronator, child | | | | |L3206 |NU | |((Orthopedic shoe, hightop, |21+ |N |Purchase | | | | |normal last, each, size 3-8) | | | | | | | |Orthopedic shoe, hightop with| | | | | | | |supinator or pronator, child | | | | |L3206 |NU | |((Orthopedic shoe, hightop, |All |N |Purchase | | |EP |U1 |normal last, each, size | | | | | | | |8½-12) Orthopedic shoe, | | | | | | | |hightop with supinator or | | | | | | | |pronator, child | | | | |L3207 |NU | |((Straight last hightop shoe,|All |N |Purchase | | |EP | |each, size 2-8) Orthopedic | | | | | | | |shoe, hightop with supinator | | | | | | | |or pronator, junior | | | | |L3207 |NU | |((Straight last hightop shoe,|All |N |Purchase | | |EP |U1 |each, size 8½-12) Orthopedic| | | | | | | |shoe, hightop with supinator | | | | | | | |or pronator, junior | | | | |L3207 |NU | |((Regular last hightop shoe, |All |N |Purchase | | |EP |U1 |each, size 3-6) Orthopedic | | | | | | | |shoe, hightop with supinator | | | | | | | |or pronator, junior | | | | |L3207 |NU | |((Regular last hightop shoe, |All |N |Purchase | | |EP |U1 |each, size 8½-12) Orthopedic| | | | | | | |shoe, hightop with supinator | | | | | | | |or pronator, junior | | | | |L3207 |NU | |((Reverse last closed toe) |All |N |Purchase | | |EP |U1 |Orthopedic shoe, hightop with| | | | | | | |supinator or pronator, junior| | | | |L3207 |NU | |((Orthopedic shoe, hightop, |21+ |N |Purchase | | | | |normal last, each, size 3-8) | | | | | | | |Orthopedic shoe, hightop with| | | | | | | |supinator or pronator, junior| | | | |L3207 |NU | |((Orthopedic shoe, hightop, |All |N |Purchase | | |EP |U1 |normal last, each, size | | | | | | | |8½-12) Orthopedic shoe, | | | | | | | |hightop with supinator or | | | | | | | |pronator, junior | | | | |L3207 |NU | |((Orthopedic shoe, hightop, |All |N |Purchase | | |EP | |normal last, each, size | | | | | | | |8½-12) Orthopedic shoe, | | | | | | | |hightop with supinator or | | | | | | | |pronator, junior | | | | |L3208 |EP | |Surgical boot, each, infant |U21 |N/A |Purchase | |L3209 |EP | |Surgical boot, each, child |U21 |N/A |Purchase | |L3211 |EP | |Surgical boot, each, junior |U21 |N/A |Purchase | |L3215 |NU | |Orthopedic footwear, woman’s |All |Y |Purchase | | |EP | |shoes, oxford, each | | | | |L3216 |NU | |Orthopedic footwear, woman’s |All |Y |Purchase | | |EP | |shoes, depth inlay, each | | | | |L3217 |NU | |((Straight last hightop shoe,|All |N |Purchase | | |EP | |each, size 2-8) Orthopedic | | | | | | | |footwear, woman’s shoes, | | | | | | | |hightop, depth inlay, each | | | | |L3217 |NU |U1 |((Straight last hightop shoe,|All |N |Purchase | | |EP |U1 |each, size 8½-12) Orthopedic| | | | | | | |footwear, woman’s shoes, | | | | | | | |hightop, depth inlay, each | | | | |L3217 |NU | |((Regular last hightop shoe, |All |N |Purchase | | |EP |U1 |each, size 3-6) Orthopedic | | | | | | | |footwear, woman’s shoes, | | | | | | | |hightop, depth inlay, each | | | | |L3217 |NU | |((Regular last hightop shoe, |All |N |Purchase | | |EP |U1 |each, size 8½-12) Orthopedic| | | | | | | |footwear, woman’s shoes, | | | | | | | |hightop, depth inlay, each | | | | |L3217 |NU | |((Reverse last closed toe) |All |N |Purchase | | |EP |U1 |Orthopedic footwear, woman’s | | | | | | | |shoes, hightop, depth inlay, | | | | | | | |each | | | | |L3219 |NU | |Orthopedic footwear, man’s |All |Y |Purchase | | |EP | |shoes, oxford, each | | | | |L3221 |NU | |Orthopedic footwear, man’s |All |Y |Purchase | | |EP | |shoes, depth inlay, each | | | | |L3222 |NU | |((Straight last hightop shoe,|All |N |Purchase | | |EP | |each, size 2-8) Orthopedic | | | | | | | |footwear, man’s shoes, | | | | | | | |hightop, depth inlay, each | | | | |L3222 |NU |U1 |((Straight last hightop shoe,|All |N |Purchase | | |EP |U1 |each, size 8½-12) Orthopedic| | | | | | | |footwear, man’s shoes, | | | | | | | |hightop, depth inlay, each | | | | |L3222 |NU |U1 |((Regular last hightop shoe, |All |N |Purchase | | |EP |U1 |each, size 3-6) Orthopedic | | | | | | | |footwear, man’s shoes, | | | | | | | |high-top, depth inlay, each | | | | |L3222 |NU |U1 |((Regular last hightop shoe, |All |N |Purchase | | |EP |U1 |each, size 8½-12) Orthopedic| | | | | | | |footwear, man’s shoes, | | | | | | | |hightop, depth inlay, each | | | | |L3222 |NU |U1 |((Reverse last closed toe) |All |N |Purchase | | |EP |U1 |Orthopedic footwear, man’s | | | | | | | |shoes, hightop, depth inlay, | | | | | | | |each | | | | |L3224 |NU | |Orthopedic footwear, woman’s |21+ |N |Purchase | | | | |shoe, Oxford, used as an | | | | | | | |integral part of a brace | | | | | | | |(orthosis) | | | | |L3225 |NU | |Orthopedic footwear, man’s |21+ |N |Purchase | | | | |shoe, oxford, used as an | | | | | | | |integral part of a brace | | | | | | | |(orthosis) | | | | |L3230 |NU | |Orthopedic footwear, custom |All |Y |Purchase | | |EP | |shoes, depth inlay, each | | | | |L3250 |NU | |Orthopedic footwear, custom |All |Y |Purchase | | |EP | |molded shoe, removable inner | | | | | | | |mold, prosthetic shoe, each | | | | |L3253 |NU | |Foot, molded shoe Plastazote |All |Y |Purchase | | |EP | |(or similar), custom fitted, | | | | | | | |each | | | | |L3257 |NU | |Orthopedic footwear, |All |Y |Purchase | | |EP | |additional charge for split | | | | | | | |size | | | | |L3260 |NU | |Surgical boot/shoe, each |All |N |Manually | | | | | | | |Priced | | |EP | | | | |Purchase | |L3265 |NU | |Plastazote sandal, each |All |N |Purchase | | |EP | | | | | | |L3310 |NU | |Lift, elevation, heel and |All |N |Purchase | | |EP | |sole, neoprene, per in. | | | | |L3332 |NU | |Lift, elevation, inside shoe,|All |N |Purchase | | |EP | |tapered, up to one-half in. | | | | |L3334 |NU | |Lift, elevation, heel, per |All |N |Purchase | | |EP | |inch | | | | |L3350 |NU | |Heel wedge |All |N |Purchase | | |EP | | | | | | |L3360 |NU | |Sole wedge, outside sole |All |N |Purchase | | |EP | | | | | | |L3370 |NU | |Sole wedge, between sole |All |N |Purchase | | |EP | | | | | | |L3400 |NU | |Metatarsal bar wedge, rocker |All |N |Purchase | | |EP | | | | | | |L3420 |NU | |Full sole and heel wedge, |All |N |Purchase | | |EP | |between sole | | | | |L3450 |NU | |Heel, SACH cushion type |All |N |Purchase | | |EP | | | | | | |L3455 |NU | |Heel, new leather, standard |All |N |Purchase | | |EP | | | | | | |L3465 |NU | |Heel, Thomas with wedge |All |N |Purchase | | |EP | | | | | | |L3540 |NU | |Orthopedic shoe addition, |All |N |Purchase | | |EP | |sole, full | | | | |L3580 |NU | |Orthopedic shoe addition, |All |N |Purchase | | |EP | |convert instep to Velcro | | | | | | | |closure | | | | |L3590 |NU | |Orthopedic shoe addition, |All |N |Purchase | | |EP | |convert firm shoe counter to | | | | | | | |soft counter | | | | |L3600 |NU | |Transfer of an orthosis from |All |N |Purchase | | |EP | |one shoe to another, caliper | | | | | | | |plate, existing | | | | |L3620 |NU | |Transfer of an orthosis from |All |N |Purchase | | |EP | |one shoe to another, solid | | | | | | | |stirrup, existing | | | | |L3630 |NU | |Transfer of an orthosis from |All |N |Purchase | | |EP | |one shoe to another, solid | | | | | | | |stirrup, new | | | | |L3649 |NU |U1 |((Unlisted prosthetic devices|All |Y |Manually | | |EP |U1 |or orthotic appliances; the | | |Priced | | | | |manufacturer’s invoice must | | | | | | | |be attached to all claims.) | | | | | | | |Orthopedic shoe, | | | | | | | |modification, addition or | | | | | | | |transfer, NOS | | | | |L3649 |EP | |((Orthopedic footwear, wooden|U21 |N/A |Purchase | | | | |sole shoe, each) Orthopedic | | | | | | | |shoe, modification, addition | | | | | | | |or transfer, NOS | | | | |L3649 |NU | |((Orthopedic footwear, wooden|All |N |Manually | | | | |sole shoe, each) Orthopedic | | |Priced | | | | |shoe, modification, addition | | | | | | | |or transfer, NOS | | | | |L3650 |NU | |SO, figure of eight design |All |N |Purchase | | |EP | |abduction re-strainer | | | | | | | |prefabricated, includes | | | | | | | |fitting and adjustment | | | | |L3660 |NU | |SO, figure of eight design, |All |N |Purchase | | |EP | |abduction restrainer, canvas | | | | | | | |and webbing, prefabricated, | | | | | | | |includes fitting and | | | | | | | |adjustment | | | | |L3670 |NU | |SO, acromio/clavicular |All |N |Purchase | | |EP | |(canvas and webbing type) | | | | | | | |prefabricated, includes | | | | | | | |fitting and adjustment | | | | |L3674 |NU | |Shoulder orthosis, abduction |All |N |Purchase | | |EP | |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 | | | | |L3675 |NU | |SO, vest type abduction |21+ |N |Purchase | | | | |restrainer, canvas webbing | | | | | | | |type, or equal, | | | | | | | |prefabricated, includes | | | | | | | |fitting and adjustment | | | | |L3710 |NU | |EO, elastic with metal |All |N |Purchase | | |EP | |joints, prefabricated, | | | | | | | |includes fitting and | | | | | | | |adjustment | | | | |L3720 |NU | |EO, double upright with |All |N |Purchase | | |EP | |forearm/arm cuffs, free | | | | | | | |motion, custom fabricated | | | | |L3730 |NU | |EO, double upright with |All |Y |Purchase | | |EP | |forearm/arm cuffs, | | | | | | | |extension/flexion assist, | | | | | | | |custom fabricated | | | | |L3740 |NU | |EO, double upright with |All |Y |Purchase | | |EP | |forearm/arm cuffs, adjustable| | | | | | | |position lock with active | | | | | | | |control, custom fabricated | | | | |L3807 |NU | |WHFO, without joint(s), |All |N |Purchase | | |EP | |prefabricated, includes | | | | | | | |fitting and adjustments, any | | | | | | | |type | | | | |L3808 |NU | |Wrist-hand-finger orthotic |All |N |Purchase | | |EP | |(WHFO), rigid without joints,| | | | | | | |may include soft interface | | | | | | | |material; straps, custom | | | | | | | |fabricated, includes fitting | | | | | | | |and adjustment | | | | |L3891 |EP | |Addition to upper extremity |U21 |Y |Manually | | | | |joint, wrist or elbow, | | |Priced | | | | |concentric adjustable torsion| | | | | | | |style mechanism for custom | | | | | | | |fabricated orthotics only, | | | | | | | |each | | | | |L3900 |NU | |WHFO, dynamic flexor hinge, |All |Y |Purchase | | |EP | |reciprocal wrist | | | | | | | |extension/flexion, finger | | | | | | | |flexion/extension, wrist or | | | | | | | |finger driven, custom | | | | | | | |fabricated | | | | |L3901 |NU | |WHFO, dynamic flexor hinge, |All |Y |Purchase | | |EP | |reciprocal wrist | | | | | | | |extension/flexion, finger | | | | | | | |flexion/extension, cable | | | | | | | |driven, custom fabricated | | | | |L3904 |NU | |WHFO, external powered, |All |Y |Purchase | | |EP | |electric, custom fabricated | | | | |L3906** |NU | |Wrist hand orthosis, without |All |N |Purchase | | |EP | |joints, may include soft | | | | | | | |interface, straps, custom | | | | | | | |fabricated, includes fitting | | | | | | | |and adjustment | | | | |L3908 |NU | |WHO, wrist extension control |All |N |Purchase | | |EP | |cock-up, nonmolded, | | | | | | | |prefabricated, includes | | | | | | | |fitting and adjustment | | | | |L3912 |NU | |HFO, flexion glove with |All |N |Purchase | | |EP | |elastic finger control, | | | | | | | |prefabricated, includes | | | | | | | |fitting and adjustment | | | | |L3915+ |NU | |Wrist, hand orthosis, |All |N |Manually | | |EP | |includes one or more | | |Priced | | | | |nontorsion joint(s), elastic | | | | | | | |bands, turnbuckles, may | | | | | | | |include soft interface, | | | | | | | |straps, prefabricated, | | | | | | | |includes fitting and | | | | | | | |adjustment | | | | |L3925 |NU | |FO, proximal interphalangeal |All |N |Purchase | | |EP | |(PIP)/distal interphalangeal | | | | | | | |(DIP), nontorsion | | | | | | | |joint/spring, | | | | | | | |extension/flexion, may | | | | | | | |include soft interface | | | | | | | |material, prefabricated, | | | | | | | |includes fitting and | | | | | | | |adjustment | | | | |L3929 |NU | |HFO, includes one or more |All |N |Purchase | | |EP | |nontorsion joint(s) | | | | | | | |turnbuckles, elastic | | | | | | | |bands/springs, may include | | | | | | | |soft interface material, | | | | | | | |straps, prefabricated, | | | | | | | |includes fitting and | | | | | | | |adjustment | | | | |L3931 |NU | |WHFO, includes one or more |All |N |Purchase | | |EP | |nontorsion joint(s), | | | | | | | |turnbuckles, elastic | | | | | | | |bands/springs, may include | | | | | | | |soft interface material, | | | | | | | |straps, prefabricated, | | | | | | | |includes fitting and | | | | | | | |adjustment | | | | |L3956 |NU | |Addition of joint to upper |21+ |N |Manually | | | | |extremity orthosis, any | | |Priced | | | | |material; per joint | | | | |L3960 |NU | |SEWHO, abduction, |All |Y |Purchase | | |EP | |positioning, airplane design,| | | | | | | |prefabricated, includes | | | | | | | |fitting and adjustment | | | | |L3962 |NU | |SEWHO, abduction positioning,|All |N |Purchase | | |EP | |Erb’s palsy design, | | | | | | | |prefabricated, includes | | | | | | | |fitting and adjustment | | | | |L3964 |NU | |SEO, mobile arm supports |All |N |Purchase | | |EP | |attached to wheelchair, | | | | | | | |balanced, adjustable, | | | | | | | |prefabricated, includes | | | | | | | |fitting and adjustment | | | | |L3965 |NU | |SEO mobile arm support |All |Y |Purchase | | |EP | |attached to wheelchair, | | | | | | | |balanced, adjustable Rancho | | | | | | | |type, prefabricated, includes| | | | | | | |fitting and adjustment | | | | |L3966 |NU | |SEO, mobile arm support |All |Y |Purchase | | |EP | |attached to wheelchair, | | | | | | | |balanced, reclining, | | | | | | | |prefabricated, includes | | | | | | | |fitting and adjustment | | | | |L3969 |NU | |SEO, mobile arm support, |All |N |Purchase | | |EP | |monosuspension arm and hand | | | | | | | |support, overhead elbow | | | | | | | |forearm hand sling support, | | | | | | | |yoke type arm suspension | | | | | | | |support, prefabricated, | | | | | | | |includes fitting and | | | | | | | |adjustment | | | | |L3980 |NU | |Upper extremity fracture |All |N |Purchase | | |EP | |orthosis, humeral, | | | | | | | |prefabricated, includes | | | | | | | |fitting and adjustment | | | | |L3982 |NU | |Upper extremity fracture |All |N |Purchase | | |EP | |orthosis, radius/ulnar | | | | | | | |prefabricated, includes | | | | | | | |fitting and adjustment | | | | |L3984 |NU | |Upper extremity fracture |All |N |Purchase | | |EP | |orthosis, wrist, | | | | | | | |prefabricated, includes | | | | | | | |fitting and adjustment | | | | |L3995 |NU | |Addition to upper extremity |All |N |Purchase | | |EP | |orthosis sock, fracture or | | | | | | | |equal, each | | | | |L3999 |NU | |((The manufacturer’s invoice |All |Y |Manually | | | | |must be attached to all | | |Priced | | |EP | |claims.) Upper limb | | |Manually | | | | |orthosis, NOS | | |Priced | |L4000 |NU | |Replace girdle for spinal |All |Y |Purchase | | |EP | |orthosis (CTLSO or SO) | | | | |L4002 |NU | |Replace strap, any orthosis, |All |N |Manually | | |EP | |includes all components, any | | |Priced | | | | |length, any type | | | | |L4010 |NU | |Replace trilateral socket |All |N |Purchase | | |EP | |brim | | | | |L4020 |NU | |Replace quadrilateral socket |All |N |Purchase | | |EP | |brim, molded to patient model| | | | |L4030 |NU | |Replace quadrilateral socket |All |N |Purchase | | |EP | |brim, custom fitted | | | | |L4040 |NU | |Replace molded thigh lacer, |All |N |Purchase | | |EP | |for custom fabricated | | | | | | | |orthosis only | | | | |L4045 |NU | |Replace nonmolded thigh |All |N |Purchase | | |EP | |lacer, for custom fabricated | | | | | | | |orthosis only | | | | |L4050 |NU | |Replace molded calf lacer, |All |N |Purchase | | |EP | |for custom fabricated | | | | | | | |orthosis only | | | | |L4055 |NU | |Replace nonmolded calf lacer,|All |N |Purchase | | |EP | |for custom fabricated | | | | | | | |orthosis only | | | | |L4060 |NU | |Replace high roll cuff |All |N |Purchase | | |EP | | | | | | |L4070 |NU | |Replace proximal and distal |All |N |Purchase | | |EP | |upright for KAFO | | | | |L4080 |NU | |Replace metal bands KAFO, |All |N |Purchase | | |EP | |proximal thigh | | | | |L4090 |NU | |((Custom night A frame-KAFO, |All |N |Purchase | | |EP | |torsion control, bilateral | | | | | | | |night “A” frame) Replace | | | | | | | |metal bands KAFO-AFO, calf or| | | | | | | |distal thigh | | | | |L4100 |NU | |Replace leather cuff KAFO, |All |N |Purchase | | |EP | |proximal thigh | | | | |L4110 |NU | |Replace leather cuff |All |N |Purchase | | |EP | |KAFO-AFO, calf or distal | | | | | | | |thigh | | | | |L4130 |NU | |Replace pretibial shell |All |N |Purchase | | |EP | | | | | | |L4205 |NU | |Repair of orthotic device, |All |Y |Purchase | | |EP | |labor component, per 15 | | | | | | | |minutes | | | | |L4210 |NU | |Repair of orthotic device, |All |Y |Purchase | | |EP | |repair or replace minor parts| | | | |L4350 |NU | |Ankle control orthosis, |All |N |Purchase | | |EP | |stirrup style, rigid, | | | | | | | |includes any type interface | | | | | | | |(e.g., pneumatic, gel), | | | | | | | |prefabricated, includes | | | | | | | |fitting and adjustment | | | | |L4360 |NU | |Walking boot, pneumatic with |All |N |Purchase | | |EP | |or without joints, with or | | | | | | | |without interface material, | | | | | | | |prefabricated, includes | | | | | | | |fitting and adjustment | | | | |L4370 |NU | |Pneumatic full leg splint, |All |N |Purchase | | |EP | |prefabricated, includes | | | | | | | |fitting and adjustment | | | | |L4380 |NU | |Pneumatic knee splint, |All |N |Purchase | | |EP | |prefabricated, includes | | | | | | | |fitting and adjustment | | | | |L4392 |NU | |Replacement soft interface |21+ |N |Purchase | | | | |material, static AFO | | | | |L4394 |NU | |Replace soft interface |21+ |N |Purchase | | | | |material, foot drop splint | | | | |L4396 |NU | |Static ankle foot orthosis, |21+ |N |Purchase | | | | |including soft interface | | | | | | | |material, adjustable for fit,| | | | | | | |for positioning, pressure | | | | | | | |reduction, may be used for | | | | | | | |minimal ambulation, | | | | | | | |prefabricated, includes | | | | | | | |fitting and adjustment | | | | |L4398 |NU | |Foot drop splint, recumbent |21+ |N |Purchase | | | | |positioning device, | | | | | | | |prefabricated, includes | | | | | | | |fitting and adjustment | | | | |L5999 |NU | |((Unlisted Prosthetic Devices|All |Y |Manually | | | | |or Orthotic Appliances; the | | |Priced | | |EP | |manufacturer’s invoice must | | |Manually | | | | |be attached to all claims.) | | |Priced | | | | |Lower extremity prosthesis, | | | | | | | |not otherwise specified | | | | |L7499 |NU | |((Unlisted Prosthetic Devices|All |Y |Manually | | | | |or Orthotic Appliances; the | | |Priced | | |EP | |manufacturer’s invoice must | | |Manually | | | | |be attached to all claims.) | | |Priced | | | | |Upper extremity prosthesis, | | | | | | | |not otherwise specified | | | | |L7510 |NU | |Repair of prosthetic device, |All |Y |Purchase | | |EP |UB |hourly rate | | | | |L7520 |NU | |Repair prosthetic device, |All |Y |Purchase | | |EP | |labor component, per 15 | | | | | | | |minutes | | | | |L8499 |NU | |((Unlisted Prosthetic Devices|All |Y |Manually | | |EP | |or Orthotic Appliances; the | | |Priced | | | | |manufacturer’s invoice must | | | | | | | |be attached to all claims.) | | | | | | | |Unlisted procedure for | | | | | | | |miscellaneous prosthetic | | | | | | | |services | | | |

|242.190 Prosthetic Devices for Beneficiaries of All Ages |9-1-17 |

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

Modifiers in this section are indicated by the headings M1 and M2. Prior authorization requirements are shown under the heading PA. If prior authorization is needed for beneficiaries age 21 and older, that information is indicated with a “Y” in the column; if not, an “N” is shown.

When codes are payable for all ages, “All” is indicated in the column, “U21” is shown when the code is payable only for beneficiaries under age 21 and “21+” is shown when the code is payable only for those beneficiaries age 21 and older. 1 The purchase of this component is limited to one per five-year period for beneficiaries age 21 and over. * Replacement only ((…) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product. When using a procedure code with this symbol, the product must meet the indicated Arkansas Medicaid description.

NOTE: Procedure codes for prosthetic eyes and information regarding prosthetic eye care is located in the Arkansas Medicaid Visual Care Program Manual. |Prosthetic Devices, All Ages (Section 242.190) | |Procedure |M1 |M2 |Description |All |PA |Payment | |Code | | | |U21 |21+ |Method | | | | | |21+ | | | |L1499 |NU | |((Unlisted Prosthetic Devices |All |Y |Manually | | | | |or Orthotic Appliances; the | | |Priced | | |EP | |manufacturer’s invoice must be | | |Manually | | | | |attached to all claims.) | | |Priced | | | | |Spinal orthosis, not otherwise | | | | | | | |specified | | | | |L2999 |NU | |((Unlisted Prosthetic Devices |All |Y |Manually | | | | |or Orthotic Appliances; the | | |Priced | | |EP | |manufacturer’s invoice must be | | |Manually | | | | |attached to all claims.) Lower| | |Priced | | | | |extremity orthoses, NOS | | | | |L3649 |NU | |Orthopedic shoe, modification, |All |N |Purchase | | |EP | |addition or transfer, NOS | | | | |L3649 |NU |U1 |((Unlisted Prosthetic Devices |All |Y |Manually | | | | |or Orthotic Appliances; the | | |Priced | | |EP |U1 |manufacturer’s invoice must be | | |Manually | | | | |attached to all claims.) | | |Priced | | | | |Orthopedic shoe, modification, | | | | | | | |addition or transfer, NOS | | | | |L3999 |NU | |((Unlisted Prosthetic Devices |All |Y |Manually | | | | |or Orthotic Appliances; the | | |Priced | | |EP | |manufacturer’s invoice must be | | |Manually | | | | |attached to all claims.) Upper| | |Priced | | | | |limb orthosis, NOS | | | | |L4205 |NU | |((Orthotics and Prosthetics |All |Y |Manually | | | | |Repairs) Repair of orthotic | | |Priced | | |EP | |device, labor component, per 15| | |Purchase | | | | |minutes | | | | |L4210 |NU | |((Orthotics and Prosthetics |All |Y |Manually | | | | |Repairs) Repair of orthotic | | |Priced | | |EP | |device, repair or replace minor| | |Purchase | | | | |parts | | | | |L4386 |NU | |Walking boot, nonpneumatic, |All |N |Purchase | | |EP | |with or without joints, with or| | | | | | | |without interface material, | | | | | | | |prefabricated, includes fitting| | | | | | | |and adjustment | | | | |L4631 |NU | |Ankle foot orthosis, walking |All |N |Purchase | | |EP | |boot type, varus/valgas | | | | | | | |correction, rocker bottom, | | | | | | | |anterior tibial shell, soft | | | | | | | |interface, custom arch support,| | | | | | | |plastic or other material, | | | | | | | |includes straps and closures, | | | | | | | |custom fabricated | | | | |L5000 |NU | |Partial foot, shoe insert with |All |N |Purchase | | |EP | |longitudinal arch, toe filler | | | | |L5010 |NU | |Partial foot, molded socket, |All |Y |Purchase | | |EP | |ankle height, with toe filler | | | | |L5020 |NU | |Partial foot, molded socket, |All |Y |Purchase | | |EP | |tibial tubercle height, with | | | | | | | |toe filler | | | | |L5050 |NU | |Ankle, Symes, molded socket, |All |Y |Purchase | | |EP | |SACH foot | | | | |L5060 |NU | |Ankle, Symes, metal frame, |All |Y |Purchase | | |EP | |molded leather socket, | | | | | | | |articulated ankle/foot | | | | |L5100 |NU | |Below knee, molded socket, |All |Y |Purchase | | |EP | |shin, SACH foot | | | | |L5105 |NU | |Below knee, plastic socket, |All |Y |Purchase | | |EP | |joints and thigh lacer, SACH | | | | | | | |foot | | | | |L5150 |NU | |Knee disarticulation (or |All |Y |Purchase | | |EP | |through knee), molded socket, | | | | | | | |external knee joints, shin, | | | | | | | |SACH foot | | | | |L5160 |NU | |Knee disarticulation (or |All |Y |Purchase | | |EP | |through knee), molded socket, | | | | | | | |bent knee configuration, | | | | | | | |external knee joints, shin, | | | | | | | |SACH foot | | | | |L5200 |NU | |Above knee, molded socket, |All |Y |Purchase | | |EP | |single axis constant friction | | | | | | | |knee, shin, SACH foot | | | | |L5210 |NU | |Above knee, short prosthesis, |All |Y |Purchase | | |EP | |no knee joint (“stubbies”), | | | | | | | |with foot blocks, no ankle | | | | | | | |joints, each | | | | |L5220 |NU | |Above knee, short prosthesis, |All |Y |Purchase | | |EP | |no knee joint (“stubbies”), | | | | | | | |with articulated ankle/foot, | | | | | | | |dynamically aligned, each | | | | |L5230 |NU | |Above knee, for proximal |All |Y |Purchase | | |EP | |femoral focal deficiency, | | | | | | | |constant friction knee, shin, | | | | | | | |SACH foot | | | | |L5250 |NU | |Hip disarticulation, Canadian |All |Y |Purchase | | |EP | |type, molded socket, hip joint,| | | | | | | |single axis constant friction | | | | | | | |knee, shin, SACH foot | | | | |L5270 |NU | |Hip disarticulation, tilt table|All |Y |Purchase | | |EP | |type, molded socket, locking | | | | | | | |hip joint, single axis constant| | | | | | | |friction knee, shin, SACH foot | | | | |L5280 |NU | |Hemipelvectomy, Canadian type, |All |Y |Purchase | | |EP | |molded socket, hip joint, | | | | | | | |single axis constant friction | | | | | | | |knee, shin, SACH foot | | | | |L5301 |NU | |Below knee, molded socket, |All |Y |Purchase | | |EP | |shin, SACH foot, endoskeletal | | | | | | | |system | | | | |L5312 |NU | |Knee disarticulation (or |All |Y |Purchase | | |EP | |through knee), molded socket, | | | | | | | |single axis knee, pylon, SACH | | | | | | | |foot, endoskeletal system | | | | |L5321 |NU | |Above knee, molded socket, open|All |Y |Purchase | | |EP | |end, SACH foot, endoskeletal | | | | | | | |system, single axis knee | | | | |L5331 |NU | |Hip disarticulation, Canadian |All |Y |Purchase | | |EP | |type, molded socket, | | | | | | | |endoskeletal system, hip joint,| | | | | | | |single axis knee, SACH foot | | | | |L5341 |NU | |Hemipelvectomy, Canadian type, |All |Y |Purchase | | |EP | |molded socket, endoskeletal | | | | | | | |system, hip joint, single axis | | | | | | | |knee, SACH foot | | | | |L5400 |NU | |Immediate post-surgical or |All |N |Purchase | | |EP | |early fitting, application of | | | | | | | |initial rigid dressing, | | | | | | | |including fitting, alignment, | | | | | | | |suspension, and one cast | | | | | | | |change, below knee | | | | |L5410 |NU | |Immediate post-surgical or |All |N |Purchase | | |EP | |early fitting, application of | | | | | | | |initial rigid dressing, | | | | | | | |including fitting, alignment | | | | | | | |and suspension, below knee, | | | | | | | |each additional cast change and| | | | | | | |realignment | | | | |L5420 |NU | |Immediate post-surgical or |All |Y |Purchase | | |EP | |early fitting, application of | | | | | | | |initial rigid dressing, | | | | | | | |including fitting, alignment | | | | | | | |and suspension, and one cast | | | | | | | |change “AK” or knee | | | | | | | |disarticulation | | | | |L5430 |NU | |Immediate post-surgical or |All |N |Purchase | | |EP | |early fitting, application of | | | | | | | |initial rigid dressing, | | | | | | | |including fitting, alignment | | | | | | | |and suspension , “AK” or knee | | | | | | | |disarticulation, each | | | | | | | |additional cast change and | | | | | | | |realignment | | | | |L5450 |NU | |Immediate post-surgical or |All |N |Purchase | | |EP | |early fitting, application of | | | | | | | |nonweight bearing rigid | | | | | | | |dressing, below knee | | | | |L5460 |NU | |Immediate post-surgical or |All |N |Purchase | | |EP | |early fitting, application of | | | | | | | |nonweight bearing rigid | | | | | | | |dressing, above knee | | | | |L5500 |NU | |Initial, below knee (“PTB” |All |N |Purchase | | |EP | |type socket, non-alignable | | | | | | | |system, pylon, no cover, SACH | | | | | | | |foot, plaster socket, direct | | | | | | | |formed | | | | |L5505 |NU | |Initial, above knee-knee |All |Y |Purchase | | |EP | |disarticulation (ischial level | | | | | | | |socket, non-alignable system, | | | | | | | |pylon, no cover, SACH foot | | | | | | | |plaster socket, direct formed | | | | |L5510 |NU | |Preparatory, below knee “PTB” |All |Y |Purchase | | |EP | |type socket, non-alignable | | | | | | | |system, pylon, no cover, SACH | | | | | | | |foot, plaster socket, molded to| | | | | | | |model | | | | |L5520 |NU | |Preparatory, below knee “PTB” |All |Y |Purchase | | |EP | |type socket, non-alignable | | | | | | | |pylon, no cover, SACH foot, | | | | | | | |thermoplastic or equal, direct | | | | | | | |formed | | | | |L5530 |NU | |Preparatory, below knee “PTB” |All |Y |Purchase | | |EP | |type socket, non-alignable | | | | | | | |system, pylon, no cover, SACH | | | | | | | |foot, thermoplastic or equal, | | | | | | | |molded to model | | | | |L5535 |NU | |Preparatory, below knee “PTB” |All |Y |Purchase | | |EP | |type socket, non-alignable | | | | | | | |system, pylon, no cover, SACH | | | | | | | |foot, prefabricated, adjustable| | | | | | | |open end socket | | | | |L5540 |NU | |Preparatory, below knee “PTB” |All |Y |Purchase | | |EP | |type socket, non alignable, | | | | | | | |pylon, no cover, SACH foot, | | | | | | | |laminated socket, molded to | | | | | | | |model | | | | |L5560 |NU | |Preparatory, above knee-knee |All |Y |Purchase | | |EP | |disarticulation ischial level | | | | | | | |socket, non-alignable system, | | | | | | | |pylon, no cover, SACH foot, | | | | | | | |plaster socket, molded to model| | | | |L5570 |NU | |Preparatory, above knee-knee |All |Y |Purchase | | |EP | |disarticulation ischial level | | | | | | | |socket, non-alignable system, | | | | | | | |pylon, no cover, SACH foot | | | | | | | |thermoplastic or equal, direct | | | | | | | |formed | | | | |L5580 |NU | |Preparatory, above knee-knee |All |Y |Purchase | | |EP | |disarticulation, ischial level | | | | | | | |socket, non-alignable system, | | | | | | | |pylon, no cover, SACH foot, | | | | | | | |thermoplastic or equal, molded | | | | | | | |to model | | | | |L5585 |NU | |Preparatory, above knee-knee |All |Y |Purchase | | |EP | |disarticulation, ischial level | | | | | | | |socket, non-alignable system, | | | | | | | |pylon, no cover, SACH foot, | | | | | | | |prefabricated adjustable open | | | | | | | |end socket | | | | |L5590 |NU | |Preparatory, above knee-knee |All |Y |Purchase | | |EP | |disarticulation, ischial level | | | | | | | |socket, non-alignable system, | | | | | | | |pylon, no cover, SACH foot, | | | | | | | |laminated socket, molded to | | | | | | | |model | | | | |L5595 |NU | |Preparatory, hip |All |Y |Purchase | | |EP | |disarticulation-hemipelvectomy,| | | | | | | |pylon, no cover, SACH foot, | | | | | | | |thermoplastic or equal, molded | | | | | | | |to patient model | | | | |L5600 |NU | |Preparatory, hip |All |Y |Purchase | | |EP | |disarticulation-hemipelvectomy,| | | | | | | |pylon, no cover, SACH foot, | | | | | | | |laminated socket, molded to | | | | | | | |patient model | | | | |L5610 |NU | |Addition to lower extremity, |All |Y |Purchase | | |EP | |endoskeletal system, above | | | | | | | |knee, hydracadence system | | | | |L5611 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |endoskeletal system, above | | | | | | | |knee-knee disarticulation, | | | | | | | |4-bar linkage, with friction | | | | | | | |swing phase control | | | | |L5613 |NU | |Addition to lower extremity, |All |Y |Purchase | | |EP | |endoskeletal system, above | | | | | | | |knee-knee disarticulation, | | | | | | | |4-bar linkage, with hydraulic | | | | | | | |swing phase control | | | | |L5614 |NU | |Addition to lower extremity, |21+ |Y |Purchase | | | | |endoskeletal system, above knee| | | | | | | |–knee disarticulation, 4-bar | | | | | | | |linkage, with pneumatic swing | | | | | | | |phase control | | | | |L5616 |NU | |Addition to lower extremity, |All |Y |Purchase | | |EP | |endoskeletal system above knee,| | | | | | | |universal multiplex system, | | | | | | | |friction swing phase control | | | | |L5617 |NU | |Addition to lower extremity, |21+ |Y |Purchase | | | | |quick change self-aligning | | | | | | | |unit, above or below knee, each| | | | |L5618 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |test socket, Symes | | | | |L5620 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |test socket, below knee | | | | |L5622 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |test socket, knee | | | | | | | |disarticulation | | | | |L5624 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |test socket, above knee | | | | |L5626 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |test socket, hip | | | | | | | |disarticulation | | | | |L5628 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |test socket, hemipelvectomy | | | | |L5629 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |below knee, acrylic socket | | | | |L5630 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |Symes type, expandable wall | | | | | | | |socket | | | | |L5631 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |above knee or knee | | | | | | | |disarticulation, acrylic socket| | | | |L5632 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |Symes type, “PTB” brim design | | | | | | | |socket | | | | |L5634 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |Symes type posterior opening | | | | | | | |(Canadian) socket | | | | |L5636 |NU | |Additions to lower extremity, |All |N |Purchase | | |EP | |Symes type, medial opening | | | | | | | |socket | | | | |L5637 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |below knee, total contact | | | | |L5638 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |below knee, leather socket | | | | |L5639 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |below knee, wood socket | | | | |L5640 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |knee disarticulation, leather | | | | | | | |socket | | | | |L5642 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |above knee, leather socket | | | | |L5643 |NU | |Addition to lower extremity, |All |Y |Purchase | | |EP | |hip disarticulation, flexible | | | | | | | |inner socket, external frame | | | | |L5644 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |above knee, wood socket | | | | |L5645 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |below knee, flexible inner | | | | | | | |socket, external frame | | | | |L5646 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |below knee, air, fluid, gel or | | | | | | | |equal, cushion socket | | | | |L5647 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |below knee suction socket | | | | |L5648 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |above knee, air, fluid, gel or | | | | | | | |equal, cushion socket | | | | |L5649 |NU | |Addition to lower extremity, |All |Y |Purchase | | |EP | |ischial containment/narrow M-L | | | | | | | |socket | | | | |L5650 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |total contact, above knee or | | | | | | | |knee disarticulation socket | | | | |L5651 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |above knee, flexible inner | | | | | | | |socket, external frame | | | | |L5652 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |suction suspension, above knee | | | | | | | |or knee disarticulation, socket| | | | |L5653 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |knee disarticulation, | | | | | | | |expandable wall socket | | | | |L5654 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |socket insert, Symes, (Kemblo, | | | | | | | |Pelite, Aliplast, Plastazote or| | | | | | | |equal) | | | | |L5655 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |socket insert, below knee | | | | | | | |(Kemblo, Pelite, Aliplast, | | | | | | | |Plastazote or equal) | | | | |L5656 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |socket insert, knee | | | | | | | |disarticulation (Kemblo, | | | | | | | |Pelite, Aliplast, Plastazote or| | | | | | | |equal) | | | | |L5658 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |socket insert, above knee | | | | | | | |(Kemblo, Pelite, Aliplast, | | | | | | | |Plastazote or equal) | | | | |L5661 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |socket insert, multi-durometer | | | | | | | |Symes | | | | |L5665 |EP | |Addition to lower extremity, |U21 |N/A |Purchase | | | | |socket insert, multi-durometer,| | | | | | | |below knee | | | | |L5666 |NU | |Additions to lower extremity, |All |N |Purchase | | |EP | |below knee, cuff suspension | | | | |L5668 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |below knee, molded distal | | | | | | | |cushion | | | | |L5670 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |below knee, molded | | | | | | | |supracondylar suspension (“PTS”| | | | | | | |or similar) | | | | |L5671 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |below knee/above knee, | | | | | | | |suspension locking mechanism | | | | | | | |(shuttle, lanyard or equal), | | | | | | | |excludes socket insert | | | | |L5672 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |below knee, removable medial | | | | | | | |brim suspension | | | | |L5673 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |below knee/above knee, custom | | | | | | | |fabricated from existing mold | | | | | | | |or prefabricated, socket | | | | | | | |insert, silicone gel, | | | | | | | |elastomeric or equal, for use | | | | | | | |with locking mechanism | | | | |L5676 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |below knee, knee joints, single| | | | | | | |axis, pair | | | | |L5677 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |below knee, knee joints, | | | | | | | |polycentric, pair | | | | |L5678 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |below knee, joint covers, pair | | | | |L5679 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |below knee/above knee, custom | | | | | | | |fabricated from existing mold | | | | | | | |or prefabricated, socket | | | | | | | |insert, silicone gel, | | | | | | | |elastomeric or equal, not for | | | | | | | |use with locking mechanism | | | | |L5680 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |below knee, thigh lacer, | | | | | | | |nonmolded | | | | |L5681 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |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 | | | | |L5682 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |below knee, thigh lacer, | | | | | | | |gluteal/ischial, molded | | | | |L5683 |EP | |Addition to lower extremity, |U21 |N |Purchase | | | | |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| | | | |L5684 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |below knee, fork strap | | | | |L5685 |NU | |Addition to lower extremity |All |N |Manually | | |EP | |prosthesis, below knee, | | |Priced | | | | |suspension/sealing sleeve, with| | | | | | | |or without valve, any material,| | | | | | | |each | | | | |L5686 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |below knee, back check | | | | | | | |(extension control) | | | | |L5688 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |below knee, waist belt, webbing| | | | |L5690 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |below knee, waist belt, padded | | | | | | | |and lined | | | | |L5692 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |above knee, pelvic control | | | | | | | |belt, light | | | | |L5694 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |above knee, pelvic control | | | | | | | |belt, padded and lined | | | | |L5695 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |above knee, pelvic control, | | | | | | | |sleeve suspension, neoprene or | | | | | | | |equal, each | | | | |L5696 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |above knee or knee | | | | | | | |disarticulation, pelvic joint | | | | |L5697 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |above knee or knee | | | | | | | |disarticulation, pelvic band | | | | |L5698 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |above knee or knee | | | | | | | |disarticulation, Silesian | | | | | | | |bandage | | | | |L5699 |NU | |All lower extremity prosthesis,|All |N |Purchase | | |EP | |shoulder harness | | | | |L5700 |NU | |Replacement, socket, below |21+ |Y |Purchase | | | | |knee, molded to patient model | | | | |L5701 |NU | |Replacement, socket, above |21+ |Y |Purchase | | | | |knee/knee disarticulation, | | | | | | | |including attachment plate, | | | | | | | |molded to patient model | | | | |L5702 |NU | |Replacement, socket, hip |21+ |Y |Purchase | | | | |disarticulation, including hip | | | | | | | |joint, molded to patient model | | | | |L5704 |NU | |Custom shaped protective cover,|All |N |Purchase | | |EP | |below knee | | | | |L5705 |NU | |Custom shaped protective cover,|21+ |N |Purchase | | | | |above knee | | | | |L5706 |NU | |Custom shaped protective cover,|21+ |N |Purchase | | | | |knee disarticulation | | | | |L5707 |NU | |Custom shaped protective cover,|21+ |N |Purchase | | | | |hip disarticulation | | | | |L5710 |NU | |Addition, exoskeletal knee-shin|All |N |Purchase | | |EP | |system, single axis, manual | | | | | | | |lock | | | | |L5711 |NU | |Addition exoskeletal knee-shin |All |N |Purchase | | |EP | |system, single axis, manual | | | | | | | |lock, ultra-light material | | | | |L5712 |NU | |Addition exoskeletal knee-shin |All |N |Purchase | | |EP | |system, single axis, friction | | | | | | | |swing and stance phase control | | | | | | | |(safety knee) | | | | |L5714 |NU | |Addition, exoskeletal knee-shin|All |N |Purchase | | |EP | |system, single axis, variable | | | | | | | |friction swing phase control | | | | |L5716 |NU | |Addition, exoskeletal knee-shin|All |N |Purchase | | |EP | |system, polycentric, mechanical| | | | | | | |stance phase lock | | | | |L5718 |NU | |Addition, exoskeletal knee-shin|All |N |Purchase | | |EP | |system, polycentric, friction | | | | | | | |swing and stance phase control | | | | |L5722 |NU | |Addition, exoskeletal knee-shin|All |N |Purchase | | |EP | |system, single axis, pneumatic | | | | | | | |swing, friction stance phase | | | | | | | |control | | | | |L5724 |NU | |Addition, exoskeletal knee-shin|All |Y |Purchase | | |EP | |system, single axis, fluid | | | | | | | |swing phase control | | | | |L5726 |NU | |Addition, exoskeletal knee-shin|All |Y |Purchase | | |EP | |system, single axis, external | | | | | | | |joints, fluid swing phase | | | | | | | |control | | | | |L5728 |NU | |Addition, exoskeletal knee-shin|All |Y |Purchase | | |EP | |system, single axis, fluid | | | | | | | |swing and stance phase control | | | | |L5780 |NU | |Addition, exoskeletal knee-shin|All |N |Purchase | | |EP | |system, single axis, | | | | | | | |pneumatic/hydra pneumatic swing| | | | | | | |phase control | | | | |L5785 |NU | |Addition, exoskeletal system, |All |N |Purchase | | |EP | |below knee, ultra-light | | | | | | | |material (titanium, carbon | | | | | | | |fiber or equal) | | | | |L5790 |NU | |Addition, exoskeletal system, |All |N |Purchase | | |EP | |above knee, ultra-light | | | | | | | |material (titanium, carbon | | | | | | | |fiber or equal) | | | | |L5795 |NU | |Addition, exoskeletal system, |All |N |Purchase | | |EP | |hip disarticulation, | | | | | | | |ultra-light material (titanium,| | | | | | | |carbon fiber or equal) | | | | |L5810 |NU | |Addition, endoskeletal |All |N |Purchase | | |EP | |knee-shin system, single axis, | | | | | | | |manual lock | | | | |L5811 |NU | |Addition, endoskeletal |All |N |Purchase | | |EP | |knee-shin system, single axis, | | | | | | | |manual lock, ultra-light | | | | | | | |material | | | | |L5812 |NU | |Addition, endoskeletal |All |N |Purchase | | |EP | |knee-shin system, single axis, | | | | | | | |friction swing and stance phase| | | | | | | |control (safety knee) | | | | |L5814 |NU | |Addition, endoskeletal |21+ |Y |Purchase | | | | |knee-shin system, polycentric, | | | | | | | |hydraulic swing phase control, | | | | | | | |mechanical stance phase lock | | | | |L5816 |NU | |Addition, endoskeletal |All |N |Purchase | | |EP | |knee-shin system, polycentric, | | | | | | | |mechanical stance phase lock | | | | |L5818 |NU | |Addition, endoskeletal |All |N |Purchase | | |EP | |knee-shin system, polycentric, | | | | | | | |friction swing, and stance | | | | | | | |phase control | | | | |L5822 |NU | |Addition, endoskeletal |All |Y |Purchase | | |EP | |knee-shin system, single axis, | | | | | | | |pneumatic swing, friction | | | | | | | |stance phase control | | | | |L5824 |NU | |Addition, endoskeletal |All |Y |Purchase | | |EP | |knee-shin system, single axis, | | | | | | | |fluid swing phase control | | | | |L5826 |NU | |Addition, endoskeletal |21+ |Y |Purchase | | | | |knee-shin system, single axis, | | | | | | | |hydraulic swing phase control | | | | | | | |with miniature high activity | | | | | | | |frame | | | | |L5828 |NU | |Addition, endoskeletal |All |Y |Purchase | | |EP | |knee-shin system, single axis, | | | | | | | |fluid swing and stance phase | | | | | | | |control | | | | |L5830 |NU | |Addition, endoskeletal |All |Y |Purchase | | |EP | |knee-shin system, single axis, | | | | | | | |pneumatic/swing phase control | | | | |L5840 |NU | |Addition, endoskeletal |21+ |N |Purchase | | | | |knee-shin system, 4-bar linkage| | | | | | | |or multiaxial, pneumatic swing | | | | | | | |phase control | | | | |L5845 |NU | |Addition, endoskeletal |21+ |Y |Purchase | | | | |knee-shin system, stance | | | | | | | |flexion feature, adjustable | | | | |L5850 |NU | |Addition, endoskeletal system, |All |N |Purchase | | |EP | |above knee or hip | | | | | | | |disarticulation, knee extension| | | | | | | |assist | | | | |L5855 |NU | |Addition, endoskeletal system, |21+ |N |Purchase | | | | |hip disarticulation, mechanical| | | | | | | |hip extension assist | | | | |L5910 |NU | |Addition, endoskeletal system, |All |N |Purchase | | |EP | |below knee, alignable system | | | | |L5920 |NU | |Addition, endoskeletal system, |All |N |Purchase | | |EP | |above knee or hip | | | | | | | |disarticulation, alignable | | | | | | | |system | | | | |L5925 |NU | |Addition, endoskeletal system, |21+ |N |Purchase | | | | |above knee, knee | | | | | | | |disarticulation, manual lock | | | | |L5930 |NU | |Addition, endoskeletal system, |21+ |Y |Purchase | | | | |high activity knee control | | | | | | | |frame | | | | |L5940 |NU | |Addition, endoskeletal system, |All |N |Purchase | | |EP | |below knee, ultra-light | | | | | | | |material (titanium, carbon | | | | | | | |fiber or equal) | | | | |L5950 |NU | |Addition, endoskeletal system, |All |N |Purchase | | |EP | |above knee, ultra-light | | | | | | | |material (titanium, carbon | | | | | | | |fiber or equal) | | | | |L5960 |NU | |Addition, endoskeletal system, |All |N |Purchase | | |EP | |hip disarticulation, | | | | | | | |ultra-light material (titanium,| | | | | | | |carbon fiber or equal) | | | | |L5961 |NU | |Addition, endoskeletal system, |All |N |Manually | | |EP | |polycentric hip joint, | | |Priced | | | | |pneumatic or hydraulic control,| | | | | | | |rotation control, with or | | | | | | | |without flexion, and/or | | | | | | | |extension control | | | | |L5962 |NU | |Addition, endoskeletal system, |All |N |Purchase | | |EP | |below knee, flexible protective| | | | | | | |outer surface covering system | | | | |L5964 |NU | |Addition, endoskeletal system, |21+ |N |Purchase | | | | |above knee, flexible protective| | | | | | | |outer surface covering system | | | | |L5966 |NU | |Addition, endoskeletal system, |21+ |N |Purchase | | | | |hip disarticulation, flexible | | | | | | | |protective outer surface | | | | | | | |covering system | | | | |L5968 |NU | |Addition to lower limb |21+ |Y |Purchase | | | | |prostheses, multiaxial ankle | | | | | | | |with swing phase active | | | | | | | |dorsiflexion feature | | | | |L5970 |NU | |All lower extremity prostheses,|All |N |Purchase | | |EP | |foot, external keel, SACH foot | | | | |L5972 |NU | |All lower extremity prostheses,|All |N |Purchase | | |EP | |flexible keel foot (SAFE, STEN,| | | | | | | |Bock Dynamic or equal) | | | | |L5974 |NU | |All lower extremity prostheses,|All |N |Purchase | | |EP | |foot, single axis ankle/foot | | | | |L5975 |NU | |All lower extremity prosthesis,|21+ |N |Purchase | | | | |combination single axis ankle | | | | | | | |and flexible keel foot | | | | |L5976 |NU | |All lower extremity prostheses,|All |N |Purchase | | |EP | |energy storing foot (Seattle | | | | | | | |Carbon Copy II or equal) | | | | |L5978 |NU | |All lower extremity prostheses,|All |N |Purchase | | |EP | |foot, multiaxial ankle/foot | | | | |L5979 |NU | |All lower extremity prostheses,|All |Y |Purchase | | |EP | |multi-axial ankle, dynamic | | | | | | | |response foot, one piece system| | | | |L5980 |NU | |All lower extremity prostheses,|All |Y |Purchase | | |EP | |flex-foot system | | | | |L5981 |NU | |All lower extremity prostheses,|All |Y |Purchase | | |EP | |flex-walk system or equal | | | | |L5982 |NU | |All exoskeletal lower extremity|All |N |Purchase | | |EP | |prostheses, axial rotation unit| | | | |L5984 |NU | |All endoskeletal lower |All |N |Purchase | | |EP | |extremity prosthesis, axial | | | | | | | |rotation unit, with or without | | | | | | | |adjustability | | | | |L5985 |NU | |All endoskeletal lower |21+ |N |Purchase | | | | |extremity prostheses, dynamic | | | | | | | |prosthetic pylon | | | | |L5986 |NU | |All lower extremity prostheses,|All |N |Purchase | | |EP | |multi-axial rotation unit | | | | | | | |(“MCP” or equal) | | | | |L5987 |NU | |All lower extremity prostheses,|21+ |Y |Purchase | | | | |shank foot system with vertical| | | | | | | |loading pylon | | | | |L5988 |NU | |Addition to lower limb |21+ |Y |Purchase | | | | |prosthesis, vertical shock | | | | | | | |reducing pylon feature | | | | |L5999 |NU | |((Unlisted Prosthetic Devices |All |Y |Manually | | | | |or Orthotic Appliances; the | | |Priced | | |EP | |manufacturer’s invoice must be | | |Manually | | | | |attached to all claims.) Lower| | |Priced | | | | |extremity prosthesis, not | | | | | | | |otherwise specified | | | | |L6000 |NU | |Partial hand, Robin-Aids, thumb|All |N |Purchase | | |EP | |remaining (or equal) | | | | |L6010 |NU | |Partial hand, Robin-Aids, |All |N |Purchase | | |EP | |little and/or ring finger | | | | | | | |remaining (or equal) | | | | |L6020 |NU | |Partial hand, Robin-Aids, no |All |N |Purchase | | |EP | |finger remaining (or equal) | | | | |L6050 |NU | |Wrist disarticulation, molded |All |Y |Purchase | | |EP | |socket, flexible elbow hinges, | | | | | | | |triceps pad | | | | |L6055 |NU | |Wrist disarticulation, molded |All |Y |Purchase | | |EP | |socket with expandable | | | | | | | |interface, flexible elbow | | | | | | | |hinges, triceps pad | | | | |L6100 |NU | |Below elbow, molded socket, |All |Y |Purchase | | |EP | |flexible elbow hinge, triceps | | | | | | | |pad | | | | |L6110 |NU | |Below elbow, molded socket |All |Y |Purchase | | |EP | |(Muenster or Northwestern | | | | | | | |suspension types) | | | | |L6120 |NU | |Below elbow, molded double wall|All |Y |Purchase | | |EP | |split socket, step-up hinges, | | | | | | | |half cuff | | | | |L6130 |NU | |Below elbow, molded double wall|All |Y |Purchase | | |EP | |split socket, stump activated | | | | | | | |locking hinge, half cuff | | | | |L6200 |NU | |Elbow disarticulation, molded |All |Y |Purchase | | |EP | |socket, outside locking hinge, | | | | | | | |forearm | | | | |L6205 |NU | |Elbow disarticulation, molded |All |Y |Purchase | | |EP | |socket with expandable | | | | | | | |interface, outside locking | | | | | | | |hinges, forearm | | | | |L6250 |NU | |Above elbow, molded double wall|All |Y |Purchase | | |EP | |socket, internal locking elbow,| | | | | | | |forearm | | | | |L6300 |NU | |Shoulder disarticulation, |All |Y |Purchase | | |EP | |molded socket, shoulder | | | | | | | |bulkhead, humeral section, | | | | | | | |internal locking elbow, forearm| | | | |L6310 |NU | |Shoulder disarticulation, |All |Y |Purchase | | |EP | |passive restoration (complete | | | | | | | |prosthesis) | | | | |L6320 |NU | |Shoulder disarticulation, |All |Y |Purchase | | |EP | |passive restoration (shoulder | | | | | | | |cap only) | | | | |L6350 |NU | |Interscapular thoracic, molded |All |Y |Purchase | | |EP | |socket, shoulder bulkhead, | | | | | | | |humeral section, internal | | | | | | | |locking elbow, forearm | | | | |L6360 |NU | |Interscapular thoracic, passive|All |Y |Purchase | | |EP | |restoration (complete | | | | | | | |prosthesis) | | | | |L6370 |NU | |Interscapular thoracic, passive|All |Y |Purchase | | |EP | |restoration (shoulder cap only)| | | | |L6380 |NU | |Immediate post-surgical or |All |N |Purchase | | |EP | |early fitting, application of | | | | | | | |initial rigid dressing, | | | | | | | |including fitting alignment and| | | | | | | |suspension of components, and | | | | | | | |one cast change, wrist | | | | | | | |disarticulation or below elbow | | | | |L6382 |NU | |Immediate post-surgical or |All |N |Purchase | | |EP | |early fitting, application of | | | | | | | |initial rigid dressing | | | | | | | |including fitting alignment and| | | | | | | |suspension of components, and | | | | | | | |one cast change, elbow | | | | | | | |disarticulation or above elbow | | | | |L6384 |NU | |Immediate post-surgical or |All |Y |Purchase | | |EP | |early fitting, application of | | | | | | | |initial rigid dressing | | | | | | | |including fitting alignment and| | | | | | | |suspension of components, and | | | | | | | |one cast change, shoulder | | | | | | | |disarticulation or | | | | | | | |interscapular thoracic | | | | |L6386 |NU | |Immediate post-surgical or |All |N |Purchase | | |EP | |early fitting, each additional | | | | | | | |cast change and realignment | | | | |L6388 |NU | |Immediate post-surgical or |All |N |Purchase | | |EP | |early fitting, application of | | | | | | | |rigid dressing only | | | | |L6400 |NU | |Below elbow, molded socket, |All |Y |Purchase | | |EP | |endoskeletal system, including | | | | | | | |soft prosthetic tissue shaping | | | | |L6450 |NU | |Elbow disarticulation, molded |All |Y |Purchase | | |EP | |socket, endoskeletal system, | | | | | | | |including soft prosthetic | | | | | | | |tissue shaping | | | | |L6500 |NU | |Above elbow, molded socket, |All |Y |Purchase | | |EP | |endoskeletal system, including | | | | | | | |soft prosthetic tissue shaping | | | | |L6550 |NU | |Shoulder disarticulation, |All |Y |Purchase | | |EP | |molded socket, endoskeletal | | | | | | | |system, including soft | | | | | | | |prosthetic tissue shaping | | | | |L6570 |NU | |Interscapular thoracic, molded |All |Y |Purchase | | |EP | |socket, endoskeletal system | | | | | | | |including soft prosthetic | | | | | | | |tissue shaping | | | | |L6580 |NU | |Preparatory, wrist |All |Y |Purchase | | |EP | |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 | | | | |L6582 |NU | |Preparatory, wrist |All |N |Purchase | | |EP | |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 | | | | |L6584 |NU | |Preparatory, elbow |All |Y |Purchase | | |EP | |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 | | | | |L6586 |NU | |Preparatory, elbow |All |Y |Purchase | | |EP | |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 | | | | |L6588 |NU | |Preparatory, shoulder |All |Y |Purchase | | |EP | |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 | | | | |L6590 |NU | |Preparatory, shoulder |All |Y |Purchase | | |EP | |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 | | | | |L6600 |NU | |Upper extremity additions, |All |N |Purchase | | |EP | |polycentric hinge, pair | | | | |L6605 |NU | |Upper extremity additions, |All |N |Purchase | | |EP | |single pivot hinge, pair | | | | |L6610 |NU | |Upper extremity additions, |All |N |Purchase | | |EP | |flexible metal hinge, pair | | | | |L6615 |NU | |Upper extremity addition, |All |N |Purchase | | |EP | |disconnect locking wrist unit | | | | |L6616 |NU | |Upper extremity addition, |All |N |Purchase | | |EP | |additional disconnect insert | | | | | | | |for locking wrist unit, each | | | | |L6620 |NU | |Upper extremity addition, |All |N |Purchase | | |EP | |flexion/extension wrist unit, | | | | | | | |with or without friction | | | | |L6623 |NU | |Upper extremity addition, |All |N |Purchase | | |EP | |spring assisted rotational | | | | | | | |wrist unit with latch release | | | | |L6624 |NU | |Upper extremity addition, |All |Y |Purchase | | |EP | |flexion/extension and rotation | | | | | | | |wrist unit | | | | |L6625 |NU | |Upper extremity addition, |All |N |Purchase | | |EP | |rotation wrist unit with cable | | | | | | | |lock | | | | |L6628 |NU | |Upper extremity addition, quick|All |N |Purchase | | |EP | |disconnect hook adapter, Otto | | | | | | | |Bock or equal | | | | |L6629 |NU | |Upper extremity addition, quick|All |N |Purchase | | |EP | |disconnect lamination collar | | | | | | | |with coupling piece, Otto Bock | | | | | | | |or equal | | | | |L6630 |NU | |Upper extremity addition, |All |N |Purchase | | |EP | |stainless steel, any wrist | | | | |L6632 |NU | |Upper extremity addition, latex|All |N |Purchase | | |EP | |suspension sleeve, each | | | | |L6635 |NU | |Upper extremity additions, lift|All |N |Purchase | | |EP | |assist for elbow | | | | |L6637 |NU | |Upper extremity addition, nudge|All |N |Purchase | | |EP | |control elbow lock | | | | |L6640 |NU | |Upper extremity additions, |All |N |Purchase | | |EP | |shoulder abduction joint, pair | | | | |L6641 |NU | |Upper extremity addition, |All |N |Purchase | | |EP | |excursion amplifier, pulley | | | | | | | |type | | | | |L6642 |NU | |Upper extremity addition, |All |N |Purchase | | |EP | |excursion amplifier, lever type| | | | |L6645 |NU | |Upper extremity addition, |All |N |Purchase | | |EP | |shoulder flexion-abduction | | | | | | | |joint, each | | | | |L6650 |NU | |Upper extremity addition, |All |N |Purchase | | |EP | |shoulder universal joint, each | | | | |L6655 |NU | |Upper extremity addition, |All |N |Purchase | | |EP | |standard control cable, extra | | | | |L6660 |NU | |Upper extremity addition, |All |N |Purchase | | |EP | |heavy-duty control cable | | | | |L6665 |NU | |Upper extremity addition, |All |N |Purchase | | |EP | |Teflon, or equal, cable lining | | | | |L6670 |NU | |Upper extremity addition, hook |All |N |Purchase | | |EP | |to hand cable adapter | | | | |L6672 |NU | |Upper extremity addition, |All |N |Purchase | | |EP | |harness, chest or shoulder, | | | | | | | |saddle type | | | | |L6675 |NU | |Upper extremity addition, |All |N |Purchase | | |EP | |harness, (e.g., figure of eight| | | | | | | |type), single cable design | | | | |L6676 |NU | |Upper extremity additions, |All |N |Purchase | | |EP | |harness, (e.g., figure of eight| | | | | | | |type), dual cable design | | | | |L6680 |NU | |Upper extremity addition, test |All |N |Purchase | | |EP | |socket, wrist disarticulation | | | | | | | |or below elbow | | | | |L6682 |NU | |Upper extremity addition, test |All |N |Purchase | | |EP | |socket, elbow disarticulation | | | | | | | |or above elbow | | | | |L6684 |NU | |Upper extremity addition, test |All |N |Purchase | | |EP | |socket, shoulder | | | | | | | |disarticulation or | | | | | | | |interscapular thoracic | | | | |L6686 |NU | |Upper extremity addition, |All |N |Purchase | | |EP | |suction socket | | | | |L6687 |NU | |Upper extremity addition, frame|All |N |Purchase | | |EP | |type socket, below elbow or | | | | | | | |wrist disarticulation | | | | |L6688 |NU | |Upper extremity addition, frame|All |N |Purchase | | |EP | |type socket, above elbow or | | | | | | | |elbow disarticulation | | | | |L6689 |NU | |Upper extremity addition, frame|All |N |Purchase | | |EP | |type socket, shoulder | | | | | | | |disarticulation | | | | |L6690 |NU | |Upper extremity addition, frame|All |N |Purchase | | |EP | |type socket, | | | | | | | |interscapular-thoracic | | | | |L6691 |NU | |Upper extremity addition, |All |N |Purchase | | |EP | |removable insert, each | | | | |L6692 |NU | |Upper extremity addition, |All |N |Purchase | | |EP | |silicone gel insert or equal, | | | | | | | |each | | | | |L6693 |NU | |Upper extremity addition, |21+ |Y |Purchase | | | | |locking elbow, forearm | | | | | | | |counterbalance | | | | |L67031 |NU | |Terminal device, passive |All |N |Purchase | | |EP | |hand/mitt, any material, any | | | | | | | |size | | | | |L67041 |NU | |Terminal device, |All |N |Purchase | | |EP | |sport/recreational/work | | | | | | | |attachment, any material, any | | | | | | | |size | | | | |L67061 |NU | |Terminal device, hook, |All |N |Purchase | | |EP | |mechanical, voluntary opening, | | | | | | | |any material, any size, lined | | | | | | | |or unlined | | | | |L67071 |NU | |Terminal device, hook, |All |N |Purchase | | |EP | |mechanical, voluntary closing, | | | | | | | |any material, any size, lined | | | | | | | |or unlined | | | | |L67081 |NU | |Terminal device, hand, |All |N |Purchase | | |EP | |mechanical, voluntary opening, | | | | | | | |any material, any size | | | | |L67091 |NU | |Terminal device, hand, |All |N |Purchase | | |EP | |mechanical, voluntary closing, | | | | | | | |any material, any size | | | | |L6711 |EP | |Terminal device, hook, |U21 |Y |Purchase | | | | |mechanical, voluntary opening, | | | | | | | |any material, any size, lined | | | | | | | |or unlined, pediatric | | | | |L6712 |EP | |Terminal device, hook, |U21 |Y |Purchase | | | | |mechanical, voluntary closing, | | | | | | | |any material, any size, lined | | | | | | | |or unlined, pediatric | | | | |L6713 |EP | |Terminal device, hand, |U21 |Y |Purchase | | | | |mechanical, voluntary opening, | | | | | | | |any material, any size, | | | | | | | |pediatric | | | | |L6714 |EP | |Terminal device, hand, |U21 |N/A |Purchase | | | | |mechanical, voluntary closing, | | | | | | | |any material, any size, | | | | | | | |pediatric | | | | |L6721 |NU | |Terminal device, hook or hand, |21+ |Y |Purchase | | | | |heavy-duty, mechanical, | | | | | | | |voluntary opening, any | | | | | | | |material, any size, lined or | | | | | | | |unlined | | | | |L6722 |NU | |Terminal device, hook or hand, |21+ |Y |Purchase | | | | |heavy-duty, mechanical, | | | | | | | |voluntary closing, any | | | | | | | |material, any size, lined or | | | | | | | |unlined | | | | |L6805 |NU | |Terminal device, modifier wrist|All |N |Purchase | | |EP | |flexion unit | | | | |L6810 |NU | |Terminal device, pincher tool, |All |N |Purchase | | |EP | |Otto Bock or equal | | | | |L6880 |NU | |Electric hand, switch or |All |Y |Purchase | | |EP | |myoelectric controlled, | | | | | | | |independently articulating | | | | | | | |digits, any grasp pattern or | | | | | | | |combination of grasp patterns, | | | | | | | |includes motor(s) | | | | |L6890 |NU | |Terminal device, gloves for |All |N |Purchase | | |EP | |above hands, production glove | | | | |L6895 |NU | |Terminal device, glove for |All |N |Purchase | | |EP | |above hands, custom glove | | | | |L6900 |NU | |Hand restoration (casts, |All |N |Purchase | | |EP | |shading and measurements | | | | | | | |included), partial hand, with | | | | | | | |glove, thumb or one finger | | | | | | | |remaining | | | | |L6905 |NU | |Hand restoration (casts, |All |N |Purchase | | |EP | |shading and measurements | | | | | | | |included), partial hand, with | | | | | | | |glove, multiple fingers | | | | | | | |remaining | | | | |L6910 |NU | |Hand restoration (casts, |All |N |Purchase | | |EP | |shading and measurements | | | | | | | |included), partial hand, with | | | | | | | |glove, no fingers remaining | | | | |L6915 |NU | |Hand restoration (shading and |All |N |Purchase | | |EP | |measurements included), | | | | | | | |replacement glove for above | | | | |L6920* |NU | |Wrist disarticulation, external|All |Y |Purchase | | |EP | |power, self-suspended inner | | | | | | | |socket, removable forearm | | | | | | | |shell, Otto Bock or equal, | | | | | | | |switch, cables, two batteries | | | | | | | |and one charger, switch control| | | | | | | |of terminal device | | | | |L6925* |NU | |Wrist disarticulation, external|All |Y |Purchase | | |EP | |power, self-suspended inner | | | | | | | |socket, removable forearm | | | | | | | |shell, Otto Bock or equal | | | | | | | |electrodes, cables, two | | | | | | | |batteries and one charger, | | | | | | | |myoelectronic control of | | | | | | | |terminal device | | | | |L6930* |NU | |Below elbow, external power, |All |Y |Purchase | | |EP | |self-suspended inner socket, | | | | | | | |removable forearm shell, Otto | | | | | | | |Bock or equal switch, cables, | | | | | | | |two batteries and one charger, | | | | | | | |switch control of terminal | | | | | | | |device | | | | |L6935* |NU | |Below elbow, external power, |All |Y |Purchase | | |EP | |self-suspended inner socket, | | | | | | | |removable forearm shell, Otto | | | | | | | |Bock or equal electrodes, | | | | | | | |cables, two batteries and one | | | | | | | |charger, myoelectronic control | | | | | | | |of terminal device | | | | |L6940* |NU | |Elbow disarticulation, external|All |Y |Purchase | | |EP | |power, molded inner socket, | | | | | | | |removable humeral shell, | | | | | | | |outside locking hinges, | | | | | | | |forearm, Otto Bock or equal | | | | | | | |switch, cables, two batteries | | | | | | | |and one charger, switch control| | | | | | | |of terminal device | | | | |L6945* |NU | |Elbow disarticulation, external|All |Y |Purchase | | |EP | |power, molded inner socket, | | | | | | | |removable humeral shell, | | | | | | | |outside locking hinges, | | | | | | | |forearm, Otto Bock or equal | | | | | | | |electrodes, cables, two | | | | | | | |batteries and one charger, | | | | | | | |myoelectronic control of | | | | | | | |terminal device | | | | |L6950* |NU | |Above elbow, external power, |All |Y |Purchase | | |EP | |molded inner socket, removable | | | | | | | |humeral shell, internal locking| | | | | | | |elbow, forearm, Otto Bock or | | | | | | | |equal switch, cables, two | | | | | | | |batteries and one charger, | | | | | | | |switch control of terminal | | | | | | | |device | | | | |L6955* |NU | |Above elbow, external power, |All |Y |Purchase | | |EP | |molded inner socket, removable | | | | | | | |humeral shell, internal locking| | | | | | | |elbow, forearm, Otto Bock or | | | | | | | |equal electrodes, cables, two | | | | | | | |batteries and one charger, | | | | | | | |myoelectronic control of | | | | | | | |terminal device | | | | |L6960* |NU | |Shoulder disarticulation, |All |Y |Purchase | | |EP | |external power, molded inner | | | | | | | |socket, removable shoulder | | | | | | | |shell, shoulder bulkhead, | | | | | | | |humeral section, mechanical | | | | | | | |elbow, forearm, Otto Bock or | | | | | | | |equal switch, cables, two | | | | | | | |batteries and one charger, | | | | | | | |switch control of terminal | | | | | | | |device | | | | |L6965* |NU | |Shoulder disarticulation, |All |Y |Purchase | | |EP | |external power, molded inner | | | | | | | |socket, removable shoulder | | | | | | | |shell, shoulder bulkhead, | | | | | | | |humeral section, mechanical | | | | | | | |elbow, forearm, Otto Bock or | | | | | | | |equal electrodes, cables, two | | | | | | | |batteries and one charger, | | | | | | | |myoelectronic control of | | | | | | | |terminal device | | | | |L6970* |NU | |Interscapular-thoracic, |All |Y |Purchase | | |EP | |external power, molded inner | | | | | | | |socket, removable shoulder | | | | | | | |shell, shoulder bulkhead, | | | | | | | |humeral section, mechanical | | | | | | | |elbow, forearm, Otto Bock or | | | | | | | |equal switch, cables, two | | | | | | | |batteries and one charger, | | | | | | | |switch control of terminal | | | | | | | |device | | | | |L6975* |NU | |Interscapular-thoracic, |All |Y |Purchase | | |EP | |external power, molded inner | | | | | | | |socket, removable shoulder | | | | | | | |shell, shoulder bulkhead, | | | | | | | |humeral section, mechanical | | | | | | | |elbow, forearm, Otto Bock or | | | | | | | |equal electrodes, cables, two | | | | | | | |batteries and one charger, | | | | | | | |myoelectronic control of | | | | | | | |terminal device | | | | |L70071* |NU | |Electric hand, switch or |All |Y |Purchase | | |EP | |myoelectric controlled, adult | | | | |L70081* |NU | |Electric hand, switch or |All |Y |Purchase | | |EP | |myoelectric, controlled, | | | | | | | |pediatric | | | | |L7009 |NU | |Electric hook, switch or |All |Y |Purchase | | |EP | |myoelectric controlled, adult | | | | |L7040* |NU | |Prehensile actuator, Hosmer or |All |Y |Purchase | | |EP | |equal, switch controlled | | | | |L7045* |NU | |Electronic hook, child, |All |Y |Purchase | | |EP | |Michigan or equal, switch | | | | | | | |controlled | | | | |L7170* |NU | |Electronic elbow, Hosmer or |All |Y |Purchase | | |EP | |equal, switch controlled | | | | |L7180* |NU | |Electronic elbow, Utah or |All |Y |Purchase | | |EP | |equal, myoelectronically | | | | | | | |controlled | | | | |L7185 |EP | |Electronic elbow, adolescent, |U21 |N/A |Purchase | | | | |Variety Village or equal, | | | | | | | |switch controlled | | | | |L7186 |EP | |Electronic elbow, child, |U21 |N/A |Purchase | | | | |Variety Village or equal, | | | | | | | |switch controlled | | | | |L7190 |EP | |Electronic elbow, adolescent, |U21 |N/A |Purchase | | | | |Variety Village or equal, | | | | | | | |myoelectronically controlled | | | | |L7191 |EP | |Electronic elbow, child, |U21 |N/A |Purchase | | | | |Variety Village or equal, | | | | | | | |myoelectronically controlled | | | | |L7260* |NU | |Electronic wrist rotator, Otto |All |Y |Purchase | | |EP | |Bock or equal | | | | |L7261* |NU | |Electronic wrist rotator, for |All |Y |Purchase | | |EP | |Utah arm | | | | |L7360* |NU | |Six volt battery, Otto Bock or |All |N |Purchase | | |EP | |equal, each | | | | |L7362* |NU | |Battery charger, six volt, Otto|All |N |Purchase | | |EP | |Bock or equal | | | | |L7364* |NU | |Twelve volt battery, Utah or |All |N |Purchase | | |EP | |equal, each | | | | |L7366* |NU | |Battery charger, twelve volt, |All |N |Purchase | | |EP | |Utah or equal | | | | |L7499 |NU | |((Unlisted Prosthetic Devices |All |Y |Manually | | | | |or Orthotic Appliances; the | | |Priced | | |EP | |manufacturer’s invoice must be | | |Manually | | | | |attached to all claims.) Upper| | |Priced | | | | |extremity prosthesis, NOS | | | | |L7510 |NU | |((Orthotics and Prosthetics |All |Y |Manually | | | | |Repairs) Repair of prosthetic | | |Priced | | |EP |UB |device, repair or replace minor| | |Purchase | | | | |parts | | | | |L7510 |NU | |((Twister cables - |All |N |Manually | | | | |repair/replace) Repair of | | |Priced | | |EP | |prosthetic device, repair or | | |Purchase | | | | |replace minor parts | | | | |L7520 |NU | |((Orthotics and Prosthetics |All |Y |Manually | | | | |Repairs) Repair prosthetic | | |Priced | | |EP | |device, labor component, per 15| | |Purchase | | | | |minutes | | | | |L8000 |NU | |Breast prosthesis, mastectomy |All |N |Purchase | | |EP | |bra | | | | |L8010 |NU | |Breast prosthesis, mastectomy |All |N |Purchase | | |EP | |sleeve | | | | |L8015 |NU | |External breast prosthesis |21+ |N |Purchase | | | | |garment, with mastectomy form, | | | | | | | |post-mastectomy | | | | |L8020 |NU | |Breast prosthesis, mastectomy |All |N |Purchase | | |EP | |form | | | | |L8030 |NU | |Breast prosthesis, silicone or |All |N |Purchase | | |EP | |equal | | | | |L8031 |NU | |Breast prosthesis, silicone or |All |N |Purchase | | |EP | |equal, with integral adhesive | | | | |L8032 |NU | |Nipple prosthesis, reusable, |All |N |Purchase | | |EP | |any type, each | | | | |L8300 |NU | |Truss, single with standard pad|All |N |Purchase | | |EP | | | | | | |L8310 |NU | |Truss, double with standard |All |N |Purchase | | |EP | |pads | | | | |L8320 |NU | |Truss, addition to standard |All |N |Purchase | | |EP | |pad, water pad | | | | |L8330 |NU | |Truss, addition to standard |All |N |Purchase | | |EP | |pad, scrotal pad | | | | |L8400 |NU | |Prosthetic sheath, below knee, |All |N |Purchase | | |EP | |each | | | | |L8410 |NU | |Prosthetic sheath, above knee, |All |N |Purchase | | |EP | |each | | | | |L8415 |NU | |Prosthetic sheath, upper limb, |All |N |Purchase | | |EP | |each | | | | |L8417 |NU | |Prosthetic sheath/sock, |21+ |N |Purchase | | | | |including a gel cushion layer, | | | | | | | |below knee or above knee, each | | | | |L8420 |NU | |Prosthetic sock, multiple ply, |All |N |Purchase | | |EP | |below knee, each | | | | |L8430 |NU | |Prosthetic sock, multiple ply, |All |N |Purchase | | |EP | |above knee, each | | | | |L8435 |NU | |Prosthetic sock, multiple ply |All |N |Purchase | | |EP | |upper limb, each | | | | |L8440 |NU | |Prosthetic shrinker, below |All |N |Purchase | | |EP | |knee, each | | | | |L8460 |NU | |Prosthetic shrinker, above |All |N |Purchase | | |EP | |knee, each | | | | |L8465 |NU | |Prosthetic shrinker, upper |All |N |Purchase | | |EP | |limb, each | | | | |L8470 |NU | |Prosthetic sock, single ply, |All |N |Purchase | | |EP | |fitting below knee, each | | | | |L8480 |NU | |Prosthetic sock, single ply |All |N |Purchase | | |EP | |fitting, above knee, each | | | | |L8485 |NU | |Prosthetic sock, single ply, |21+ |N |Purchase | | | | |fitting, upper limb, each | | | | |L8499 |NU | |((Unlisted Prosthetic Devices |All |Y |Manually | | | | |or Orthotic Appliances; the | | |Priced | | |EP | |manufacturer’s invoice must be | | |Manually | | | | |attached to all claims.) | | |Priced | | | | |Unlisted procedure for | | | | | | | |miscellaneous prosthetic | | | | | | | |services | | | | |L8500 |NU | |Artificial larynx, any type |All |N |Purchase | | |EP | | | | | | |L8501 |NU | |Tracheostomy speaking valve |All |N |Purchase | | |EP | | | | | | |L8600 |EP | |Implantable breast prosthesis, |U21 |N |Manually | | | | |silicone or equal | | |Priced | |L8605 |NU | |Injectable bulking agent, |18+ |N |Manually | | | | |dextranomer/hyaluronic acid | | |Priced | | | | |copolymer implant, anal canal, | | | | | | | |1ml, includes shipping and | | | | | | | |necessary supplies (covered | | | | | | | |only for ages 18 and over) | | | | |L8693 |EP | |Auditory osseointegrated device|U21 |N |Manually | | | | |abutment, any length, | | |Priced | | | | |replacement only | | | | |V2623 |NU | |Prosthetic eye, plastic, custom|All |Y |Purchase | |V2624 |NU | |Polishing/resurfacing of ocular|All |Y |Purchase | | | | |prosthesis | | | | |V2625 |NU | |Enlargement of ocular |All |Y |Purchase | | | | |prosthesis | | | | |V2626 |NU | |Reduction of ocular prosthesis |All |Y |Purchase | |V2628 |NU | |Fabrication and fitting of |All |N |Purchase | | | | |ocular conformer | | | | |Prosthetic Devices, All Ages (Section 242.190) | |Procedure |M1 |M2 |Description |All |PA |Payment | |Code | | | |U21 |21+ |Method | | | | | |21+ | | | |L1499 |NU | |((Unlisted Prosthetic Devices |All |Y |Manually | | | | |or Orthotic Appliances; the | | |Priced | | |EP | |manufacturer’s invoice must be | | |Manually | | | | |attached to all claims.) | | |Priced | | | | |Spinal orthosis, not otherwise | | | | | | | |specified | | | | |L2999 |NU | |((Unlisted Prosthetic Devices |All |Y |Manually | | | | |or Orthotic Appliances; the | | |Priced | | |EP | |manufacturer’s invoice must be | | |Manually | | | | |attached to all claims.) Lower| | |Priced | | | | |extremity orthoses, NOS | | | | |L3649 |NU | |Orthopedic shoe, modification, |All |N |Purchase | | |EP | |addition or transfer, NOS | | | | |L3649 |NU |U1 |((Unlisted Prosthetic Devices |All |Y |Manually | | | | |or Orthotic Appliances; the | | |Priced | | |EP |U1 |manufacturer’s invoice must be | | |Manually | | | | |attached to all claims.) | | |Priced | | | | |Orthopedic shoe, modification, | | | | | | | |addition or transfer, NOS | | | | |L3999 |NU | |((Unlisted Prosthetic Devices |All |Y |Manually | | | | |or Orthotic Appliances; the | | |Priced | | |EP | |manufacturer’s invoice must be | | |Manually | | | | |attached to all claims.) Upper| | |Priced | | | | |limb orthosis, NOS | | | | |L4205 |NU | |((Orthotics and Prosthetics |All |Y |Manually | | | | |Repairs) Repair of orthotic | | |Priced | | |EP | |device, labor component, per 15| | |Purchase | | | | |minutes | | | | |L4210 |NU | |((Orthotics and Prosthetics |All |Y |Manually | | | | |Repairs) Repair of orthotic | | |Priced | | |EP | |device, repair or replace minor| | |Purchase | | | | |parts | | | | |L4386 |NU | |Walking boot, nonpneumatic, |All |N |Purchase | | |EP | |with or without joints, with or| | | | | | | |without interface material, | | | | | | | |prefabricated, includes fitting| | | | | | | |and adjustment | | | | |L4631 |NU | |Ankle foot orthosis, walking |All |N |Purchase | | |EP | |boot type, varus/valgas | | | | | | | |correction, rocker bottom, | | | | | | | |anterior tibial shell, soft | | | | | | | |interface, custom arch support,| | | | | | | |plastic or other material, | | | | | | | |includes straps and closures, | | | | | | | |custom fabricated | | | | |L5000 |NU | |Partial foot, shoe insert with |All |N |Purchase | | |EP | |longitudinal arch, toe filler | | | | |L5010 |NU | |Partial foot, molded socket, |All |Y |Purchase | | |EP | |ankle height, with toe filler | | | | |L5020 |NU | |Partial foot, molded socket, |All |Y |Purchase | | |EP | |tibial tubercle height, with | | | | | | | |toe filler | | | | |L5050 |NU | |Ankle, Symes, molded socket, |All |Y |Purchase | | |EP | |SACH foot | | | | |L5060 |NU | |Ankle, Symes, metal frame, |All |Y |Purchase | | |EP | |molded leather socket, | | | | | | | |articulated ankle/foot | | | | |L5100 |NU | |Below knee, molded socket, |All |Y |Purchase | | |EP | |shin, SACH foot | | | | |L5105 |NU | |Below knee, plastic socket, |All |Y |Purchase | | |EP | |joints and thigh lacer, SACH | | | | | | | |foot | | | | |L5150 |NU | |Knee disarticulation (or |All |Y |Purchase | | |EP | |through knee), molded socket, | | | | | | | |external knee joints, shin, | | | | | | | |SACH foot | | | | |L5160 |NU | |Knee disarticulation (or |All |Y |Purchase | | |EP | |through knee), molded socket, | | | | | | | |bent knee configuration, | | | | | | | |external knee joints, shin, | | | | | | | |SACH foot | | | | |L5200 |NU | |Above knee, molded socket, |All |Y |Purchase | | |EP | |single axis constant friction | | | | | | | |knee, shin, SACH foot | | | | |L5210 |NU | |Above knee, short prosthesis, |All |Y |Purchase | | |EP | |no knee joint (“stubbies”), | | | | | | | |with foot blocks, no ankle | | | | | | | |joints, each | | | | |L5220 |NU | |Above knee, short prosthesis, |All |Y |Purchase | | |EP | |no knee joint (“stubbies”), | | | | | | | |with articulated ankle/foot, | | | | | | | |dynamically aligned, each | | | | |L5230 |NU | |Above knee, for proximal |All |Y |Purchase | | |EP | |femoral focal deficiency, | | | | | | | |constant friction knee, shin, | | | | | | | |SACH foot | | | | |L5250 |NU | |Hip disarticulation, Canadian |All |Y |Purchase | | |EP | |type, molded socket, hip joint,| | | | | | | |single axis constant friction | | | | | | | |knee, shin, SACH foot | | | | |L5270 |NU | |Hip disarticulation, tilt table|All |Y |Purchase | | |EP | |type, molded socket, locking | | | | | | | |hip joint, single axis constant| | | | | | | |friction knee, shin, SACH foot | | | | |L5280 |NU | |Hemipelvectomy, Canadian type, |All |Y |Purchase | | |EP | |molded socket, hip joint, | | | | | | | |single axis constant friction | | | | | | | |knee, shin, SACH foot | | | | |L5301 |NU | |Below knee, molded socket, |All |Y |Purchase | | |EP | |shin, SACH foot, endoskeletal | | | | | | | |system | | | | |L5312 |NU | |Knee disarticulation (or |All |Y |Purchase | | |EP | |through knee), molded socket, | | | | | | | |single axis knee, pylon, SACH | | | | | | | |foot, endoskeletal system | | | | |L5321 |NU | |Above knee, molded socket, open|All |Y |Purchase | | |EP | |end, SACH foot, endoskeletal | | | | | | | |system, single axis knee | | | | |L5331 |NU | |Hip disarticulation, Canadian |All |Y |Purchase | | |EP | |type, molded socket, | | | | | | | |endoskeletal system, hip joint,| | | | | | | |single axis knee, SACH foot | | | | |L5341 |NU | |Hemipelvectomy, Canadian type, |All |Y |Purchase | | |EP | |molded socket, endoskeletal | | | | | | | |system, hip joint, single axis | | | | | | | |knee, SACH foot | | | | |L5400 |NU | |Immediate post-surgical or |All |N |Purchase | | |EP | |early fitting, application of | | | | | | | |initial rigid dressing, | | | | | | | |including fitting, alignment, | | | | | | | |suspension, and one cast | | | | | | | |change, below knee | | | | |L5410 |NU | |Immediate post-surgical or |All |N |Purchase | | |EP | |early fitting, application of | | | | | | | |initial rigid dressing, | | | | | | | |including fitting, alignment | | | | | | | |and suspension, below knee, | | | | | | | |each additional cast change and| | | | | | | |realignment | | | | |L5420 |NU | |Immediate post-surgical or |All |Y |Purchase | | |EP | |early fitting, application of | | | | | | | |initial rigid dressing, | | | | | | | |including fitting, alignment | | | | | | | |and suspension, and one cast | | | | | | | |change “AK” or knee | | | | | | | |disarticulation | | | | |L5430 |NU | |Immediate post-surgical or |All |N |Purchase | | |EP | |early fitting, application of | | | | | | | |initial rigid dressing, | | | | | | | |including fitting, alignment | | | | | | | |and suspension , “AK” or knee | | | | | | | |disarticulation, each | | | | | | | |additional cast change and | | | | | | | |realignment | | | | |L5450 |NU | |Immediate post-surgical or |All |N |Purchase | | |EP | |early fitting, application of | | | | | | | |nonweight bearing rigid | | | | | | | |dressing, below knee | | | | |L5460 |NU | |Immediate post-surgical or |All |N |Purchase | | |EP | |early fitting, application of | | | | | | | |nonweight bearing rigid | | | | | | | |dressing, above knee | | | | |L5500 |NU | |Initial, below knee (“PTB” |All |N |Purchase | | |EP | |type socket, non-alignable | | | | | | | |system, pylon, no cover, SACH | | | | | | | |foot, plaster socket, direct | | | | | | | |formed | | | | |L5505 |NU | |Initial, above knee-knee |All |Y |Purchase | | |EP | |disarticulation (ischial level | | | | | | | |socket, non-alignable system, | | | | | | | |pylon, no cover, SACH foot | | | | | | | |plaster socket, direct formed | | | | |L5510 |NU | |Preparatory, below knee “PTB” |All |Y |Purchase | | |EP | |type socket, non-alignable | | | | | | | |system, pylon, no cover, SACH | | | | | | | |foot, plaster socket, molded to| | | | | | | |model | | | | |L5520 |NU | |Preparatory, below knee “PTB” |All |Y |Purchase | | |EP | |type socket, non-alignable | | | | | | | |pylon, no cover, SACH foot, | | | | | | | |thermoplastic or equal, direct | | | | | | | |formed | | | | |L5530 |NU | |Preparatory, below knee “PTB” |All |Y |Purchase | | |EP | |type socket, non-alignable | | | | | | | |system, pylon, no cover, SACH | | | | | | | |foot, thermoplastic or equal, | | | | | | | |molded to model | | | | |L5535 |NU | |Preparatory, below knee “PTB” |All |Y |Purchase | | |EP | |type socket, non-alignable | | | | | | | |system, pylon, no cover, SACH | | | | | | | |foot, prefabricated, adjustable| | | | | | | |open end socket | | | | |L5540 |NU | |Preparatory, below knee “PTB” |All |Y |Purchase | | |EP | |type socket, non alignable, | | | | | | | |pylon, no cover, SACH foot, | | | | | | | |laminated socket, molded to | | | | | | | |model | | | | |L5560 |NU | |Preparatory, above knee-knee |All |Y |Purchase | | |EP | |disarticulation ischial level | | | | | | | |socket, non-alignable system, | | | | | | | |pylon, no cover, SACH foot, | | | | | | | |plaster socket, molded to model| | | | |L5570 |NU | |Preparatory, above knee-knee |All |Y |Purchase | | |EP | |disarticulation ischial level | | | | | | | |socket, non-alignable system, | | | | | | | |pylon, no cover, SACH foot | | | | | | | |thermoplastic or equal, direct | | | | | | | |formed | | | | |L5580 |NU | |Preparatory, above knee-knee |All |Y |Purchase | | |EP | |disarticulation, ischial level | | | | | | | |socket, non-alignable system, | | | | | | | |pylon, no cover, SACH foot, | | | | | | | |thermoplastic or equal, molded | | | | | | | |to model | | | | |L5585 |NU | |Preparatory, above knee-knee |All |Y |Purchase | | |EP | |disarticulation, ischial level | | | | | | | |socket, non-alignable system, | | | | | | | |pylon, no cover, SACH foot, | | | | | | | |prefabricated adjustable open | | | | | | | |end socket | | | | |L5590 |NU | |Preparatory, above knee-knee |All |Y |Purchase | | |EP | |disarticulation, ischial level | | | | | | | |socket, non-alignable system, | | | | | | | |pylon, no cover, SACH foot, | | | | | | | |laminated socket, molded to | | | | | | | |model | | | | |L5595 |NU | |Preparatory, hip |All |Y |Purchase | | |EP | |disarticulation-hemipelvectomy,| | | | | | | |pylon, no cover, SACH foot, | | | | | | | |thermoplastic or equal, molded | | | | | | | |to patient model | | | | |L5600 |NU | |Preparatory, hip |All |Y |Purchase | | |EP | |disarticulation-hemipelvectomy,| | | | | | | |pylon, no cover, SACH foot, | | | | | | | |laminated socket, molded to | | | | | | | |patient model | | | | |L5610 |NU | |Addition to lower extremity, |All |Y |Purchase | | |EP | |endoskeletal system, above | | | | | | | |knee, hydracadence system | | | | |L5611 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |endoskeletal system, above | | | | | | | |knee-knee disarticulation, | | | | | | | |4-bar linkage, with friction | | | | | | | |swing phase control | | | | |L5613 |NU | |Addition to lower extremity, |All |Y |Purchase | | |EP | |endoskeletal system, above | | | | | | | |knee-knee disarticulation, | | | | | | | |4-bar linkage, with hydraulic | | | | | | | |swing phase control | | | | |L5614 |NU | |Addition to lower extremity, |21+ |Y |Purchase | | | | |endoskeletal system, above knee| | | | | | | |–knee disarticulation, 4-bar | | | | | | | |linkage, with pneumatic swing | | | | | | | |phase control | | | | |L5616 |NU | |Addition to lower extremity, |All |Y |Purchase | | |EP | |endoskeletal system above knee,| | | | | | | |universal multiplex system, | | | | | | | |friction swing phase control | | | | |L5617 |NU | |Addition to lower extremity, |21+ |Y |Purchase | | | | |quick change self-aligning | | | | | | | |unit, above or below knee, each| | | | |L5618 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |test socket, Symes | | | | |L5620 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |test socket, below knee | | | | |L5622 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |test socket, knee | | | | | | | |disarticulation | | | | |L5624 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |test socket, above knee | | | | |L5626 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |test socket, hip | | | | | | | |disarticulation | | | | |L5628 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |test socket, hemipelvectomy | | | | |L5629 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |below knee, acrylic socket | | | | |L5630 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |Symes type, expandable wall | | | | | | | |socket | | | | |L5631 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |above knee or knee | | | | | | | |disarticulation, acrylic socket| | | | |L5632 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |Symes type, “PTB” brim design | | | | | | | |socket | | | | |L5634 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |Symes type posterior opening | | | | | | | |(Canadian) socket | | | | |L5636 |NU | |Additions to lower extremity, |All |N |Purchase | | |EP | |Symes type, medial opening | | | | | | | |socket | | | | |L5637 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |below knee, total contact | | | | |L5638 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |below knee, leather socket | | | | |L5639 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |below knee, wood socket | | | | |L5640 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |knee disarticulation, leather | | | | | | | |socket | | | | |L5642 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |above knee, leather socket | | | | |L5643 |NU | |Addition to lower extremity, |All |Y |Purchase | | |EP | |hip disarticulation, flexible | | | | | | | |inner socket, external frame | | | | |L5644 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |above knee, wood socket | | | | |L5645 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |below knee, flexible inner | | | | | | | |socket, external frame | | | | |L5646 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |below knee, air, fluid, gel or | | | | | | | |equal, cushion socket | | | | |L5647 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |below knee suction socket | | | | |L5648 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |above knee, air, fluid, gel or | | | | | | | |equal, cushion socket | | | | |L5649 |NU | |Addition to lower extremity, |All |Y |Purchase | | |EP | |ischial containment/narrow M-L | | | | | | | |socket | | | | |L5650 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |total contact, above knee or | | | | | | | |knee disarticulation socket | | | | |L5651 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |above knee, flexible inner | | | | | | | |socket, external frame | | | | |L5652 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |suction suspension, above knee | | | | | | | |or knee disarticulation, socket| | | | |L5653 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |knee disarticulation, | | | | | | | |expandable wall socket | | | | |L5654 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |socket insert, Symes, (Kemblo, | | | | | | | |Pelite, Aliplast, Plastazote or| | | | | | | |equal) | | | | |L5655 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |socket insert, below knee | | | | | | | |(Kemblo, Pelite, Aliplast, | | | | | | | |Plastazote or equal) | | | | |L5656 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |socket insert, knee | | | | | | | |disarticulation (Kemblo, | | | | | | | |Pelite, Aliplast, Plastazote or| | | | | | | |equal) | | | | |L5658 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |socket insert, above knee | | | | | | | |(Kemblo, Pelite, Aliplast, | | | | | | | |Plastazote or equal) | | | | |L5661 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |socket insert, multi-durometer | | | | | | | |Symes | | | | |L5665 |EP | |Addition to lower extremity, |U21 |N/A |Purchase | | | | |socket insert, multi-durometer,| | | | | | | |below knee | | | | |L5666 |NU | |Additions to lower extremity, |All |N |Purchase | | |EP | |below knee, cuff suspension | | | | |L5668 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |below knee, molded distal | | | | | | | |cushion | | | | |L5670 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |below knee, molded | | | | | | | |supracondylar suspension (“PTS”| | | | | | | |or similar) | | | | |L5671 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |below knee/above knee, | | | | | | | |suspension locking mechanism | | | | | | | |(shuttle, lanyard or equal), | | | | | | | |excludes socket insert | | | | |L5672 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |below knee, removable medial | | | | | | | |brim suspension | | | | |L5673 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |below knee/above knee, custom | | | | | | | |fabricated from existing mold | | | | | | | |or prefabricated, socket | | | | | | | |insert, silicone gel, | | | | | | | |elastomeric or equal, for use | | | | | | | |with locking mechanism | | | | |L5676 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |below knee, knee joints, single| | | | | | | |axis, pair | | | | |L5677 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |below knee, knee joints, | | | | | | | |polycentric, pair | | | | |L5678 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |below knee, joint covers, pair | | | | |L5679 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |below knee/above knee, custom | | | | | | | |fabricated from existing mold | | | | | | | |or prefabricated, socket | | | | | | | |insert, silicone gel, | | | | | | | |elastomeric or equal, not for | | | | | | | |use with locking mechanism | | | | |L5680 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |below knee, thigh lacer, | | | | | | | |nonmolded | | | | |L5681 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |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 | | | | |L5682 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |below knee, thigh lacer, | | | | | | | |gluteal/ischial, molded | | | | |L5683 |EP | |Addition to lower extremity, |U21 |N |Purchase | | | | |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| | | | |L5684 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |below knee, fork strap | | | | |L5685 |NU | |Addition to lower extremity |All |N |Manually | | |EP | |prosthesis, below knee, | | |Priced | | | | |suspension/sealing sleeve, with| | | | | | | |or without valve, any material,| | | | | | | |each | | | | |L5686 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |below knee, back check | | | | | | | |(extension control) | | | | |L5688 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |below knee, waist belt, webbing| | | | |L5690 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |below knee, waist belt, padded | | | | | | | |and lined | | | | |L5692 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |above knee, pelvic control | | | | | | | |belt, light | | | | |L5694 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |above knee, pelvic control | | | | | | | |belt, padded and lined | | | | |L5695 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |above knee, pelvic control, | | | | | | | |sleeve suspension, neoprene or | | | | | | | |equal, each | | | | |L5696 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |above knee or knee | | | | | | | |disarticulation, pelvic joint | | | | |L5697 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |above knee or knee | | | | | | | |disarticulation, pelvic band | | | | |L5698 |NU | |Addition to lower extremity, |All |N |Purchase | | |EP | |above knee or knee | | | | | | | |disarticulation, Silesian | | | | | | | |bandage | | | | |L5699 |NU | |All lower extremity prosthesis,|All |N |Purchase | | |EP | |shoulder harness | | | | |L5700 |NU | |Replacement, socket, below |21+ |Y |Purchase | | | | |knee, molded to patient model | | | | |L5701 |NU | |Replacement, socket, above |21+ |Y |Purchase | | | | |knee/knee disarticulation, | | | | | | | |including attachment plate, | | | | | | | |molded to patient model | | | | |L5702 |NU | |Replacement, socket, hip |21+ |Y |Purchase | | | | |disarticulation, including hip | | | | | | | |joint, molded to patient model | | | | |L5704 |NU | |Custom shaped protective cover,|All |N |Purchase | | |EP | |below knee | | | | |L5705 |NU | |Custom shaped protective cover,|21+ |N |Purchase | | | | |above knee | | | | |L5706 |NU | |Custom shaped protective cover,|21+ |N |Purchase | | | | |knee disarticulation | | | | |L5707 |NU | |Custom shaped protective cover,|21+ |N |Purchase | | | | |hip disarticulation | | | | |L5710 |NU | |Addition, exoskeletal knee-shin|All |N |Purchase | | |EP | |system, single axis, manual | | | | | | | |lock | | | | |L5711 |NU | |Addition exoskeletal knee-shin |All |N |Purchase | | |EP | |system, single axis, manual | | | | | | | |lock, ultra-light material | | | | |L5712 |NU | |Addition exoskeletal knee-shin |All |N |Purchase | | |EP | |system, single axis, friction | | | | | | | |swing and stance phase control | | | | | | | |(safety knee) | | | | |L5714 |NU | |Addition, exoskeletal knee-shin|All |N |Purchase | | |EP | |system, single axis, variable | | | | | | | |friction swing phase control | | | | |L5716 |NU | |Addition, exoskeletal knee-shin|All |N |Purchase | | |EP | |system, polycentric, mechanical| | | | | | | |stance phase lock | | | | |L5718 |NU | |Addition, exoskeletal knee-shin|All |N |Purchase | | |EP | |system, polycentric, friction | | | | | | | |swing and stance phase control | | | | |L5722 |NU | |Addition, exoskeletal knee-shin|All |N |Purchase | | |EP | |system, single axis, pneumatic | | | | | | | |swing, friction stance phase | | | | | | | |control | | | | |L5724 |NU | |Addition, exoskeletal knee-shin|All |Y |Purchase | | |EP | |system, single axis, fluid | | | | | | | |swing phase control | | | | |L5726 |NU | |Addition, exoskeletal knee-shin|All |Y |Purchase | | |EP | |system, single axis, external | | | | | | | |joints, fluid swing phase | | | | | | | |control | | | | |L5728 |NU | |Addition, exoskeletal knee-shin|All |Y |Purchase | | |EP | |system, single axis, fluid | | | | | | | |swing and stance phase control | | | | |L5780 |NU | |Addition, exoskeletal knee-shin|All |N |Purchase | | |EP | |system, single axis, | | | | | | | |pneumatic/hydra pneumatic swing| | | | | | | |phase control | | | | |L5785 |NU | |Addition, exoskeletal system, |All |N |Purchase | | |EP | |below knee, ultra-light | | | | | | | |material (titanium, carbon | | | | | | | |fiber or equal) | | | | |L5790 |NU | |Addition, exoskeletal system, |All |N |Purchase | | |EP | |above knee, ultra-light | | | | | | | |material (titanium, carbon | | | | | | | |fiber or equal) | | | | |L5795 |NU | |Addition, exoskeletal system, |All |N |Purchase | | |EP | |hip disarticulation, | | | | | | | |ultra-light material (titanium,| | | | | | | |carbon fiber or equal) | | | | |L5810 |NU | |Addition, endoskeletal |All |N |Purchase | | |EP | |knee-shin system, single axis, | | | | | | | |manual lock | | | | |L5811 |NU | |Addition, endoskeletal |All |N |Purchase | | |EP | |knee-shin system, single axis, | | | | | | | |manual lock, ultra-light | | | | | | | |material | | | | |L5812 |NU | |Addition, endoskeletal |All |N |Purchase | | |EP | |knee-shin system, single axis, | | | | | | | |friction swing and stance phase| | | | | | | |control (safety knee) | | | | |L5814 |NU | |Addition, endoskeletal |21+ |Y |Purchase | | | | |knee-shin system, polycentric, | | | | | | | |hydraulic swing phase control, | | | | | | | |mechanical stance phase lock | | | | |L5816 |NU | |Addition, endoskeletal |All |N |Purchase | | |EP | |knee-shin system, polycentric, | | | | | | | |mechanical stance phase lock | | | | |L5818 |NU | |Addition, endoskeletal |All |N |Purchase | | |EP | |knee-shin system, polycentric, | | | | | | | |friction swing, and stance | | | | | | | |phase control | | | | |L5822 |NU | |Addition, endoskeletal |All |Y |Purchase | | |EP | |knee-shin system, single axis, | | | | | | | |pneumatic swing, friction | | | | | | | |stance phase control | | | | |L5824 |NU | |Addition, endoskeletal |All |Y |Purchase | | |EP | |knee-shin system, single axis, | | | | | | | |fluid swing phase control | | | | |L5826 |NU | |Addition, endoskeletal |21+ |Y |Purchase | | | | |knee-shin system, single axis, | | | | | | | |hydraulic swing phase control | | | | | | | |with miniature high activity | | | | | | | |frame | | | | |L5828 |NU | |Addition, endoskeletal |All |Y |Purchase | | |EP | |knee-shin system, single axis, | | | | | | | |fluid swing and stance phase | | | | | | | |control | | | | |L5830 |NU | |Addition, endoskeletal |All |Y |Purchase | | |EP | |knee-shin system, single axis, | | | | | | | |pneumatic/swing phase control | | | | |L5840 |NU | |Addition, endoskeletal |21+ |N |Purchase | | | | |knee-shin system, 4-bar linkage| | | | | | | |or multiaxial, pneumatic swing | | | | | | | |phase control | | | | |L5845 |NU | |Addition, endoskeletal |21+ |Y |Purchase | | | | |knee-shin system, stance | | | | | | | |flexion feature, adjustable | | | | |L5850 |NU | |Addition, endoskeletal system, |All |N |Purchase | | |EP | |above knee or hip | | | | | | | |disarticulation, knee extension| | | | | | | |assist | | | | |L5855 |NU | |Addition, endoskeletal system, |21+ |N |Purchase | | | | |hip disarticulation, mechanical| | | | | | | |hip extension assist | | | | |L5910 |NU | |Addition, endoskeletal system, |All |N |Purchase | | |EP | |below knee, alignable system | | | | |L5920 |NU | |Addition, endoskeletal system, |All |N |Purchase | | |EP | |above knee or hip | | | | | | | |disarticulation, alignable | | | | | | | |system | | | | |L5925 |NU | |Addition, endoskeletal system, |21+ |N |Purchase | | | | |above knee, knee | | | | | | | |disarticulation, manual lock | | | | |L5930 |NU | |Addition, endoskeletal system, |21+ |Y |Purchase | | | | |high activity knee control | | | | | | | |frame | | | | |L5940 |NU | |Addition, endoskeletal system, |All |N |Purchase | | |EP | |below knee, ultra-light | | | | | | | |material (titanium, carbon | | | | | | | |fiber or equal) | | | | |L5950 |NU | |Addition, endoskeletal system, |All |N |Purchase | | |EP | |above knee, ultra-light | | | | | | | |material (titanium, carbon | | | | | | | |fiber or equal) | | | | |L5960 |NU | |Addition, endoskeletal system, |All |N |Purchase | | |EP | |hip disarticulation, | | | | | | | |ultra-light material (titanium,| | | | | | | |carbon fiber or equal) | | | | |L5961 |NU | |Addition, endoskeletal system, |All |N |Manually | | |EP | |polycentric hip joint, | | |Priced | | | | |pneumatic or hydraulic control,| | | | | | | |rotation control, with or | | | | | | | |without flexion, and/or | | | | | | | |extension control | | | | |L5962 |NU | |Addition, endoskeletal system, |All |N |Purchase | | |EP | |below knee, flexible protective| | | | | | | |outer surface covering system | | | | |L5964 |NU | |Addition, endoskeletal system, |21+ |N |Purchase | | | | |above knee, flexible protective| | | | | | | |outer surface covering system | | | | |L5966 |NU | |Addition, endoskeletal system, |21+ |N |Purchase | | | | |hip disarticulation, flexible | | | | | | | |protective outer surface | | | | | | | |covering system | | | | |L5968 |NU | |Addition to lower limb |21+ |Y |Purchase | | | | |prostheses, multiaxial ankle | | | | | | | |with swing phase active | | | | | | | |dorsiflexion feature | | | | |L5970 |NU | |All lower extremity prostheses,|All |N |Purchase | | |EP | |foot, external keel, SACH foot | | | | |L5972 |NU | |All lower extremity prostheses,|All |N |Purchase | | |EP | |flexible keel foot (SAFE, STEN,| | | | | | | |Bock Dynamic or equal) | | | | |L5974 |NU | |All lower extremity prostheses,|All |N |Purchase | | |EP | |foot, single axis ankle/foot | | | | |L5975 |NU | |All lower extremity prosthesis,|21+ |N |Purchase | | | | |combination single axis ankle | | | | | | | |and flexible keel foot | | | | |L5976 |NU | |All lower extremity prostheses,|All |N |Purchase | | |EP | |energy storing foot (Seattle | | | | | | | |Carbon Copy II or equal) | | | | |L5978 |NU | |All lower extremity prostheses,|All |N |Purchase | | |EP | |foot, multiaxial ankle/foot | | | | |L5979 |NU | |All lower extremity prostheses,|All |Y |Purchase | | |EP | |multi-axial ankle, dynamic | | | | | | | |response foot, one piece system| | | | |L5980 |NU | |All lower extremity prostheses,|All |Y |Purchase | | |EP | |flex-foot system | | | | |L5981 |NU | |All lower extremity prostheses,|All |Y |Purchase | | |EP | |flex-walk system or equal | | | | |L5982 |NU | |All exoskeletal lower extremity|All |N |Purchase | | |EP | |prostheses, axial rotation unit| | | | |L5984 |NU | |All endoskeletal lower |All |N |Purchase | | |EP | |extremity prosthesis, axial | | | | | | | |rotation unit, with or without | | | | | | | |adjustability | | | | |L5985 |NU | |All endoskeletal lower |21+ |N |Purchase | | | | |extremity prostheses, dynamic | | | | | | | |prosthetic pylon | | | | |L5986 |NU | |All lower extremity prostheses,|All |N |Purchase | | |EP | |multi-axial rotation unit | | | | | | | |(“MCP” or equal) | | | | |L5987 |NU | |All lower extremity prostheses,|21+ |Y |Purchase | | | | |shank foot system with vertical| | | | | | | |loading pylon | | | | |L5988 |NU | |Addition to lower limb |21+ |Y |Purchase | | | | |prosthesis, vertical shock | | | | | | | |reducing pylon feature | | | | |L5999 |NU | |((Unlisted Prosthetic Devices |All |Y |Manually | | | | |or Orthotic Appliances; the | | |Priced | | |EP | |manufacturer’s invoice must be | | |Manually | | | | |attached to all claims.) Lower| | |Priced | | | | |extremity prosthesis, not | | | | | | | |otherwise specified | | | | |L6000 |NU | |Partial hand, Robin-Aids, thumb|All |N |Purchase | | |EP | |remaining (or equal) | | | | |L6010 |NU | |Partial hand, Robin-Aids, |All |N |Purchase | | |EP | |little and/or ring finger | | | | | | | |remaining (or equal) | | | | |L6020 |NU | |Partial hand, Robin-Aids, no |All |N |Purchase | | |EP | |finger remaining (or equal) | | | | |L6050 |NU | |Wrist disarticulation, molded |All |Y |Purchase | | |EP | |socket, flexible elbow hinges, | | | | | | | |triceps pad | | | | |L6055 |NU | |Wrist disarticulation, molded |All |Y |Purchase | | |EP | |socket with expandable | | | | | | | |interface, flexible elbow | | | | | | | |hinges, triceps pad | | | | |L6100 |NU | |Below elbow, molded socket, |All |Y |Purchase | | |EP | |flexible elbow hinge, triceps | | | | | | | |pad | | | | |L6110 |NU | |Below elbow, molded socket |All |Y |Purchase | | |EP | |(Muenster or Northwestern | | | | | | | |suspension types) | | | | |L6120 |NU | |Below elbow, molded double wall|All |Y |Purchase | | |EP | |split socket, step-up hinges, | | | | | | | |half cuff | | | | |L6130 |NU | |Below elbow, molded double wall|All |Y |Purchase | | |EP | |split socket, stump activated | | | | | | | |locking hinge, half cuff | | | | |L6200 |NU | |Elbow disarticulation, molded |All |Y |Purchase | | |EP | |socket, outside locking hinge, | | | | | | | |forearm | | | | |L6205 |NU | |Elbow disarticulation, molded |All |Y |Purchase | | |EP | |socket with expandable | | | | | | | |interface, outside locking | | | | | | | |hinges, forearm | | | | |L6250 |NU | |Above elbow, molded double wall|All |Y |Purchase | | |EP | |socket, internal locking elbow,| | | | | | | |forearm | | | | |L6300 |NU | |Shoulder disarticulation, |All |Y |Purchase | | |EP | |molded socket, shoulder | | | | | | | |bulkhead, humeral section, | | | | | | | |internal locking elbow, forearm| | | | |L6310 |NU | |Shoulder disarticulation, |All |Y |Purchase | | |EP | |passive restoration (complete | | | | | | | |prosthesis) | | | | |L6320 |NU | |Shoulder disarticulation, |All |Y |Purchase | | |EP | |passive restoration (shoulder | | | | | | | |cap only) | | | | |L6350 |NU | |Interscapular thoracic, molded |All |Y |Purchase | | |EP | |socket, shoulder bulkhead, | | | | | | | |humeral section, internal | | | | | | | |locking elbow, forearm | | | | |L6360 |NU | |Interscapular thoracic, passive|All |Y |Purchase | | |EP | |restoration (complete | | | | | | | |prosthesis) | | | | |L6370 |NU | |Interscapular thoracic, passive|All |Y |Purchase | | |EP | |restoration (shoulder cap only)| | | | |L6380 |NU | |Immediate post-surgical or |All |N |Purchase | | |EP | |early fitting, application of | | | | | | | |initial rigid dressing, | | | | | | | |including fitting alignment and| | | | | | | |suspension of components, and | | | | | | | |one cast change, wrist | | | | | | | |disarticulation or below elbow | | | | |L6382 |NU | |Immediate post-surgical or |All |N |Purchase | | |EP | |early fitting, application of | | | | | | | |initial rigid dressing | | | | | | | |including fitting alignment and| | | | | | | |suspension of components, and | | | | | | | |one cast change, elbow | | | | | | | |disarticulation or above elbow | | | | |L6384 |NU | |Immediate post-surgical or |All |Y |Purchase | | |EP | |early fitting, application of | | | | | | | |initial rigid dressing | | | | | | | |including fitting alignment and| | | | | | | |suspension of components, and | | | | | | | |one cast change, shoulder | | | | | | | |disarticulation or | | | | | | | |interscapular thoracic | | | | |L6386 |NU | |Immediate post-surgical or |All |N |Purchase | | |EP | |early fitting, each additional | | | | | | | |cast change and realignment | | | | |L6388 |NU | |Immediate post-surgical or |All |N |Purchase | | |EP | |early fitting, application of | | | | | | | |rigid dressing only | | | | |L6400 |NU | |Below elbow, molded socket, |All |Y |Purchase | | |EP | |endoskeletal system, including | | | | | | | |soft prosthetic tissue shaping | | | | |L6450 |NU | |Elbow disarticulation, molded |All |Y |Purchase | | |EP | |socket, endoskeletal system, | | | | | | | |including soft prosthetic | | | | | | | |tissue shaping | | | | |L6500 |NU | |Above elbow, molded socket, |All |Y |Purchase | | |EP | |endoskeletal system, including | | | | | | | |soft prosthetic tissue shaping | | | | |L6550 |NU | |Shoulder disarticulation, |All |Y |Purchase | | |EP | |molded socket, endoskeletal | | | | | | | |system, including soft | | | | | | | |prosthetic tissue shaping | | | | |L6570 |NU | |Interscapular thoracic, molded |All |Y |Purchase | | |EP | |socket, endoskeletal system | | | | | | | |including soft prosthetic | | | | | | | |tissue shaping | | | | |L6580 |NU | |Preparatory, wrist |All |Y |Purchase | | |EP | |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 | | | | |L6582 |NU | |Preparatory, wrist |All |N |Purchase | | |EP | |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 | | | | |L6584 |NU | |Preparatory, elbow |All |Y |Purchase | | |EP | |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 | | | | |L6586 |NU | |Preparatory, elbow |All |Y |Purchase | | |EP | |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 | | | | |L6588 |NU | |Preparatory, shoulder |All |Y |Purchase | | |EP | |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 | | | | |L6590 |NU | |Preparatory, shoulder |All |Y |Purchase | | |EP | |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 | | | | |L6600 |NU | |Upper extremity additions, |All |N |Purchase | | |EP | |polycentric hinge, pair | | | | |L6605 |NU | |Upper extremity additions, |All |N |Purchase | | |EP | |single pivot hinge, pair | | | | |L6610 |NU | |Upper extremity additions, |All |N |Purchase | | |EP | |flexible metal hinge, pair | | | | |L6615 |NU | |Upper extremity addition, |All |N |Purchase | | |EP | |disconnect locking wrist unit | | | | |L6616 |NU | |Upper extremity addition, |All |N |Purchase | | |EP | |additional disconnect insert | | | | | | | |for locking wrist unit, each | | | | |L6620 |NU | |Upper extremity addition, |All |N |Purchase | | |EP | |flexion/extension wrist unit, | | | | | | | |with or without friction | | | | |L6623 |NU | |Upper extremity addition, |All |N |Purchase | | |EP | |spring assisted rotational | | | | | | | |wrist unit with latch release | | | | |L6624 |NU | |Upper extremity addition, |All |Y |Purchase | | |EP | |flexion/extension and rotation | | | | | | | |wrist unit | | | | |L6625 |NU | |Upper extremity addition, |All |N |Purchase | | |EP | |rotation wrist unit with cable | | | | | | | |lock | | | | |L6628 |NU | |Upper extremity addition, quick|All |N |Purchase | | |EP | |disconnect hook adapter, Otto | | | | | | | |Bock or equal | | | | |L6629 |NU | |Upper extremity addition, quick|All |N |Purchase | | |EP | |disconnect lamination collar | | | | | | | |with coupling piece, Otto Bock | | | | | | | |or equal | | | | |L6630 |NU | |Upper extremity addition, |All |N |Purchase | | |EP | |stainless steel, any wrist | | | | |L6632 |NU | |Upper extremity addition, latex|All |N |Purchase | | |EP | |suspension sleeve, each | | | | |L6635 |NU | |Upper extremity additions, lift|All |N |Purchase | | |EP | |assist for elbow | | | | |L6637 |NU | |Upper extremity addition, nudge|All |N |Purchase | | |EP | |control elbow lock | | | | |L6640 |NU | |Upper extremity additions, |All |N |Purchase | | |EP | |shoulder abduction joint, pair | | | | |L6641 |NU | |Upper extremity addition, |All |N |Purchase | | |EP | |excursion amplifier, pulley | | | | | | | |type | | | | |L6642 |NU | |Upper extremity addition, |All |N |Purchase | | |EP | |excursion amplifier, lever type| | | | |L6645 |NU | |Upper extremity addition, |All |N |Purchase | | |EP | |shoulder flexion-abduction | | | | | | | |joint, each | | | | |L6650 |NU | |Upper extremity addition, |All |N |Purchase | | |EP | |shoulder universal joint, each | | | | |L6655 |NU | |Upper extremity addition, |All |N |Purchase | | |EP | |standard control cable, extra | | | | |L6660 |NU | |Upper extremity addition, |All |N |Purchase | | |EP | |heavy-duty control cable | | | | |L6665 |NU | |Upper extremity addition, |All |N |Purchase | | |EP | |Teflon, or equal, cable lining | | | | |L6670 |NU | |Upper extremity addition, hook |All |N |Purchase | | |EP | |to hand cable adapter | | | | |L6672 |NU | |Upper extremity addition, |All |N |Purchase | | |EP | |harness, chest or shoulder, | | | | | | | |saddle type | | | | |L6675 |NU | |Upper extremity addition, |All |N |Purchase | | |EP | |harness, (e.g., figure of eight| | | | | | | |type), single cable design | | | | |L6676 |NU | |Upper extremity additions, |All |N |Purchase | | |EP | |harness, (e.g., figure of eight| | | | | | | |type), dual cable design | | | | |L6680 |NU | |Upper extremity addition, test |All |N |Purchase | | |EP | |socket, wrist disarticulation | | | | | | | |or below elbow | | | | |L6682 |NU | |Upper extremity addition, test |All |N |Purchase | | |EP | |socket, elbow disarticulation | | | | | | | |or above elbow | | | | |L6684 |NU | |Upper extremity addition, test |All |N |Purchase | | |EP | |socket, shoulder | | | | | | | |disarticulation or | | | | | | | |interscapular thoracic | | | | |L6686 |NU | |Upper extremity addition, |All |N |Purchase | | |EP | |suction socket | | | | |L6687 |NU | |Upper extremity addition, frame|All |N |Purchase | | |EP | |type socket, below elbow or | | | | | | | |wrist disarticulation | | | | |L6688 |NU | |Upper extremity addition, frame|All |N |Purchase | | |EP | |type socket, above elbow or | | | | | | | |elbow disarticulation | | | | |L6689 |NU | |Upper extremity addition, frame|All |N |Purchase | | |EP | |type socket, shoulder | | | | | | | |disarticulation | | | | |L6690 |NU | |Upper extremity addition, frame|All |N |Purchase | | |EP | |type socket, | | | | | | | |interscapular-thoracic | | | | |L6691 |NU | |Upper extremity addition, |All |N |Purchase | | |EP | |removable insert, each | | | | |L6692 |NU | |Upper extremity addition, |All |N |Purchase | | |EP | |silicone gel insert or equal, | | | | | | | |each | | | | |L6693 |NU | |Upper extremity addition, |21+ |Y |Purchase | | | | |locking elbow, forearm | | | | | | | |counterbalance | | | | |L67031 |NU | |Terminal device, passive |All |N |Purchase | | |EP | |hand/mitt, any material, any | | | | | | | |size | | | | |L67041 |NU | |Terminal device, |All |N |Purchase | | |EP | |sport/recreational/work | | | | | | | |attachment, any material, any | | | | | | | |size | | | | |L67061 |NU | |Terminal device, hook, |All |N |Purchase | | |EP | |mechanical, voluntary opening, | | | | | | | |any material, any size, lined | | | | | | | |or unlined | | | | |L67071 |NU | |Terminal device, hook, |All |N |Purchase | | |EP | |mechanical, voluntary closing, | | | | | | | |any material, any size, lined | | | | | | | |or unlined | | | | |L67081 |NU | |Terminal device, hand, |All |N |Purchase | | |EP | |mechanical, voluntary opening, | | | | | | | |any material, any size | | | | |L67091 |NU | |Terminal device, hand, |All |N |Purchase | | |EP | |mechanical, voluntary closing, | | | | | | | |any material, any size | | | | |L6711 |EP | |Terminal device, hook, |U21 |Y |Purchase | | | | |mechanical, voluntary opening, | | | | | | | |any material, any size, lined | | | | | | | |or unlined, pediatric | | | | |L6712 |EP | |Terminal device, hook, |U21 |Y |Purchase | | | | |mechanical, voluntary closing, | | | | | | | |any material, any size, lined | | | | | | | |or unlined, pediatric | | | | |L6713 |EP | |Terminal device, hand, |U21 |Y |Purchase | | | | |mechanical, voluntary opening, | | | | | | | |any material, any size, | | | | | | | |pediatric | | | | |L6714 |EP | |Terminal device, hand, |U21 |N/A |Purchase | | | | |mechanical, voluntary closing, | | | | | | | |any material, any size, | | | | | | | |pediatric | | | | |L6721 |NU | |Terminal device, hook or hand, |21+ |Y |Purchase | | | | |heavy-duty, mechanical, | | | | | | | |voluntary opening, any | | | | | | | |material, any size, lined or | | | | | | | |unlined | | | | |L6722 |NU | |Terminal device, hook or hand, |21+ |Y |Purchase | | | | |heavy-duty, mechanical, | | | | | | | |voluntary closing, any | | | | | | | |material, any size, lined or | | | | | | | |unlined | | | | |L6805 |NU | |Terminal device, modifier wrist|All |N |Purchase | | |EP | |flexion unit | | | | |L6810 |NU | |Terminal device, pincher tool, |All |N |Purchase | | |EP | |Otto Bock or equal | | | | |L6880 |NU | |Electric hand, switch or |All |Y |Purchase | | |EP | |myoelectric controlled, | | | | | | | |independently articulating | | | | | | | |digits, any grasp pattern or | | | | | | | |combination of grasp patterns, | | | | | | | |includes motor(s) | | | | |L6890 |NU | |Terminal device, gloves for |All |N |Purchase | | |EP | |above hands, production glove | | | | |L6895 |NU | |Terminal device, glove for |All |N |Purchase | | |EP | |above hands, custom glove | | | | |L6900 |NU | |Hand restoration (casts, |All |N |Purchase | | |EP | |shading and measurements | | | | | | | |included), partial hand, with | | | | | | | |glove, thumb or one finger | | | | | | | |remaining | | | | |L6905 |NU | |Hand restoration (casts, |All |N |Purchase | | |EP | |shading and measurements | | | | | | | |included), partial hand, with | | | | | | | |glove, multiple fingers | | | | | | | |remaining | | | | |L6910 |NU | |Hand restoration (casts, |All |N |Purchase | | |EP | |shading and measurements | | | | | | | |included), partial hand, with | | | | | | | |glove, no fingers remaining | | | | |L6915 |NU | |Hand restoration (shading and |All |N |Purchase | | |EP | |measurements included), | | | | | | | |replacement glove for above | | | | |L6920* |NU | |Wrist disarticulation, external|All |Y |Purchase | | |EP | |power, self-suspended inner | | | | | | | |socket, removable forearm | | | | | | | |shell, Otto Bock or equal, | | | | | | | |switch, cables, two batteries | | | | | | | |and one charger, switch control| | | | | | | |of terminal device | | | | |L6925* |NU | |Wrist disarticulation, external|All |Y |Purchase | | |EP | |power, self-suspended inner | | | | | | | |socket, removable forearm | | | | | | | |shell, Otto Bock or equal | | | | | | | |electrodes, cables, two | | | | | | | |batteries and one charger, | | | | | | | |myoelectronic control of | | | | | | | |terminal device | | | | |L6930* |NU | |Below elbow, external power, |All |Y |Purchase | | |EP | |self-suspended inner socket, | | | | | | | |removable forearm shell, Otto | | | | | | | |Bock or equal switch, cables, | | | | | | | |two batteries and one charger, | | | | | | | |switch control of terminal | | | | | | | |device | | | | |L6935* |NU | |Below elbow, external power, |All |Y |Purchase | | |EP | |self-suspended inner socket, | | | | | | | |removable forearm shell, Otto | | | | | | | |Bock or equal electrodes, | | | | | | | |cables, two batteries and one | | | | | | | |charger, myoelectronic control | | | | | | | |of terminal device | | | | |L6940* |NU | |Elbow disarticulation, external|All |Y |Purchase | | |EP | |power, molded inner socket, | | | | | | | |removable humeral shell, | | | | | | | |outside locking hinges, | | | | | | | |forearm, Otto Bock or equal | | | | | | | |switch, cables, two batteries | | | | | | | |and one charger, switch control| | | | | | | |of terminal device | | | | |L6945* |NU | |Elbow disarticulation, external|All |Y |Purchase | | |EP | |power, molded inner socket, | | | | | | | |removable humeral shell, | | | | | | | |outside locking hinges, | | | | | | | |forearm, Otto Bock or equal | | | | | | | |electrodes, cables, two | | | | | | | |batteries and one charger, | | | | | | | |myoelectronic control of | | | | | | | |terminal device | | | | |L6950* |NU | |Above elbow, external power, |All |Y |Purchase | | |EP | |molded inner socket, removable | | | | | | | |humeral shell, internal locking| | | | | | | |elbow, forearm, Otto Bock or | | | | | | | |equal switch, cables, two | | | | | | | |batteries and one charger, | | | | | | | |switch control of terminal | | | | | | | |device | | | | |L6955* |NU | |Above elbow, external power, |All |Y |Purchase | | |EP | |molded inner socket, removable | | | | | | | |humeral shell, internal locking| | | | | | | |elbow, forearm, Otto Bock or | | | | | | | |equal electrodes, cables, two | | | | | | | |batteries and one charger, | | | | | | | |myoelectronic control of | | | | | | | |terminal device | | | | |L6960* |NU | |Shoulder disarticulation, |All |Y |Purchase | | |EP | |external power, molded inner | | | | | | | |socket, removable shoulder | | | | | | | |shell, shoulder bulkhead, | | | | | | | |humeral section, mechanical | | | | | | | |elbow, forearm, Otto Bock or | | | | | | | |equal switch, cables, two | | | | | | | |batteries and one charger, | | | | | | | |switch control of terminal | | | | | | | |device | | | | |L6965* |NU | |Shoulder disarticulation, |All |Y |Purchase | | |EP | |external power, molded inner | | | | | | | |socket, removable shoulder | | | | | | | |shell, shoulder bulkhead, | | | | | | | |humeral section, mechanical | | | | | | | |elbow, forearm, Otto Bock or | | | | | | | |equal electrodes, cables, two | | | | | | | |batteries and one charger, | | | | | | | |myoelectronic control of | | | | | | | |terminal device | | | | |L6970* |NU | |Interscapular-thoracic, |All |Y |Purchase | | |EP | |external power, molded inner | | | | | | | |socket, removable shoulder | | | | | | | |shell, shoulder bulkhead, | | | | | | | |humeral section, mechanical | | | | | | | |elbow, forearm, Otto Bock or | | | | | | | |equal switch, cables, two | | | | | | | |batteries and one charger, | | | | | | | |switch control of terminal | | | | | | | |device | | | | |L6975* |NU | |Interscapular-thoracic, |All |Y |Purchase | | |EP | |external power, molded inner | | | | | | | |socket, removable shoulder | | | | | | | |shell, shoulder bulkhead, | | | | | | | |humeral section, mechanical | | | | | | | |elbow, forearm, Otto Bock or | | | | | | | |equal electrodes, cables, two | | | | | | | |batteries and one charger, | | | | | | | |myoelectronic control of | | | | | | | |terminal device | | | | |L70071* |NU | |Electric hand, switch or |All |Y |Purchase | | |EP | |myoelectric controlled, adult | | | | |L70081* |NU | |Electric hand, switch or |All |Y |Purchase | | |EP | |myoelectric, controlled, | | | | | | | |pediatric | | | | |L7009 |NU | |Electric hook, switch or |All |Y |Purchase | | |EP | |myoelectric controlled, adult | | | | |L7040* |NU | |Prehensile actuator, Hosmer or |All |Y |Purchase | | |EP | |equal, switch controlled | | | | |L7045* |NU | |Electronic hook, child, |All |Y |Purchase | | |EP | |Michigan or equal, switch | | | | | | | |controlled | | | | |L7170* |NU | |Electronic elbow, Hosmer or |All |Y |Purchase | | |EP | |equal, switch controlled | | | | |L7180* |NU | |Electronic elbow, Utah or |All |Y |Purchase | | |EP | |equal, myoelectronically | | | | | | | |controlled | | | | |L7185 |EP | |Electronic elbow, adolescent, |U21 |N/A |Purchase | | | | |Variety Village or equal, | | | | | | | |switch controlled | | | | |L7186 |EP | |Electronic elbow, child, |U21 |N/A |Purchase | | | | |Variety Village or equal, | | | | | | | |switch controlled | | | | |L7190 |EP | |Electronic elbow, adolescent, |U21 |N/A |Purchase | | | | |Variety Village or equal, | | | | | | | |myoelectronically controlled | | | | |L7191 |EP | |Electronic elbow, child, |U21 |N/A |Purchase | | | | |Variety Village or equal, | | | | | | | |myoelectronically controlled | | | | |L7260* |NU | |Electronic wrist rotator, Otto |All |Y |Purchase | | |EP | |Bock or equal | | | | |L7261* |NU | |Electronic wrist rotator, for |All |Y |Purchase | | |EP | |Utah arm | | | | |L7360* |NU | |Six volt battery, Otto Bock or |All |N |Purchase | | |EP | |equal, each | | | | |L7362* |NU | |Battery charger, six volt, Otto|All |N |Purchase | | |EP | |Bock or equal | | | | |L7364* |NU | |Twelve volt battery, Utah or |All |N |Purchase | | |EP | |equal, each | | | | |L7366* |NU | |Battery charger, twelve volt, |All |N |Purchase | | |EP | |Utah or equal | | | | |L7499 |NU | |((Unlisted Prosthetic Devices |All |Y |Manually | | | | |or Orthotic Appliances; the | | |Priced | | |EP | |manufacturer’s invoice must be | | |Manually | | | | |attached to all claims.) Upper| | |Priced | | | | |extremity prosthesis, NOS | | | | |L7510 |NU | |((Orthotics and Prosthetics |All |Y |Manually | | | | |Repairs) Repair of prosthetic | | |Priced | | |EP |UB |device, repair or replace minor| | |Purchase | | | | |parts | | | | |L7510 |NU | |((Twister cables - |All |N |Manually | | | | |repair/replace) Repair of | | |Priced | | |EP | |prosthetic device, repair or | | |Purchase | | | | |replace minor parts | | | | |L7520 |NU | |((Orthotics and Prosthetics |All |Y |Manually | | | | |Repairs) Repair prosthetic | | |Priced | | |EP | |device, labor component, per 15| | |Purchase | | | | |minutes | | | | |L8000 |NU | |Breast prosthesis, mastectomy |All |N |Purchase | | |EP | |bra | | | | |L8010 |NU | |Breast prosthesis, mastectomy |All |N |Purchase | | |EP | |sleeve | | | | |L8015 |NU | |External breast prosthesis |21+ |N |Purchase | | | | |garment, with mastectomy form, | | | | | | | |post-mastectomy | | | | |L8020 |NU | |Breast prosthesis, mastectomy |All |N |Purchase | | |EP | |form | | | | |L8030 |NU | |Breast prosthesis, silicone or |All |N |Purchase | | |EP | |equal | | | | |L8031 |NU | |Breast prosthesis, silicone or |All |N |Purchase | | |EP | |equal, with integral adhesive | | | | |L8032 |NU | |Nipple prosthesis, reusable, |All |N |Purchase | | |EP | |any type, each | | | | |L8300 |NU | |Truss, single with standard pad|All |N |Purchase | | |EP | | | | | | |L8310 |NU | |Truss, double with standard |All |N |Purchase | | |EP | |pads | | | | |L8320 |NU | |Truss, addition to standard |All |N |Purchase | | |EP | |pad, water pad | | | | |L8330 |NU | |Truss, addition to standard |All |N |Purchase | | |EP | |pad, scrotal pad | | | | |L8400 |NU | |Prosthetic sheath, below knee, |All |N |Purchase | | |EP | |each | | | | |L8410 |NU | |Prosthetic sheath, above knee, |All |N |Purchase | | |EP | |each | | | | |L8415 |NU | |Prosthetic sheath, upper limb, |All |N |Purchase | | |EP | |each | | | | |L8417 |NU | |Prosthetic sheath/sock, |21+ |N |Purchase | | | | |including a gel cushion layer, | | | | | | | |below knee or above knee, each | | | | |L8420 |NU | |Prosthetic sock, multiple ply, |All |N |Purchase | | |EP | |below knee, each | | | | |L8430 |NU | |Prosthetic sock, multiple ply, |All |N |Purchase | | |EP | |above knee, each | | | | |L8435 |NU | |Prosthetic sock, multiple ply |All |N |Purchase | | |EP | |upper limb, each | | | | |L8440 |NU | |Prosthetic shrinker, below |All |N |Purchase | | |EP | |knee, each | | | | |L8460 |NU | |Prosthetic shrinker, above |All |N |Purchase | | |EP | |knee, each | | | | |L8465 |NU | |Prosthetic shrinker, upper |All |N |Purchase | | |EP | |limb, each | | | | |L8470 |NU | |Prosthetic sock, single ply, |All |N |Purchase | | |EP | |fitting below knee, each | | | | |L8480 |NU | |Prosthetic sock, single ply |All |N |Purchase | | |EP | |fitting, above knee, each | | | | |L8485 |NU | |Prosthetic sock, single ply, |21+ |N |Purchase | | | | |fitting, upper limb, each | | | | |L8499 |NU | |((Unlisted Prosthetic Devices |All |Y |Manually | | | | |or Orthotic Appliances; the | | |Priced | | |EP | |manufacturer’s invoice must be | | |Manually | | | | |attached to all claims.) | | |Priced | | | | |Unlisted procedure for | | | | | | | |miscellaneous prosthetic | | | | | | | |services | | | | |L8500 |NU | |Artificial larynx, any type |All |N |Purchase | | |EP | | | | | | |L8501 |NU | |Tracheostomy speaking valve |All |N |Purchase | | |EP | | | | | | |L8600 |EP | |Implantable breast prosthesis, |U21 |N |Manually | | | | |silicone or equal | | |Priced | |L8605 |NU | |Injectable bulking agent, |18+ |N |Manually | | | | |dextranomer/hyaluronic acid | | |Priced | | | | |copolymer implant, anal canal, | | | | | | | |1ml, includes shipping and | | | | | | | |necessary supplies (covered | | | | | | | |only for ages 18 and over) | | | | |L8693 |EP | |Auditory osseointegrated device|U21 |N |Manually | | | | |abutment, any length, | | |Priced | | | | |replacement only | | | | |V2623 |NU | |Prosthetic eye, plastic, custom|All |Y |Purchase | |V2624 |NU | |Polishing/resurfacing of ocular|All |Y |Purchase | | | | |prosthesis | | | | |V2625 |NU | |Enlargement of ocular |All |Y |Purchase | | | | |prosthesis | | | | |V2626 |NU | |Reduction of ocular prosthesis |All |Y |Purchase | |V2628 |NU | |Fabrication and fitting of |All |N |Purchase | | | | |ocular conformer | | | |

|242.191 Wheelchairs and Wheelchair Seating Systems for |9-1-17 | |Individuals Ages Two Through Adult | |

Arkansas Medicaid covers wheelchairs and wheelchair seating systems for individuals ages two through adult.

For any item to be covered by Arkansas Medicaid, the beneficiary must be eligible for a defined Medicaid Aid Category. Coverage is subject to the requirement that the equipment must be medically necessary for the diagnosis or treatment of an illness or injury to improve the functioning of an affected body part, and must meet all other Medicaid statutory and regulatory requirements and established criteria.

The beneficiary’s diagnosis must warrant the type of equipment being purchased. Items may not be covered in every instance.

Providers are cautioned that an approved prior authorization does not guarantee payment. Reimbursement is contingent upon eligibility of both the beneficiary and the provider at the time service is provided and submission of an accurate and complete request. The DME provider is responsible for verifying the eligibility of the beneficiary at the time service is provided.

Specialized wheelchairs and wheelchair seating systems must be ordered by a physician.

For those services that are not included in the Arkansas Medicaid State Plan, (e.g., highly technological wheelchairs and rehab equipment), the PCP must complete form DMS-693, titled Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Prescription/Referral for Medically Necessary Services/Items Not Specifically Included in the Medicaid State Plan. View or print form DMS-679 and instructions for completion.

NOTE: If the service or item(s) are specifically included in the Arkansas Medicaid State Plan, the completion of form DMS-693 is not required.

When a request is submitted for a power wheelchair, Power-Operated Vehicle (POV) or specialized manual wheelchair, the following Medicaid requirements must be met:

A. A Prescription & Prior Authorization Request for Medical Equipment form (DMS-679) must be completed and submitted. This form must not be altered by the provider. View or print form DMS-679 and instructions for completion.

B. The DMS-679 must be signed and dated by the beneficiary’s PCP or the ordering physician. The signature must be original. Stamp signatures are not acceptable. Medicaid will accept electronic signatures provided the electronic signatures comply with Arkansas Code § 25-31-103 et seq.

C. Correct Medicaid procedure codes and modifiers must be utilized. Requested items will be denied if correct procedures codes and modifiers are not used.

D. All requests for prior authorization must be legible (felt pens must not be used).

E. Medicaid requires the submission of the original request.

F. Medical documentation from the beneficiary’s PCP or ordering physician which included a detailed face-to-face medical examination must be submitted to establish medical necessity.

G. An Evaluation for Wheelchair and Wheelchair Seating form (DMS-0843) must be submitted. This evaluation will be completed in three parts:

1. Part A—to be completed by the DME provider.

2. Part B—to be completed by the assistive technology practitioner or can be completed by a physical therapist or occupational therapist or seating specialist for Group 1 (one) and Group 2 (two) power wheelchairs with no power options.

3. Part C—to be completed by the beneficiary’s PCP or the ordering physician.

4. An Evaluation for Wheelchair and Wheelchair Seating form (DMS-0843) must be completed for all specialized wheelchairs except for rental wheelchairs. View or print form DMS-0843 and instructions for completion.



H. A manufacturer’s order form documenting the suggested retail price for the brand and model wheelchair and accessories and a manufacturer’s quote must be submitted with the DMS 679.

I. A DMS-693, Early and Periodic Screening, Diagnosis and Treatment (EPSDT) form, must be submitted for all pediatric wheelchairs and include detailed PCP medical documentation that clearly demonstrates medical necessity and clearly identifies the medical condition and the specific equipment that will meet the beneficiary’s medical needs. Form DMS-693 and the supporting documentation must be submitted as an attachment to the request for prior authorization. It will then be reviewed for medical necessity. View or print form DMS-693.

J. If requirements A through I are not completed correctly, the request could be denied.

K. Arkansas Medicaid requires a Durable Medical Equipment (DME) provider to employ a RESNA (Rehabilitation Engineering and Assistive Technology Society of North America) certified ATP (Assistive Technology Practitioner) who specializes in wheelchair seating. The ATP will provide direct in-person recommendations for evaluation of the beneficiary’s wheelchair selection, and is employed by the supplier. This applies for specialized manual wheelchair and power wheelchair in the category of Group 2 (single power option) and above.

The ATP’s involvement in the wheelchair selection must be documented. Documentation of the ATP’s involvement does not qualify as a face-to-face examination and may not be cosigned by a physician.

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

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

Other coding information found in the chart:

1 The purchase of this component for beneficiaries age 21 and older is limited to one per five-year period.

2 The purchase of this wheelchair component for beneficiaries under age 21 is limited to one per two-year period.

* The purchase of wheelchairs for beneficiaries age 21 and older is limited to one per five-year period.

** Bill only for beneficiaries under age 21.

# This procedure code is payable for beneficiaries ages 2 through 20. Prior authorization is required through Utilization Review.

**** Items listed require prior authorization (PA) when used in combination with other items listed and the total combined value exceeds the $1,000.00 Medicaid maximum allowable reimbursement limit.

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

Note: W/C or w/c indicates wheelchair.

⎤(…) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product. When using a procedure code with this symbol, the product must meet the indicated Arkansas Medicaid description. |Wheelchairs and Wheelchair Seating Systems for Individuals Ages Two | |Through Adult (Section 242.191) | |Procedure |M1 |M2 |Description |PA |Payment | |Code | | | | |Method | |E0700 |NU |U1 |Safety equipment, e.g., belt, |N****|Purchase | | |EP |U1 |harness or vest | | | |E0700 |NU |U2 |((Travel restraint auto safe |N****|Purchase | | |EP |U2 |harness, E-Z on vest, no known | | | | | | |comparable product) Safety | | | | | | |equipment, e.g., belt, harness | | | | | | |or vest | | | |E0950 |NU | |((Tray for W/C) W/C accessory,|Y |Purchase | | |EP | |tray, each | | | |E0950 |NU |U2 |((ABS tray, 4-SM 5-LG) W/C |Y |Purchase | | |EP |U2 |accessory, tray, each | | | |E0950 |NU |U3 |((W/C Tray, Custom) W/C |Y |Purchase | | |EP |U3 |accessory, tray, each | | | |E0950 |NU |U4 |((Tray, customized) W/C |N |Purchase | | |EP |U4 |accessory, tray, each | | | |E0950 |NU |U5U|((Clear upper Ex support |Y |Purchase | | |EP |5 |system) W/C accessory, tray, | | | | | | |each | | | |E0950 |NU |U6 |((Lap Tray Switch Array) |Y |Purchase | | |EP |U6 |Wheelchair accessory, tray, | | | | | | |each | | | |E0950 |NU |U7 |Wheelchair accessory, tray, |Y |Purchase | | |EP |U7 |each | | | |E0950 |NU |U7 |((Removable Hinged Overlay for |Y****|Purchase | | |EP |U7 |Tray) W/C accessory, tray, | | | | |UE | |each | | | |E0950 |NU |U8U|((Lap Tray for Switch Array) |Y |Purchase | | |EP |8 |Wheelchair accessory, tray, | | | | | | |each | | | |E0951 |NU | |Heel loop/holder, with or |N****|Purchase | | |EP | |without ankle strap, each | | | |E0952 |NU | |Toe loop/holder, each |N****|Purchase | | |EP | | | | | |E0955 |NU | |Wheelchair accessory, headrest,|N |Purchase | | |EP | |cushioned, any type, including | | | | | | |fixed mounting hardware, each | | | |E0956 |NU | |((Trunk supports for any W/C, |N****|Purchase | | |EP | |other than travel, with | | | | | | |hardware) Wheelchair | | | | | | |accessory, lateral trunk or hip| | | | | | |support, any type, including | | | | | | |fixed mounting hardware, each | | | |E0956 |NU |U1 |((Lateral trunk supports, |N****|Purchase | | |EP |U1 |swing-away, each) Wheelchair | | | | | | |accessory, lateral trunk or hip| | | | | | |support, any type, including | | | | | | |fixed mounting hardware, each | | | |E0956 |NU |U2 | ((Med. Chest Panel Support) |N****|Purchase | | |EP |U2 |Wheelchair accessory, lateral | | | | | | |trunk or hip support, any type,| | | | | | |including fixed mounting | | | | | | |hardware, each | | | |E0956 |NU |U3 |((Chest/Thoracic Supports) |N****|Purchase | | |EP |U3 |Wheelchair accessory, lateral | | | | | | |trunk or hip support, any type,| | | | | | |including fixed mounting | | | | | | |hardware, each | | | |E0957 |NU | |Wheelchair accessory, medial |N |Purchase | | |EP | |thigh support, ((-flip-up) any | | | | | | |type, including fixed mounting | | | | | | |hardware, each | | | |E0958 |NU | |Manual W/C accessory, one-arm |N****|Purchase | | |EP | |drive attachment, each | | | |E0959 |NU | |((Amputee adapters for |N****|Purchase | | |EP | |conventional chair, ea.) | | | | | | |Manual W/C accessory, adapter | | | | | | |for amputee, each | | | |E0959 |NU | | ((Amputee axle plate for high |N****|Purchase | | |EP | |performance manual W/C, ea.) | | | | | | |Manual wheelchair accessory, | | | | | | |adapter for amputee, each | | | |E0959 |NU |U1 |Manual W/C accessory, adapter |N |Purchase | | |EP |U1 |for amputee, each | | | |E0960 |NU | |W/C accessory, shoulder |N |Purchase | | |EP | |harness/straps or chest strap | | | | | | |including any type mounting | | | | | | |hardware | | | |E0961 |NU | |Manual W/C accessory, wheel |N****|Purchase | | |EP | |lock brake extension (handle), | | | | | | |each | | | |E0966 |NU | |Manual wheelchair accessory, |N****|Purchase | | |EP | |headrest extension, each | | | |E0967 |NU | |((Hand rim, any type) Manual |N****|Purchase | | |EP | |W/C accessory, hand rim | | | | | | |w/projections, any type, | | | | | | |replacement only, each | | | |E0967 |NU |U1 |((Hand rim, any type) Manual |N****|Purchase | | |EP |U1 |W/C accessory, hand rim | | | | | | |w/projections, any type, | | | | | | |replacement only, each | | | |E0967 |NU |U2 |((Hand rim, any type) Manual |N****|Purchase | | |EP |U2 |W/C accessory, hand rim | | | | | | |w/projections, any type, | | | | | | |replacement only, each | | | |E0967 |NU |U3 |((Hand rim, any type) Manual |N****|Purchase | | |EP |U3 |W/C accessory, hand rim | | | | | | |w/projections, any type, | | | | | | |replacement only, each | | | |E0967 |NU |U4 |((Hand rim, any type) Manual |N****|Purchase | | |EP |U4 |W/C accessory, hand rim | | | | | | |w/projections, any type, | | | | | | |replacement only, each | | | |E0970 |NU | |No. 2 footplates, except for |N****|Purchase | | |EP | |elevating leg rest | | | |E0971 |NU | |Anti-tipping device W/C |N****|Purchase | | |EP | | | | | |E0973 |NU | |W/C accessory, adjustable |N****|Purchase | | |EP | |height, detachable armrest, | | | | | | |complete assembly, each | | | |E0973 |NU |U1 |((Height Adj. Arms, |N****|Purchase | | |EP |U1 |replacement) W/C accessory, | | | | | | |adjustable height, detachable | | | | | | |armrest, complete assembly, | | | | | | |each | | | |E0974 |NU | |Manual wheelchair accessory, |N****|Purchase | | |EP | |anti-rollback device (( grade | | | | | | |aids), each | | | |E0978 |NU | |Wheelchair accessory, |N****|Purchase | | |EP | |positioning belt/safety | | | | | | |belt/pelvic strap, each | | | |E0978 |NU |U1 |((Belt, safety or chest, w/pad)|N****|Purchase | | |EP |U1 |Wheelchair accessory, |N | | | | | |positioning belt/safety belt/ | | | | | | |pelvic strap, each | | | |E0978 |NU |U2 |Wheelchair accessory, |N****|Purchase | | |EP |U2 |positioning belt/safety | | | | | | |belt/pelvic strap, each | | | |E0980 |NU | |((Chest panel, 21-SM 22-LG) |N****|Purchase | | |EP | |Safety vest, wheelchair | | | |E0980 |NU |U1 |((Shoulder retractors) Safety |N****|Purchase | | |EP |U1 |vest, W/C | | | |E0981 |NU | |W/C accessory, seat upholstery,|N |Purchase | | |EP | |replacement only, each | | | |E0982 |NU | |W/C accessory, back upholstery,|N****|Purchase | | |EP | |replacement only, each | | | |E0982 |NU |U1 |((Standard back upholstery |N****|Purchase | | |EP |U1 |replacement) W/C accessory, | | | | | | |back upholstery, replacement | | | | | | |only, each | | | |E0990 |NU | |((Elevating foot, legrest) W/C|N****|Purchase | | |EP | |accessory, elevating legrest, | | | | | | |complete assembly, each | | | |E0990 |NU |U1 |((Elevating legrest 90 Degree, |N****|Purchase | | |EP |U1 |12" - 16" Width) W/C | | | | | | |accessory, elevating legrest, | | | | | | |complete assembly, each | | | |E0992 |NU | |( (Manual wheelchair accessory,|N****|Purchase | | |EP | |solid seat) | | | |E0992 |NU |U1 |(Manual w/c accessory, solid |N****|Purchase | | |EP |U1 |seat insert (Large adjustable | | | | | | |solid seat w/hardware) | | | |E0992 |NU |U2 |((Foam and Plywood Flat Side |N****|Purchase | | |EP |U2 |Manual wheelchair accessory, | | | | | | |solid seat) | | | |E0992 |NU |U3 |((Foam & Plywood Seat, MPI Like|N****|Purchase | | |EP |U3 |Manual wheelchair accessory, | | | | | | |solid seat) | | | |E0992 |NU |U4 |((Adjustable solid standard |N****|Purchase | | |EP |U4 |seat with hardware Manual | | | | | | |wheelchair accessory, solid | | | | | | |seat) | | | |E0994 |NU | |Armrest, each |N****|Purchase | | |EP | | | | | |E1002 |NU | |W/C accessory power seating |Y( |Purchase | | |EP | |system, tilt only | | | |E1004 |NU | |W/C accessory, power seating |Y( |Purchase | | |EP | |system, recline only, with | | | | | | |mechanical shear reduction | | | |E1006 |NU | |W/C accessory, power seating |Y |Purchase | | |EP | |system, combination tilt and | | | | | | |recline, w/o shear reduction | | | |E1007 |NU | |Wheelchair accessory, power |Y |Purchase | | |EP | |seating system, combination | | | | | | |tilt and recline, with | | | | | | |mechanical shear reduction | | | |E1010 |NU | |W/C accessory, addition to |Y |Purchase | | |EP | |power seating system, power leg| | | | | | |elevation system, including | | | | | | |legrest, each | | | |E1020 |NU | |((Adjustable Contour Lateral |N****|Purchase | | |EP | |Thigh Support) Residual limb | | | | | | |support system for W/C | | | |E1028 |NU | |Wheelchair accessory, manual |N |Purchase | | |EP | |swing-away, retractable or | | | | | | |removable mounting hardware for| | | | | | |joystick, other control | | | | | | |interface or positioning | | | | | | |accessory | | | |E1029 |NU | |((Ventilator Tray With Battery |Y |Purchase | | |EP | |Tray) Wheelchair accessory, | | | | | | |ventilator tray, fixed | | | |E1030 |NU | |Wheelchair accessory, |Y |Purchase | | |EP | |ventilator tray, gimbaled | | | |E1050* |NU | |Full reclining W/C, fixed |N****|Purchase | | |EP | |full-length arms, swing-away, | | | | | | |detachable elevating legrests | | | |E1060* |NU | |Full reclining W/C, detachable |Y( |Purchase | | |EP | |arms, desk or full-length, | | | | | | |swing-away detachable, | | | | | | |elevating legrests | | | |E1070# |EP | |((A maximum use of three months|Y |Rental | | | | |only) Fully-reclining | |only | | | | |wheelchair, detachable arms, | | | | | | |(desk or full-length) | | | | | | |swing-away, detachable | | | | | | |footrest/elevated legrests | | | |E1084* |NU | |Hemi-W/C; detachable arms, desk|N****|Purchase | | |EP | |or full-length, swing-away, | | | | | | |detachable, elevating legrests | | | |E1086* |NU | |Hemi W/C; detachable arms, desk|N****|Purchase | | |EP | |or full-length, swing-away, | | | | | | |detachable footrests | | | |E1086* |NU |U1 |Hemi W/C, detachable arms, desk|Y |Purchase | | |EP |U1 |or full-length, swing-away | | | | | | |detachable footrests | | | |E1088* |NU | |High strength lightweight W/C; |Y( |Purchase | | |EP | |detachable arms, desk or | | | | | | |full-length, swing-away, | | | | | | |detachable, elevating legrests | | | |E1090 |NU | |High-strength lightweight W/C; |N****|Purchase | | |EP | |detachable arms, desk or | | | | | | |full-length, swing-away, | | | | | | |detachable footrests | | | |E1092* |NU | |Wide, heavy-duty W/C; |Y( |Purchase | | |EP | |detachable arms, desk or | | | | | | |full-length, swing-away, | | | | | | |detachable, elevating legrests | | | |E1093* |NU | |Wide, heavy-duty W/C; |Y( |Purchase | | |EP | |detachable arms, desk or | | | | | | |full-length arms, swing-away, | | | | | | |detachable footrests | | | |E1110* |NU | |Semi-reclining W/C; detachable |Y( |Purchase | | |EP | |arms, desk or full-length, | | | | | | |elevating legrests | | | |E1161 |NU | |Manual adult size W/C, includes|Y( |Purchase | | |EP | |tilt in space | | | |E1170* |NU | |Amputee W/C; fixed full-length |N****|Purchase | | |EP | |arms, swing-away, detachable, | | | | | | |elevating legrests | | | |E1172* |NU | |Amputee W/C; detachable arms, |Y( |Purchase | | |EP | |desk or full-length, without | | | | | | |footrests or legrests | | | |E1180* |NU | |Amputee W/C; detachable arms, |Y( |Purchase | | |EP | |desk or full-length, | | | | | | |swing-away, detachable | | | | | | |footrests | | | |E1200* |NU | |Amputee W/C; fixed full-length |N****|Purchase | | |EP | |arms, swing-away, detachable | | | | | | |footrests | | | |E1220* |NU | |W/C, specially sized or |Y |Manually | | |EP | |constructed (indicate brand | |Priced | | | | |name, model number, if any, and| | | | | | |justification) | | | |E1225 |NU | |((Folding Backrest, 8 Degree |N****|Purchase | | |EP | |Bend, Low, 15" - 16") Manual | | | | | | |W/C accessory, semi-reclining | | | | | | |back, (recline greater than 15 | | | | | | |degrees, but less than 80 | | | | | | |degrees), each | | | |E1228 |NU | |((Folding Backrest, Tall, 19" -|N****|Purchase | | |EP | |20") Special back height for | | | | | | |W/C | | | |E1228 |NU | |((Folding Straight Backrest, |N****|Purchase | | |EP | |Low, (15" - 16") Special back | | | | | | |height for W/C | | | |E1228 |NU | |((Folding Straight Backrest, |N****|Purchase | | |EP | |Tall, 19" - 20") Special back | | | | | | |height for W/C | | | |E1228 |NU |U1 |((High back contour seat) |N****|Purchase | | |EP |U1 |Special back height for W/C | | | |E1228 |NU |U2 |((Positioning tall back) |N****|Purchase | | |EP |U2 |Special back height for W/C | | | |E1230* |NU | |Power operated vehicle (three- |Y( |Purchase | | |EP | |or four-wheel nonhighway), | | | | | | |specify brand name and model | | | | | | |number | | | |E1230 |EP |U1 |Power operated vehicle (three- |Y( |Purchase | | |NU |U1 |or four-wheel nonhighway), | | | | | | |specify brand name and model | | | | | | |number | | | |E1232* |EP | |W/C, pediatric size, |Y( |Purchase | | | | |tilt-in-space, folding, | | | | | | |adjustable, with seating system| | | |E1233* |EP | |W/C, pediatric size, |Y( |Purchase | | | | |tilt-in-space, rigid, | | | | | | |adjustable, without seating | | | | | | |system | | | |E1234* |EP | |W/C, pediatric size, |Y( |Purchase | | | | |tilt-in-space, folding, | | | | | | |adjustable, without seating | | | | | | |system | | | |E1235* |NU | |Wheelchair, pediatric size, |Y( |Purchase | | |EP | |rigid, adjustable, with seating| | | | | | |system | | | |E12352 |EP |U1 |((Rigid W/C Frame) W/C, |Y |Purchase | | | | |pediatric size, rigid, | | | | | | |adjustable with seating system | | | |E1236 |EP | |Wheelchair, pediatric size, |Y |Purchase | | | | |folding, adjustable, with | | | | | | |seating system | | | |E1237* |EP | |W/C, pediatric size, rigid, |Y( |Purchase | | | | |adjustable, without seating | | | | | | |system | | | |E1238* |EP | |W/C, pediatric size, folding, |Y( |Purchase | | | | |adjustable, without seating | | | | | | |system | | | |E1240* |NU | |Lightweight W/C; detachable |Y( |Purchase | | |EP | |arms, desk or full-length, | | | | | | |swing-away, detachable, | | | | | | |elevating legrests | | | |E1260* |NU | |Lightweight W/C; detachable |N****|Purchase | | |EP | |arms, desk or full-length, | | | | | | |swing-away, detachable | | | | | | |footrests | | | |E1280* |NU | |Heavy-duty W/C; detachable |Y( |Purchase | | |EP | |arms, desk or full-length, | | | | | | |elevating legrests | | | |E1290* |NU | |Heavy-duty W/C; detachable |Y( |Purchase | | |EP | |arms, swing-away, detachable | | | | | | |footrests | | | |E2201 |NU | |((Seat Width 20") Manual w/c |N****|Purchase | | |EP | |accessory, nonstandard seat | | | | | | |frame width > than or equal to | | | | | | |20 inches and < 24 inches | | | |E2201 |NU |U1 |((Frame Width 14"-15") Manual |N****|Purchase | | |EP |U1 |w/c accessory, nonstandard seat| | | | | | |frame width > than or equal to | | | | | | |20 inches and < 24 inches | | | |E2201 |NU |U2 |((Frame Width 19"-20") Manual |N****|Purchase | | |EP |U2 |w/c accessory, nonstandard seat| | | | | | |frame width > than or equal to | | | | | | |20 inches and < 24 inches | | | |E2201 |NU |U3 |Manual w/c accessory, |N****|Manually | | |EP |U3 |nonstandard seat frame width > | |Priced | | | | |than or equal to 20 inches and | | | | | | |< 24 inches | | | |E2203 |NU | |((Seat Depth 15") Manual w/c |N****|Purchase | | |EP | |accessory, nonstandard seat | | | | | | |frame depth, 20 to less than 22| | | | | | |inches | | | |E2203 |NU |U1 |((Seat Depth 17" - 18") Manual|N****|Purchase | | |EP |U1 |w/c accessory, nonstandard seat| | | | | | |frame depth, 20 to less than 22| | | | | | |inches | | | |E2203 |NU |U2 |((Frame, Long; 16", 17"3, 18", |N****| | | |EP |U2 |19"3, 20" Depth) Manual w/c | |Purchase | | | | |accessory, nonstandard seat | | | | | | |frame depth, 20 to less than 22| | | | | | |inches | | | |E2203 |NU |U3 |((Seat Depth 19" - 20") Manual|N****|Purchase | | |EP |U3 |w/c accessory, nonstandard seat| | | | | | |frame depth, 20 to less than 22| | | | | | |inches | | | |E2203 |NU |U4 |Manual w/c accessory, |N |Manually | | |EP |U4 |nonstandard seat frame depth, | |Priced | | | | |20 to less than 22 inches | | | |E2206 |NU | |Manual wheelchair accessory, |N |Purchase | | |EP | |wheel lock assembly, complete, | | | | | | |each | | | |E2207 |NU | |Wheelchair accessory, crutch |N****|Purchase | | |EP | |and cane holder, each | | | |E2208 |NU | |Wheelchair accessory, cylinder |N |Purchase | | |EP | |tank carrier, each | | | |E2209 |NU | |Wheelchair accessory, arm |N |Purchase | | |EP | |trough, each | | | |E2210 |NU | |Wheelchair accessory, bearings,|N |Purchase | | |EP | |any type, replacement only, | | | | | | |each | | | |E2211 |NU | |Manual wheelchair accessory, |N |Purchase | | |EP | |pneumatic propulsion tire, any | | | | | | |size, each | | | |E2212 |NU | |Manual wheelchair accessory, |N |Purchase | | |EP | |tube for pneumatic propulsion | | | | | | |tire, any size, each | | | |E2213 |NU | |Manual wheelchair accessory, |N |Purchase | | |EP | |insert for pneumatic propulsion| | | | | | |tire (removable), any type, any| | | | | | |size, each | | | |E2214 |NU | |Manual wheelchair accessory, |N |Purchase | | |EP | |pneumatic caster tire, any | | | | | | |size, each | | | |E2215 |NU | |Manual wheelchair accessory, |N |Purchase | | |EP | |tube for pneumatic caster tire,| | | | | | |any size, each | | | |E2220 |NU | |Manual wheelchair accessory, |N |Purchase | | |EP | |solid (rubber/plastic) | | | | | | |propulsion tire, any size, each| | | |E2221 |NU | |Manual wheelchair accessory, |N |Purchase | | |EP | |solid (rubber/plastic) caster | | | | | | |tire (removable), any size, | | | | | | |each | | | |E2226 |NU | |Manual wheelchair accessory, |N |Purchase | | |EP | |caster fork, any size, | | | | | | |replacement only, each | | | |E2231 |NU | |Manual wheelchair accessory, |Y |Purchase | | |EP | |solid seat support base | | | | | | |(replaces sling seat), includes| | | | | | |any type mounting hardware | | | |E2291 |EP | |Back, planar, for |N |Manually | | | | |pediatric-size wheelchair, | |Priced | | | | |including fixed attaching | | | | | | |hardware | | | |E2292 |EP | |Seat, planar, for |N |Manually | | | | |pediatric-size wheelchair, | |Priced | | | | |including fixed attaching | | | | | | |hardware | | | |E2293 |EP | |Back, contoured, for |N |Manually | | | | |pediatric-size wheelchair, | |Priced | | | | |including fixed attaching | | | | | | |hardware | | | |E2294 |EP | |Seat, contoured, for |N |Manually | | | | |pediatric-size wheelchair, | |Priced | | | | |including fixed attaching | | | | | | |hardware | | | |E2295 |EP | |Manual wheelchair accessory, |Y |Manually | | | | |for pediatric size wheelchair, | |Priced | | | | |dynamic seating frame, allows | | | | | | |coordinated movement of | | | | | | |multiple positioning features | | | |E2310 |NU | |Power w/c accessory, electronic|Y |Purchase | | |EP | |connection between wheelchair | | | | | | |controller and one power | | | | | | |seating system motor, including| | | | | | |all related electronics, | | | | | | |indicator feature, mechanical | | | | | | |function selection switch, and | | | | | | |fixed mounting hardware | | | |E2311 |NU | |Power w/c accessory, electronic|Y |Purchase | | |EP | |connection between wheelchair | | | | | | |controller and two or more | | | | | | |power seating system motors, | | | | | | |including all related | | | | | | |electronics, indicator feature,| | | | | | |mechanical function selection | | | | | | |switch, and fixed mounting | | | | | | |hardware | | | |E2322 |NU | |Power w/c accessory, hand |Y |Purchase | | |EP | |control interface, multiple | | | | | | |mechanical switches, | | | | | | |nonproportional, including all | | | | | | |related electronics, mechanical| | | | | | |stop switch, and fixed mounting| | | | | | |hardware | | | |E2323 |NU | |Power w/c accessory, specialty |Y |Purchase | | |EP | |joystick handle for hand | | | | | | |control interface, | | | | | | |prefabricated | | | |E2324 |NU | |Power w/c accessory, chin cup |Y |Purchase | | |EP | |for chin control interface | | | |E2325 |NU | |Power w/c accessory, sip & puff|Y |Purchase | | |EP | |interface nonproportional, | | | | | | |including all related | | | | | | |electronics, mechanical stop | | | | | | |switch, and manual swing-away | | | | | | |mounting hardware | | | |E2326 |NU | |Power wheelchair accessory, |Y |Purchase | | |EP | |breath tube kit for sip and | | | | | | |puff interface ( (replacement | | | | | | |only) | | | |E2327 |NU | |Power w/c accessory, head |Y |Purchase | | |EP | |control interface, mechanical, | | | | | | |proportional, including all | | | | | | |related electronics, mechanical| | | | | | |direction change switch, and | | | | | | |fixed mounting hardware | | | |E2359 |NU | |Power w/c accessory, group 34 |N |Purchase | | |EP | |sealed lead acid battery, each | | | |E2360 |NU | |Power w/c accessory, 22 NF |N |Purchase | | |EP | |non-sealed lead acid battery, | | | | | | |each | | | |E2361 |NU | |Power w/c accessory, 22 NF |N |Purchase | | |EP | |sealed lead acid battery, each,| | | | | | |(e.g., gel cell, absorbed | | | | | | |glassmat) | | | |E2363 |NU | |Power w/c accessory, group 24 |N |Purchase | | |EP | |sealed lead acid battery, each | | | | | | |(e.g., gel cell, absorbed | | | | | | |glassmat) | | | |E2363 |NU |U1 |Power w/c accessory, group 24 |N |Purchase | | |EP |U1 |sealed lead acid battery, each | | | | | | |(e.g., gel cell, absorbed | | | | | | |glassmat) | | | |E2365 |NU | |((U-1 gel cell battery, each) |N |Purchase | | |EP | |Power wheelchair accessory, U-1| | | | | | |sealed lead acid battery, each,| | | | | | |(e.g., gel cell, absorbed | | | | | | |glassmat) | | | |E2365 |NU |U1 |Power w/c accessory, U-1 sealed|N |Purchase | | |EP |U1 |lead acid battery, each, gel | | | | | | |cell | | | |E2366 |NU | |((24-Volt Battery Charger - |N |Purchase | | |EP | |Standard, Replacement) Power | | | | | | |w/c accessory, battery charger,| | | | | | |single mode, for use with only | | | | | | |one battery type, sealed or | | | | | | |non-sealed, each | | | |E2367 |NU | |((24-Volt Battery Charger - |N |Purchase | | |EP | |Dual Mode, Replacement) Power | | | | | | |w/c accessory, battery charger,| | | | | | |dual mode, sealed or | | | | | | |non-sealed, each | | | |E2368 |NU | |Power wheelchair component, |N |Purchase | | |EP | |motor, replacement only | | | |E2369 |NU | |Power wheelchair component, |N |Purchase | | |EP | |gear box, replacement only | | | |E2370 |NU | |Power wheelchair component, |Y |Purchase | | |EP | |motor and gear box combination,| | | | | | |replacement only | | | |E2372 |NU | |Power wheelchair accessory, |Y |Purchase | | |EP | |group 27 non-sealed lead acid | | | | | | |battery, each | | | |E2373 |NU | |Power wheelchair accessory, |Y |Purchase | | |EP | |hand or chin control interface,| | | | | | |mini-proportional, compact, or | | | | | | |short throw remote joystick or | | | | | | |touchpad, proportional, | | | | | | |including all related | | | | | | |electronics and fixing mounting| | | | | | |hardware. | | | |E2375 |NU | |Power wheelchair accessory, |Y |Purchase | | |EP | |nonexpandable controller, | | | | | | |including all related | | | | | | |electronics and mounting | | | | | | |hardware, replacement only | | | |E2376 |NU | |Power wheelchair accessory, |Y |Purchase | | |EP | |expandable controller, | | | | | | |including all related | | | | | | |electronics and mounting | | | | | | |hardware, replacement only | | | |E2377 |NU | |Power wheelchair accessory, |Y |Purchase | | |EP | |expandable controller, | | | | | | |including all related | | | | | | |electronics and mounting | | | | | | |hardware, upgrade provided at | | | | | | |initial issue | | | |E2378 |NU | |Power wheelchair component, |Y |Purchase | | |EP | |actuator, replacement only | | | |E2381 |NU | |Power wheelchair accessory, |Y |Purchase | | |EP | |pneumatic drive wheel tire, any| | | | | | |size, replacement only, each | | | |E2382 |NU | |Power wheelchair accessory, |Y |Purchase | | |EP | |tube for pneumatic drive wheel | | | | | | |tire, any size, replacement | | | | | | |only, each | | | |E2383 |NU | |Power wheelchair accessory, |Y |Purchase | | |EP | |insert for pneumatic drive | | | | | | |wheel tire (removable), any | | | | | | |type, any size, replacement | | | | | | |only, each | | | |E2384 |NU | |Power wheelchair accessory, |Y |Purchase | | |EP | |pneumatic caster tire, any | | | | | | |size, replacement only, each | | | |E2385 |NU | |Power wheelchair accessory, |Y |Purchase | | |EP | |tube for pneumatic caster tire,| | | | | | |any size, replacement only, | | | | | | |each | | | |E2386 |NU | |Power wheelchair accessory, |Y |Purchase | | |EP | |foam filled drive wheel tire, | | | | | | |any size, replacement only, | | | | | | |each | | | |E2387 |NU | |Power wheelchair accessory, |Y |Purchase | | |EP | |foam caster tire, any size, | | | | | | |replacement only, each | | | |E2601 |NU | |General use wheelchair seat |N****|Purchase | | |EP | |cushion, width less than 22 | | | | |UE | |in., any depth | | | |E2602 |NU | |General use wheelchair seat |N |Purchase | | |EP | |cushion, width 22 in. or | | | | |UE | |greater, any depth | | | |E2611 |NU | |General use wheelchair back |N |Purchase | | |EP | |cushion, width less than 22 | | | | |UE | |in., any height, including any | | | | | | |type mounting hardware | | | |E2612 |NU | |General use wheelchair back |N |Purchase | | |EP | |cushion, width 22 in. or | | | | |UE | |greater, any height, including | | | | | | |any type mounting hardware | | | |E2619 |NU | |Replacement cover for |N |Purchase | | |EP | |wheelchair seat cushion or back| | | | | | |cushion, each | | | |E2622 |NU | |Skin protection wheelchair seat|N |Purchase | | |EP | |cushion, adjustable, width less| | | | |UE | |than 22 inches, any depth | | | |E2623 |NU | |Skin protection wheelchair seat|N |Purchase | | |EP | |cushion, adjustable, width 22 | | | | |UE | |inches or greater, any depth | | | |E2624 |NU | |Skin protection and positioning|N |Purchase | | |EP | |wheelchair seat cushion, | | | | |UE | |adjustable width less than 22 | | | | | | |inches, any depth | | | |E2625 |NU | |Skin protection and positioning|N |Purchase | | |EP | |wheelchair seat cushion, | | | | |UE | |adjustable width 22 inches or | | | | | | |greater, any depth | | | |E2626 |NU | |Wheelchair accessory, shoulder |Y |Purchase | | |EP | |elbow, mobile arm support | | | | | | |attached to wheelchair, | | | | | | |balanced, adjustable | | | |E2627 |NU | |Wheelchair accessory, shoulder |Y |Purchase | | |EP | |elbow, mobile arm support | | | | | | |attached to wheelchair, | | | | | | |balanced, adjustable Rancho | | | | | | |type | | | |E2628 |NU | |Wheelchair accessory, shoulder |Y |Purchase | | |EP | |elbow, mobile arm support | | | | | | |attached to wheelchair, | | | | | | |balanced, reclining | | | |E2629 |NU | |Wheelchair accessory, shoulder |Y |Purchase | | |EP | |elbow, mobile arm support | | | | | | |attached to wheelchair, | | | | | | |balanced, friction arm support | | | | | | |(friction dampening to proximal| | | | | | |and distal joints) | | | |E2630 |NU | |Wheelchair accessory, shoulder |Y |Purchase | | |EP | |elbow, mobile arm support, | | | | | | |monosuspension arm and hand | | | | | | |support, overhead elbow forearm| | | | | | |hand sling support, yoke type | | | | | | |suspension support | | | |E2631 |NU | |Wheelchair accessory, addition |Y |Purchase | | |EP | |to mobile arm support, | | | | | | |elevating proximal arm | | | |E2632 |NU | |Wheelchair accessory, addition |Y |Purchase | | |EP | |to mobile arm support, offset | | | | | | |or lateral rocker arm with | | | | | | |elastic balance control | | | |E2633 |NU | |Wheelchair accessory, addition |Y |Purchase | | |EP | |to mobile arm support, | | | | | | |supinator | | | |K0004 |NU | |High-strength lightweight |Y****|Purchase | | |EP | |wheelchair | | | |K0005* |NU | |((High-performance manual |Y( |Purchase | | |EP | |W/C-adult) Ultralightweight | | | | | | |W/C | | | |K0005* |NU |U1 |((High-performance manual W/C |Y( |Purchase | | |EP |U1 |with growth | | | | | | |adjustability-child) | | | | | | |Ultralightweight W/C | | | |K0010 |NU | |((Motorized, standard frame, |Y( |Purchase | | |EP | |DA, swing- away footrests) | | | | | | |Standard weight frame | | | | | | |motorized/power W/C | | | |K0010 |NU |U1 |((Motorized, standard frame, |Y( |Purchase | | |EP |U1 |DA, swing- away ELR) Standard | | | | | | |weight frame motorized/power | | | | | | |W/C | | | |K0011 |NUE| |((Motorized, power base or |Y( |Purchase | | |P | |conventional frame w/c | | | | | | |DA/swing-away footrests, | | | | | | |programmable electronics and | | | | | | |custom options) | | | | | | |Standard-weight frame | | | | | | |motorized/power, W/C with | | | | | | |programmable control parameters| | | | | | |for speed adjustment, tremor | | | | | | |dampening, acceleration control| | | | | | |and braking | | | |K0011 |NU |U1 |((Motorized, power base or |Y( |Purchase | | |EP |U1 |conventional frame w/c | | | | | | |DA/swing-away footrests, | | | | | | |programmable electronics and | | | | | | |custom options) | | | | | | |Standard-weight frame | | | | | | |motorized/power, W/C with | | | | | | |programmable control parameters| | | | | | |for speed adjustment, tremor | | | | | | |dampening, acceleration control| | | | | | |and braking | | | |K0012 |NU | |((Motorized folding frame, DA, |Y( |Purchase | | |EP | |swing-away footrests) | | | | | | |Lightweight portable | | | | | | |motorized/power W/C | | | |K0012 |NU |U1 |((Motorized folding frame, DA, |Y( |Purchase | | |EP |U1 |swing- away ELR) Lightweight | | | | | | |portable motorized/power W/C | | | |K00141,2 |NU | |Other motorized/power W/C base |Y( |Purchase | | |EP | | | | | |K00141,2 |NU |U1 |((Center Drive power base) |Y( |Purchase | | |EP |U1 |Other motorized/ power W/C base| | | |K00141,2 |NU |U3 |( (Motorized, Power Base or |Y( |Purchase | | |EP |U3 |conventional frame W/C | | | | | | |DA/swing-away foot rests, | | | | | | |programmable electronics and | | | | | | |custom options) Other | | | | | | |motorized/power W/C base | | | |K00141,2 |NU |U4 |( (Motorized, Power Base or |Y( |Purchase | | |EP |U4 |conventional frame W/C | | | | | | |DA/swing-away elevated foot | | | | | | |rests, programmable electronics| | | | | | |and custom options) Other | | | | | | |motorized/power W/C base | | | |K0017 |NU | |((Receiver for height |N****|Purchase | | |EP | |adjustable arms) Detachable, | | | | | | |adjustable height armrest, | | | | | | |base, each | | | |K0017 |NU |U1 |((Dual post and adjustable |N****|Purchase | | |EP |U1 |height DA) Detachable, | | | | | | |adjustable height armrest, | | | | | | |base, each | | | |K0019 |NU | |Arm pad, each |N |Purchase | | |EP | | | | | |K0020 |NU | |Fixed, adjustable height |N****|Purchase | | |EP | |armrest, pair | | | |K0038** |EP |U1 |((Knee strap) Leg strap, each |N |Purchase | |K0038 |NU | |((Single leg strap, each) Leg |N****|Purchase | | |EP | |strap, each | | | |K0038 |NU |U2 |((Foot straps, pair) Leg |N****|Purchase | | |EP |U2 |strap, each | | | |K0039 |NU | |Leg strap, H style, each |N****|Purchase | | |EP | | | | | |K0040 |NU | |Adjustable angle footplate, |N****|Purchase | | |EP | |each | | | |K0043 |NU | |((SWFR, replacement) Footrest,|N |Purchase | | |EP | |lower extension tube, each | | | |K0044 |NU | |((SWFR Hanger bracket, |N****|Purchase | | |EP | |replacement) Footrest, upper | | | | | | |hanger bracket, each | | | |K0045 |NU | |((Padded custom foot box) |N****|Purchase | | |EP | |Footrest, complete assembly | | | |K0047 |NU | |Elevating legrest, upper hanger|N****|Purchase | | |EP | |bracket, each | | | |K0056 |NU | |Seat height less than 17 inches|N****|Manually | | |EP | |or equal to or greater than 21 | |Priced | | | | |inches for a high-strength, | | | | | | |lightweight, or | | | | | | |ultralightweight W/C | | | |K0056 |NU |U1 |((Seat height 19.5"5) Seat |N****|Purchase | | |EP |U1 |height less than 17 inches or | | | | | | |equal to or greater than 21 | | | | | | |inches for a high strength, | | | | | | |lightweight or ultralightweight| | | | | | |W/C | | | |K0065 |NU | |Spoke protectors, each |N****|Purchase | | |EP | | | | | |K0070 |NU | |((Wheel assembly, complete with|N****|Purchase | | |EP | |pneumatic tires, | | | | | | |20”/22”/24”/26”/ea. | | | | | | |replacement) Rear wheel | | | | | | |assembly, complete with | | | | | | |pneumatic tire, spokes or | | | | | | |molded, each | | | |K0071 |NU |U1 |((Wheel assembly with pneumatic|N****|Purchase | | |EP |U1 |tires, 22”, pair, rear wheels) | | | | | | |Front caster assembly, | | | | | | |complete, with pneumatic tire, | | | | | | |each | | | |K0071 |NU | |((Polyurethane casters, 5”, |N****|Purchase | | |EP | |pair, front casters) Front | | | | | | |caster assembly, complete, with| | | | | | |pneumatic tire, each | | | |K0072 |NU | |((Polyurethane casters, 5”, |N****|Purchase | | |EP | |pair, front casters) Front | | | | | | |caster assembly, complete, with| | | | | | |semipneumatic tire, each | | | |K0073 |NU | |Caster pin lock, each |N****|Purchase | | |EP | | | | | |K0077 |NU | |Front caster assembly, |N |Purchase | | |EP | |complete, with solid tire, each| | | |K0108 |NU | |((W/C miscellaneous equipment; |N****|Manually | | |EP | |applicable pages from the | |Priced | | | | |manufacturer’s catalog must be | | | | | | |attached to the claim form.) | | | | | | |Other accessories | | | |K0739 |NU |U1 |((Labor only, Repair or |Y |Purchase | | |EP |U1 |non-routine service for durable| | | | | | |medical equipment requiring the| | | | | | |skill of a technician, labor | | | | | | |component, per 15 minutes. A | | | | | | |maximum of twenty units per | | | | | | |date of service is allowable, | | | | | | |20 units = 5 hours of labor) | | | |S1002 |EP | |((Wheelchair, custom molded |N****|Manually | | | | |seating system only) | |Priced | | | | |Customized item, list in | | | | | | |addition to code for basic item| | | |S1002 |NU |U1 |((Foam-in-place seat, Pindot |N****|Purchase | | |EP |U1 |quick foam contour system) | | | | | | |Customized item, list in | | | | | | |addition to code for basic item| | |

|The following procedure codes may be billed only on paper. | |Wheelchairs and Wheelchair Seating Systems for Individuals Ages Two | |Through Adult (Section 242.191) | |No National Code |M1 |

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

Modifiers in this section are indicated by the headings M1 and M2. Prior authorization requirements are shown under the heading PA. If prior authorization is needed, that information is indicated with a “Y” in the column; if not, an “N” is shown. ** Indicates that providers may bill only for beneficiaries under age 21. ( Prior authorization is not required when other insurance pays at least 50% of the Medicaid maximum allowable reimbursement amount. ((…) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product. When using a procedure code with this symbol, the product must meet the indicated Arkansas Medicaid description.

|Specialized Rehabilitative Equipment, All Ages (Section 242.192) | |Procedure |M1 |M2 |Description |PA |Payment | |Code | | | | |Method | |A8000 |NU | |Helmet, protective, soft, |N |Purchase | | |EP | |prefabricated, includes all | | | | | | |components and accessories | | | |A8001 |NU | |Helmet, protective, hard, |N |Purchase | | |EP | |prefabricated, includes all | | | | | | |components and accessories | | | |A8002 |NU | |Helmet, protective, soft, custom |N |Purchase | | |EP | |fabricated, includes all | | | | | | |components and accessories | | | |A8003 |NU | |Helmet, protective, hard, custom |N |Purchase | | |EP | |fabricated, includes all | | | | | | |components and accessories | | | |E0149 |NU | |((4 Wheel Reverse Walker) |N |Purchase | | |EP | |Walker, heavy-duty, wheeled, | | | | | | |rigid or folding, any type | | | |E0163 |EP |U1 |((Potty Chair - Small) Commode |Y |Purchase | | |NU |U1 |chair, stationary, with fixed | | | | | | |arms | | | |E0168 |EP | |((Rehab Shower/Commode Chair) |Y( |Purchase | | | | |Commode chair, extra wide and/or | | | | | | |heavy-duty, stationary or mobile,| | | | | | |with or without arms, any type, | | | | | | |each | | | |E0168 |EP |UB |((Adaptive Commode Chair) |N |Purchase | | | | |Commode chair, extra wide and/or | | | | | | |heavy-duty, stationary or mobile,| | | | | | |with or without arms, any type, | | | | | | |each | | | |E0168 |NU | |((Adaptive Commode Chair) |N |Purchase | | | | |Commode chair, extra wide and/or | | | | | | |heavy-duty, stationary or mobile,| | | | | | |with or without arms, any type, | | | | | | |each | | | |E0168 |NU |U1 |((Rehab Shower/Commode Chair) |Y( |Purchase | | | | |Commode chair, extra wide and/or | | | | | | |heavy-duty, stationary or mobile,| | | | | | |with or without arms, any type, | | | | | | |each | | | |E0241 |NU | |((Bolt-on Sm. Grab Bar) Bathroom|N |Purchase | | |EP | |wall rail, each | | | |E0241 |NU |U1 |((Bolt-on Lg. Grab Bar) Bathroom|N |Purchase | | |EP |U1 |wall rail, each | | | |E0241 |NU |U2 |((Bolt-on Med. Grab Bar) |N |Purchase | | |EP |U2 |Bathroom wall rail, each | | | |E0245 |NU | |((Adj. Bath Chair w/Back) Tub |N |Purchase | | |EP | |stool or bench | | | |E0245 |NU |U2 |((Padded Tub Transfer Bench) Tub|N |Purchase | | |EP |U2 |stool or bench | | | |E0245 |NU |U3 |((30” Bath Chair) Tub stool or |N |Purchase | | |EP |U3 |bench | | | |E0245 |NU |U4 |((38” Bath Chair) Tub stool or |N |Purchase | | |EP |U4 |bench | | | |E0245 |NU |U5 |((47” Bath Chair) Tub stool or |N |Purchase | | |EP |U5 |bench | | | |E0245 |NU |U6 |((56” Bath Chair) Tub stool or |N |Purchase | | |EP |U6 |bench | | | |E0245 |NU |UB |((Non-padded tub transfer bench) |N |Purchase | | |EP |UB |Tub stool or bench | | | |E0246 |NU | |((Clamp-on Tub Grab Bar) |N |Purchase | | |EP | |Transfer tub rail attachment | | | |E0637 |NU | |Combination sit-to-stand |Y |Purchase | | |EP | |frame/table system, any size, | | | | | | |including pediatric, with seat | | | | | | |lift feature, with or without | | | | | | |wheels | | | |E0638 |NU | |Standing frame system, any size, |Y |Purchase | | |EP | |with or without wheels | | | |E0638 |EP |U1 |Standing frame system, any size, |Y |Purchase | | |EP |U2 |with or without wheels | | | |E0700 |NU | |((Chin Guard for Safety Helmet, |N |Purchase | | |EP | |Sm.) Safety equipment, e.g., | | | | | | |belt, harness or vest | | | |E0705 |NU | |Transfer device, any type, each |Y |Purchase | | |EP | | | | | |E0911 |NU | |Trapeze bar, heavy-duty, for |N |Capped | | |EP | |patient weight capacity greater | |Rental | | | | |than 250 pounds, attached to bed,| | | | | | |with grab bar | | | |E0950 |NU |U1 |((Tray for gait trainer) |N |Purchase | | |EP |U1 |Wheelchair accessory, tray, each | | | |E1031** |EP | |((Transition Toddler Chair - Sm.)|N |Purchase | | | | |Rollabout chair, any and all | | | | | | |types with casters five inches or| | | | | | |greater | | | |E1031** |EP | |((Transition Toddler Chair - Lg.)|Y |Purchase | | | | |Rollabout chair, any and all | | | | | | |types with casters five inches or| | | | | | |greater | | | |E1031** |EP |U1 |((Corner Chair w/Tray & Casters -|N |Purchase | | | | |Sm.) Rollabout chair, any and | | | | | | |all types with casters five | | | | | | |inches or greater | | | |E1031** |EP |U2 |Rollabout chair, any and all |N |Purchase | | | | |types with casters five inches or| | | | | | |greater | | | |E1031** |EP |U3 |((Corner Chair w/Tray & Casters -|N |Purchase | | | | |Lg.) Rollabout chair, any and | | | | | | |all types with casters five | | | | | | |inches or greater | | | |E1031** |EP |U4 |((Bolster Chair w/Tray, Chest |N |Purchase | | | | |Support & Casters - Sm.) | | | | | | |Rollabout chair, any and all | | | | | | |types with casters five inches or| | | | | | |greater | | | |E1031** |EP |U5 |((Low Back Activity Chair) |N |Purchase | | | | |Rollabout chair, any and all | | | | | | |types with casters five inches or| | | | | | |greater | | | |E1035** |EP | |((Carrie Seat - Preschool) |Y |Purchase | | | | |Multi-positional patient transfer| | | | | | |system, with integrated seat, | | | | | | |operated by care giver | | | |E1035** |EP |U1 |((Carrie Seat - Elementary) |Y |Purchase | | | | |Multi-positional patient transfer| | | | | | |system, with integrated seat, | | | | | | |operated by care giver | | | |E1035** |EP |U2 |((Carrie Seat - Jr.) |Y |Purchase | | | | |Multi-positional patient transfer| | | | | | |system, with integrated seat, | | | | | | |operated by care giver | | | |E1035 |NU |U3 |((Carrie Seat - Sm. Adult) |Y( |Purchase | | |EP |U3 |Multi-positional patient transfer| | | | | | |system, with integrated seat, | | | | | | |operated by care giver | | | |E8000 |EP | |((14”) Gait trainer, pediatric |Y |Manually | | | | |size, posterior support, includes| |Priced | | | | |all accessories and components | | | |E8000 |EP |U1 |((19”) Gait trainer, pediatric |Y |Manually | | | | |size, posterior support, includes| |Priced | | | | |all accessories and components | | | |E8000 |EP |U2 |((Intermediate) Gait trainer, |Y |Manually | | | | |pediatric size, posterior | |Priced | | | | |support, includes all accessories| | | | | | |and components | | | |E8001 |EP | |((14”) Gait trainer, pediatric |Y |Manually | | | | |size, upright support, includes | |Priced | | | | |all accessories and components | | | |E8001 |EP |U1 |((19”) Gait trainer, pediatric |Y |Manually | | | | |size, upright support, includes | |Priced | | | | |all accessories and components | | | |E8001 |EP |U2 |((Intermediate) Gait trainer, |Y |Manually | | | | |pediatric size, upright support, | |Priced | | | | |includes all accessories and | | | | | | |components | | | |E8002 |EP | |((14”) Gait trainer, pediatric |Y |Manually | | | | |size, anterior support, includes | |Priced | | | | |all accessories and components | | | |E8002 |EP |U1 |((19”) Gait trainer, pediatric |Y |Manually | | | | |size, anterior support, includes | |Priced | | | | |all accessories and components | | | |E8002 |EP |U2 |((Intermediate) Gait trainer, |Y |Manually | | | | |pediatric size, anterior support,| |Priced | | | | |includes all accessories and | | | | | | |components | | |

|The following list of codes may only be billed on paper. | |Specialized Rehabilitative Equipment, All Ages (Section 242.192) | |No |M1 |Local |Description |PA |Payment | |National| |Code | | |Method | |Code | | | | | | |Bill on |NU |Z1996 |Sm. 51” Supine Stander |Y( |Purchase | |paper |EP | | | | | |Bill on |NU |Z1997 |Lg. 71” Supine Stander |Y( |Purchase | |paper |EP | | | | | |Bill on |EP |Z1998** |27” Prone Stander |Y |Purchase | |paper | | | | | | |Bill on |EP |Z1999** |35” Prone Stander |Y |Purchase | |paper | | | | | | |Bill on |EP |Z2000** |42” Prone Stander |Y( |Purchase | |paper | | | | | | |Bill on |NU |Z2001 |50” Prone Stander |Y( |Purchase | |paper |EP | | | | | |Bill on |NU |Z2002 |Adj. Abduction Wedge w/hip |N |Purchase | |paper |EP | |stabilizer | | | |Bill on |NU |Z2003 |Tray for Stander-Prone |N |Purchase | |paper |EP | | | | | |Bill on |NU |Z2004 |Tray for Stander-Supine |N |Purchase | |paper |EP | | | | | |Bill on |NU |Z2005 |Foot Sandals for Standers |N |Purchase | |paper |EP | | | | | |Bill on |EP |Z2006** |Up Rite Stander - Sm. |Y |Purchase | |paper | | | | | | |Bill on |EP |Z2007** |Up Rite Stander - Med. |Y |Purchase | |paper | | | | | | |Bill on |NU |Z2008 |Up Rite Stander - Lg. |Y |Purchase | |paper |EP | | | | | |Bill on |NU |Z2009 |Caster Base for Up Rite |N |Purchase | |paper |EP | |Stander - Sm. | | | |Bill on |NU |Z2010 |Caster Base for Up Rite |N |Purchase | |paper |EP | |Stander - Med. | | | |Bill on |NU |Z2011 |Caster Base for Up Rite |N |Purchase | |paper |EP | |Stander - Lg. | | | |Bill on |EP |Z2012** |Tumble Form Tri Stander |Y( |Purchase | |paper | | |w/Tray - Sm. | | | |Bill on |EP |Z2013** |Tumble Form Tri Stander |Y( |Purchase | |paper | | |w/Tray - Lg. | | | |Bill on |EP |Z2015** |48” Side Lyer |N |Purchase | |paper | | | | | | |Bill on |EP |Z2016** |72” Side Lyer |N |Purchase | |paper | | | | | | |Bill on |EP |Z2017** |Tumble Form Feeder Seat - |N |Purchase | |paper | | |Sm. | | | |Bill on |NU |Z2018** |Tumble Form Feeder Seat - |N |Purchase | |paper |EP | |Med. | | | |Bill on |EP |Z2019** |Tumble Form Feeder Seat - |N |Purchase | |paper | | |Lg. | | | |Bill on |EP |Z2021** |Mobile Floor Sitter Med/Lg. |N |Purchase | |paper | | | | | | |Bill on |EP |Z2038** |Therapy Ball - Sm. |N |Purchase | |paper | | | | | | |Bill on |EP |Z2039** |Therapy Ball - Med. |N |Purchase | |paper | | | | | | |Bill on |EP |Z2040** |Therapy Ball - Lg. |N |Purchase | |paper | | | | | | |Bill on |EP |Z2043** |Seat & Back Pad for Toddler |Y |Purchase | |paper | | |Chairs | | | |Bill on |EP |Z2044** |Tray for Toddler Chair |Y |Purchase | |paper | | | | | | |Bill on |EP |Z2045** |14” T&S High Back w/Support |Y |Purchase | |paper | | |Activity Chair | | | |Bill on |EP |Z2046** |16” T&S High Back w/Support |Y |Purchase | |paper | | |Activity Chair | | | |Bill on |NU |Z2047 |Orthopedic Car Seat |Y |Purchase | |paper |EP | | | | | |Bill on |NU |Z2072 |Lg. Wrap Around Bath Support|N |Purchase | |paper |EP | | | | | |Bill on |NU |Z2073 |Sm. Wrap Around Back Support|N |Purchase | |paper |EP | | | | | |Bill on |NU |Z2074 |Lg. Toilet Support w/Hi Back|N |Purchase | |paper |EP | | | | | |Bill on |NU |Z2075 |Sm. Toilet Support w/Hi Back|N |Purchase | |paper |EP | | | | | |Bill on |NU |Z2077 |Flexible Shower Hose |N |Purchase | |paper |EP | | | | | |Bill on |NU |Z2089 |Toilet Seat Reducer Ring |N |Purchase | |paper |EP | |(Padded) | | | |Bill on |NU |Z2093 |Adult Gait Trainer |Y( |Purchase | |paper |EP | | | | | |Bill on |EP |Z2094** |Tyke Strider Walker w/2 |N |Purchase | |paper | | |Wheels | | | |Bill on |EP |Z2095** |Tweener Strider Walker |N |Purchase | |paper | | |w/2 Wheels | | | |Bill on |EP |Z2096** |Middle Strider Walker w/2 |N |Purchase | |paper | | |Wheels | | | |Bill on |NU |Z2097 |Adult Strider Walker w/2 |N |Purchase | |paper |EP | |Wheels | | | |Bill on |NU |Z2099 |4 Wheel Reverse Walker |N |Purchase | |paper |EP | | | | | |Bill on |NU |Z2100 |4 Wheel Reverse Walker |N |Purchase | |paper |EP | | | | | |Bill on |NU |Z2101 |4 Wheel Reverse Walker |N |Purchase | |paper |EP | | | | | |Bill on |NU |Z2102 |4 Wheel Reverse Walker |N |Purchase | |paper |EP | | | | | |Bill on |NU |Z2104 |4 Wheel Front Swivel Reverse|N |Purchase | |paper |EP | |Walker | | | |Bill on |NU |Z2105 |4 Wheel Front Swivel Reverse|N |Purchase | |paper |EP | |Walker | | | |Bill on |NU |Z2106 |4 Wheel Front Swivel Reverse|N |Purchase | |paper |EP | |Walker | | | |Bill on |NU |Z2107 |4 Wheel Front Swivel Reverse|N |Purchase | |paper |EP | |Walker | | | |Bill on |NU |Z2239 |Bath Chair Headrest |N |Purchase | |paper |EP | | | | | |Bill on |NU |Z2605 |Diverter Valve for Handheld |N |Purchase | |paper |EP | |Shower | | |

|242.193 Augmentative Communication Device for Beneficiaries of |8-15-09 | |All Ages | |

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

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

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

NOTE: Attach a manufacturer’s invoice to the claim and indicate the item or parts billed on the invoice. A description and the amount billed for each item must be attached to the claim. If more than one item is billed under a procedure code, the description and billed amount of each item must be listed separately under each procedure code and attached to the claim. The total billed for each procedure code should be reflected in field 24F. ( Prior authorization is not required when other insurance pays at least 50% of the Medicaid maximum allowable reimbursement amount. ((…) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product. When using a procedure code with this symbol, the product must meet the indicated Arkansas Medicaid description.

|Augmentative Communication Device, All Ages (Section 242.193) | |Procedure |M1 |M2 |PA |Description |Payment | |Code | | | | |Method | |E2500 |NU | |Y( |((Light Technology Communication |Purchase| | |EP | | |Aids - communication aids that do| | | | | | |not have the memory component to | | | | | | |store the information. They are | | | | | | |often used in conjunction with | | | | | | |higher tech devices as part of a | | | | | | |multi-modal communication | | | | | | |system.) Speech-generating | | | | | | |device, digitized speech, using | | | | | | |pre-recorded messages less than | | | | | | |or equal to 8 minutes recording | | | | | | |time | | |E2502 |NU | |Y( |((Simple Voice Output Device - |Purchase| | |EP | | |simple devices with limited | | | | | | |storage capacity and voice output| | | | | | |only.) Speech-generating device,| | | | | | |digitized speech, using | | | | | | |pre-recorded messages, greater | | | | | | |than 8 minutes but less than or | | | | | | |equal to 20 minutes recording | | | | | | |time | | |E2504 |NU | |Y( |((Simple Voice Output Device - |Purchase| | |EP | | |simple devices with limited | | | | | | |storage capacity and voice output| | | | | | |only) Speech-generating device, | | | | | | |digitized speech, using | | | | | | |pre-recorded messages, greater | | | | | | |than 20 minutes but less than or | | | | | | |equal to 40 minutes recording | | | | | | |time | | |E2506 |NU | |Y( |((Simple Voice Output Device - |Purchase| | |EP | | |simple devices with limited | | | | | | |storage capacity and voice output| | | | | | |only) Speech-generating device, | | | | | | |digitized speech, using | | | | | | |pre-recorded messages, greater | | | | | | |than 40 minutes recording time. | | |E2508 |NU | |Y( |((More Advanced Voice Output |Purchase| | |EP | | |Communication Aids - offer more | | | | | | |storage capacity and often have | | | | | | |other output methods in addition | | | | | | |to voice output; e.g., LED | | | | | | |display) Speech-generating | | | | | | |device, synthesized speech, | | | | | | |requiring message formulation by | | | | | | |spelling and access by physical | | | | | | |contact with the device | | |E2510 |NU | |Y( |((Higher Technology Voice Output |Purchase| | |EP | | |Communication Aids - offer | | | | | | |greater memory capabilities, | | | | | | |various types of output, computer| | | | | | |interface options, etc.) | | | | | | |Speech-generating device | | | | | | |synthesized speech, permitting | | | | | | |multiple methods of message | | | | | | |formulation and multiple methods | | | | | | |of device access | | |E2510 |NU | |Y( |((State-of-the-Art Voice Output |Purchase| | |EP | | |Communication Aids - represents | | | | | | |state-of-the-art communication | | | | | | |aid technology. Have extensive | | | | | | |memory capabilities, various | | | | | | |output methods, computer | | | | | | |interface options; offer a | | | | | | |variety of input methods in a | | | | | | |single device and advanced | | | | | | |functions such as auditory | | | | | | |scanning, icon and word | | | | | | |prediction, etc.) | | | | | | |Speech-generating device | | | | | | |synthesized speech, permitting | | | | | | |multiple methods of message | | | | | | |formulation and multiple methods | | | | | | |of device access | | |E2511 |NU | |Y( |((Software - often recommended |Purchase| | |EP | | |for augmentative communication | | | | | | |device. Software may change as | | | | | | |the child matures.) | | | | | | |Speech-generating software | | | | | | |program, for personal computer or| | | | | | |personal digital assistant | | |E2512 |NU | |Y |Accessory for speech generating |Manually| | |EP | | |device, mounting system |Priced | |E2599 |NU | |Y( |((Switches - used with training |Manually| | |EP | | |aids and augmentative |Priced | | | | | |communication devices as a means | | | | | | |of access) Accessory for speech | | | | | | |generating device, not otherwise | | | | | | |classified | | |V5336 |NU |RP |Y |((Augmentative Communication |Manually| | |EP |RP | |Device Repair - parts only) |Priced | | | | | |Repair/modification of | | | | | | |augmentative communicative system| | | | | | |or device (excludes adaptive | | | | | | |hearing aid) | | |V5336 |NU | |Y |((Augmentative Communication |Manually| | |EP | | |Device Repair - labor only) |Priced | | | | | |Repair/modification of | | | | | | |augmentative communicative system| | | | | | |or device (excludes adaptive | | | | | | |hearing aid) | |

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

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

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

|242.194 Replacement, Growth and Modification of Specialized |5-1-17 | | |Wheelchairs and Wheelchair Seating Systems | | |

Arkansas Medicaid will cover replacement equipment as needed due to growth, normal wear and tear, theft, irreparable damage or loss not covered by insurance.

The following requirements must be met: A. Detailed documentation from the beneficiary’s PCP or ordering physician describing the significant changes in the beneficiary’s condition that require growth/modification or replacement must be submitted. B. The request must be submitted on form DMS-679 (Prescription & Prior Authorization Request for Medical Equipment). View or print form DMS-679 and instructions for completion. C. An Evaluation for Wheelchair and Wheelchair Seating form (DMS-0843) must be submitted. The evaluation must be signed and dated by the beneficiary’s PCP or ordering physician. The signature must be an original signature. A stamped signature will not be accepted by Arkansas Medicaid. An electronic signature will be accepted. View or print form DMS-0843. D. A manufacturer’s suggested retail price list and a manufacturer’s quote must be submitted. A quote created by the DME provider will not be accepted. E. Requests for replacement where malicious damage, neglect or misuse of the equipment may have occurred may be investigated by Arkansas Medicaid. Requests may be denied if such circumstances are confirmed. F. If a wheelchair is stolen or damaged by vehicle, fire or in the home, the beneficiary must provide the following with the request: 1. A police or fire report. 2. Copy of the homeowner’s or auto insurance coverage. 3. Detailed documentation of events leading to the loss and damage.

If Arkansas Medicaid denies a repair or replacement in a case of malicious damage or misuse, payment of repairs is the responsibility of the beneficiary or caregiver.

|242.195 Repairs of Specialized Wheelchairs and Wheelchair Systems |5-1-17 |

A. Arkansas Medicaid will cover repairs for wheelchairs and wheelchair seating. B. Repair services must receive prior authorization from AFMC. C. Detailed documentation from the technician that supports the equipment or services being requested must be submitted. Documentation must include the following: 1. Date and place of purchase of the current chair. 2. Brand and model name of the base. 3. Brand and model name of parts and accessories needed for repairs. D. Correct procedure codes per the current Medicaid policy must be used. E. Requests for repairs must be submitted on form DMS-679 (Prescription & Prior Authorization Request for Medical Equipment) and must be signed and dated by the beneficiary’s PCP or ordering physician. View or print form DMS-679 and instructions for completion. F. Repairs for previously authorized wheelchairs that the beneficiary has outgrown will not be covered if a new chair has been authorized. G. In the event a request is submitted for repairs for a wheelchair authorized by another state agency, documentation or a delivery ticket showing that the wheelchair was authorized by another state agency must be submitted with the request. H. Arkansas Medicaid will not cover repairs/damage due to the following: 1. Neglect. 2. Misuse. 3. Abuse. 4. Improper installation or repair by the DME provider. 5. Use of parts or changes by the DME provider or the beneficiary not authorized by Arkansas Medicaid. I. When a request is submitted for a new wheelchair with a statement that the previous wheelchair cannot be repaired, documentation from the manufacturer of the previous chair stating the reason why the previous wheelchair cannot be repaired must be included. J. If the previous wheelchair cannot be repaired, several color photographs taken at different angles must be included with the new request.

Miscellaneous

A. A wheelchair can be ordered only by a physician. B. A physician’s evaluation is valid for a period of six (6) months. After six (6) months, the beneficiary must be re-evaluated by the physician to determine medical necessity for continued need because conditions and measurements do change. A DME request is considered to be outdated by Medicaid when it is first presented to Medicaid more than ninety (90) days from the date it was written, signed and dated by the physician.

|242.200 National Place of Service and Modifier Codes |7-1-07 |

Electronic and paper claims require the same national place of service (POS) code.

|Place of Service |POS Codes | |Inpatient Hospital |21 | |Outpatient Hospital |22 | |Doctor’s Office |11 | |Patient’s Home |12 | |Day Care Facility |52 | |Night Care Facility |52 | |Nursing Facility |32 | |Skilled Nursing Facility |31 | |Ambulance |41 | |Other Locations |99 | |Independent Laboratory |81 | |Ambulatory Surgical Center |24 | |Residential Treatment Center |56 | |Specialized Treatment Facility |56 | |Comprehensive Outpatient |62 | |Rehabilitative Facility | | |Independent Kidney Disease |65 | |Treatment Center | | |Inpatient Psychiatric Facility |51 |



|Modifiers | |EP-Service provided as part of EPSDT Program | |KH-Durable Medical Equipment (DME) item, initial claim, first month's| |rental | |NU-New Equipment | |RR-Durable Medical Equipment (DME) Rental | |U1-Medicaid Level of Care 1 (defined by state) | |U2-Medicaid level of Care 2 (defined by state) | |U3-Medicaid level of care 3 (defined by state) | |U4-Medicaid level of care 4 (defined by state) | |U5-Medicaid level of care 5 (defined by state) | |UE-Used durable medical equipment (DME) | |52-Reduced Services |

|242.300 Billing Instructions - Paper Only |7-1-07 |

The Arkansas Medicaid fiscal agent offers providers several options for electronic billing. Therefore, claims submitted on paper are lower priority and are paid once a month. The only claims exempt from this rule are those that require attachments or manual pricing.

Bill Medicaid for professional services with form CMS-1500. The numbered items in the following instructions correspond to the numbered fields on the claim form. View a sample form CMS-1500.

Carefully follow these instructions to help the Arkansas Medicaid fiscal agent efficiently process claims. Accuracy, completeness, and clarity are essential. Claims cannot be processed if necessary information is omitted.

Forward completed claim forms to the Claims Department. View or print the Claims Department contact information.

NOTE: A provider delivering services without verifying beneficiary eligibility for each date of service does so at the risk of not being reimbursed for the services.

|242.310 Completion of CMS-1500 Claim Form |12-15-14 |

|Field Name and Number |Instructions for Completion | |1. (type of coverage) |Not required. | |1a. INSURED’S I.D. NUMBER |Beneficiary’s or participant’s 10-digit | |(For Program in Item 1) |Medicaid or ARKids First-A or ARKids | | |First-B identification number. | |2. PATIENT’S NAME (Last |Beneficiary’s or participant’s last name | |Name, First Name, Middle |and first name. | |Initial) | | |3. PATIENT’S BIRTH DATE |Beneficiary’s or participant’s date of | | |birth as given on the individual’s | | |Medicaid or ARKids First-A or ARKids | | |First-B identification card. Format: | | |MM/DD/YY. | | SEX |Check M for male or F for female. | |4. INSURED’S NAME (Last |Required if insurance affects this claim. | |Name, First Name, Middle |Insured’s last name, first name, and | |Initial) |middle initial. | |5. PATIENT’S ADDRESS (No. |Optional. Beneficiary’s or participant’s | |Street) |complete mailing address (street address | | |or post office box). | | CITY |Name of the city in which the beneficiary | | |or participant resides. | | STATE |Two-letter postal code for the state in | | |which the beneficiary or participant | | |resides. | | ZIP CODE |Five-digit zip code; nine digits for post | | |office box. | | TELEPHONE (Include Area |The beneficiary’s or participant’s | |Code) |telephone number or the number of a | | |reliable message/contact/ emergency | | |telephone. | |6. PATIENT RELATIONSHIP TO|If insurance affects this claim, check the| |INSURED |box indicating the patient’s relationship | | |to the insured. | |7. INSURED’S ADDRESS (No.,|Required if insured’s address is different| |Street) |from the patient’s address. | | CITY | | | STATE | | | ZIP CODE | | | TELEPHONE (Include Area | | |Code) | | |8. RESERVED |Reserved for NUCC use. | |9. OTHER INSURED’S NAME |If patient has other insurance coverage as| |(Last name, First Name, |indicated in Field 11d, the other | |Middle Initial) |insured’s last name, first name, and | | |middle initial. | |a. OTHER INSURED’S POLICY |Policy and/or group number of the insured | |OR GROUP NUMBER |individual. | |b. RESERVED |Reserved for NUCC use. | |SEX |Not required. | |c. RESERVED |Reserved for NUCC use. | |d. INSURANCE PLAN NAME OR |Name of the insurance company. | |PROGRAM NAME | | |10. IS PATIENT’S CONDITION| | |RELATED TO: | | |a. EMPLOYMENT? (Current or|Check YES or NO. | |Previous) | | |b. AUTO ACCIDENT? |Required when an auto accident is related | | |to the services. Check YES or NO. | | PLACE (State) |If 10b is YES, the two-letter postal | | |abbreviation for the state in which the | | |automobile accident took place. | |c. OTHER ACCIDENT? |Required when an accident other than | | |automobile is related to the services. | | |Check YES or NO. | |d. CLAIM CODES |The “Claim Codes” identify additional | | |information about the beneficiary’s | | |condition or the claim. When applicable, | | |use the Claim code to report appropriate | | |claim codes as designated by the NUCC. | | |When required to provide the subset of | | |Condition codes, enter the condition codes| | |in this field. The subset of approved | | |Condition Codes is found at www.nucc.org | | |under Code Sets. | |11. INSURED’S POLICY GROUP|Not required when Medicaid is the only | |OR FECA NUMBER |payer. | |a. INSURED’S DATE OF BIRTH|Not required. | | SEX |Not required. | |b. OTHER CLAIM ID NUMBER |Not required. | |c. INSURANCE PLAN NAME OR |Not required. | |PROGRAM NAME | | |d. IS THERE ANOTHER HEALTH|When private or other insurance may or | |BENEFIT PLAN? |will cover any of the services, check YES | | |and complete items 9, 9a and 9d. Only one | | |box can be marked. | |12. PATIENT’S OR |Enter “Signature on File,” “SOF” or legal | |AUTHORIZED PERSON’S |signature. | |SIGNATURE | | |13. INSURED’S OR | Enter “Signature on File,” “SOF” or legal| |AUTHORIZED PERSON’S |signature. | |SIGNATURE | | |14. DATE OF CURRENT: |Required when services furnished are | |ILLNESS (First symptom) OR|related to an accident, whether the | |INJURY (Accident) OR |accident is recent or in the past. Date | |PREGNANCY (LMP) |of the accident. | | | | | |Enter the qualifier to the right of the | | |vertical dotted line. Use Qualifier 431 | | |Onset of Current Symptoms or Illness; 484 | | |Last Menstrual Period. | |15. OTHER DATE |Enter another date related to the | | |beneficiary’s condition or treatment. | | |Enter the qualifier between the left-hand | | |set of vertical, dotted lines. | | |The “Other Date” identifies additional | | |date information about the beneficiary’s | | |condition or treatment. Use qualifiers: | | |454 Initial Treatment | | |304 Latest Visit or Consultation | | |453 Acute Manifestation of a Chronic | | |Condition | | |439 Accident | | |455 Last X-Ray | | |471 Prescription | | |090 Report Start (Assumed Care Date) | | |091 Report End (Relinquished Care Date) | | |444 First Visit or Consultation | |16. DATES PATIENT UNABLE |Not required. | |TO WORK IN CURRENT | | |OCCUPATION | | |17. NAME OF REFERRING |Primary Care Physician (PCP) referral is | |PROVIDER OR OTHER SOURCE |not required for prosthetics. If services| | |are the result of a Child Health Services | | |(EPSDT) screening/ referral, enter the | | |referral source, including name and title.| |17a. (blank) |The 9-digit Arkansas Medicaid provider ID | | |number of the referring physician. | |17b. NPI |Not required. | |18. HOSPITALIZATION DATES |When the serving/billing provider’s | |RELATED TO CURRENT |services charged on this claim are related| |SERVICES |to a beneficiary’s or participant’s | | |inpatient hospitalization, enter the | | |individual’s admission and discharge | | |dates. Format: MM/DD/YY. | |19. ADDITIONAL CLAIM |Identifies additional information about | |INFORMATION |the beneficiary’s condition or the claim. | | |Enter the appropriate qualifiers | | |describing the identifier. See | | |www.nucc.org for qualifiers. | |20. OUTSIDE LAB? |Not required. | | $ CHARGES |Not required. | |21. DIAGNOSIS OR NATURE OF|Enter the applicable ICD indicator to | |ILLNESS OR INJURY |identify which version of ICD codes is | | |being reported. | | |Use “9” for ICD-9-CM. | | |Use “0” for ICD-10-CM. | | |Enter the indicator between the vertical, | | |dotted lines in the upper right-hand | | |portion of the field. | | |Diagnosis code for the primary medical | | |condition for which services are being | | |billed. Use the appropriate International | | |Classification of Diseases (ICD). List no | | |more than 12 diagnosis codes. Relate lines| | |A-L to the lines of service in 24E by the | | |letter of the line. Use the highest level | | |of specificity. | |22. RESUBMISSION CODE |Reserved for future use. | | ORIGINAL REF. NO. |Any data or other information listed in | | |this field does not/will not adjust, void | | |or otherwise modify any previous payment | | |or denial of a claim. Claim payment | | |adjustments, voids and refunds must follow| | |previously established processes in | | |policy. | |23. PRIOR AUTHORIZATION |The prior authorization or benefit | |NUMBER |extension control number if applicable. | |24A. DATE(S) OF SERVICE |The “from” and “to” dates of service for | | |each billed service. Format: MM/DD/YY. | | |1. On a single claim detail (one charge on| | |one line), bill only for services provided| | |within a single calendar month. | | |2. Providers may bill on the same claim | | |detail for two or more sequential dates of| | |service within the same calendar month | | |when the provider furnished equal amounts | | |of the service on each day of the date | | |sequence. | |B. PLACE OF SERVICE |Two-digit national standard place of | | |service code. See Section 242.200 for | | |codes. | |C. EMG |Enter “Y” for “Yes” or leave blank if | | |“No.” EMG identifies if the service was an| | |emergency. | |D. PROCEDURES, SERVICES, | | |OR SUPPLIES | | | CPT/HCPCS |Enter the correct CPT or HCPCS procedure | | |code from Sections 242.100 through | | |242.195. | | MODIFIER |Modifier(s) if applicable. | |E. DIAGNOSIS POINTER |Enter the diagnosis code reference letter | | |(pointer) as shown in Item Number 21 to | | |relate to the date of service and the | | |procedures performed to the primary | | |diagnosis. When multiple services are | | |performed, the primary reference letter | | |for each service should be listed first; | | |other applicable services should follow. | | |The reference letter(s) should be A-L or | | |multiple letters as applicable. The | | |“Diagnosis Pointer” is the line letter | | |from Item Number 21 that relates to the | | |reason the service(s) was performed. | |F. $ CHARGES |The full charge for the service(s) totaled| | |in the detail. This charge must be the | | |usual charge to any client, patient, or | | |other beneficiary of the provider’s | | |services. | |G. DAYS OR UNITS |The units (in whole numbers) of service(s)| | |provided during the period indicated in | | |Field 24A of the detail. | |H. EPSDT/Family Plan |Enter E if the services resulted from a | | |Child Health Services (EPSDT) | | |screening/referral. | |I. ID QUAL |Not required. | |J. RENDERING PROVIDER ID #|The 9-digit Arkansas Medicaid provider ID | | |number of the individual who furnished the| | |services billed for in the detail. | | NPI |Not required. | |25. FEDERAL TAX I.D. |Not required. This information is carried| |NUMBER |in the provider’s Medicaid file. If it | | |changes, please contact Provider | | |Enrollment. | |26. PATIENT’S ACCOUNT N O.|Optional entry that may be used for | | |accounting purposes; use up to 16 numeric | | |or alphabetic characters. This number | | |appears on the Remittance Advice as “MRN.”| |27. ACCEPT ASSIGNMENT? |Not required. Assignment is automatically| | |accepted by the provider when billing | | |Medicaid. | |28. TOTAL CHARGE |Total of Column 24F—the sum all charges on| | |the claim. | |29. AMOUNT PAID |Enter the total of payments previously | | |received on this claim. Do not include | | |amounts previously paid by Medicaid. *Do | | |not include in this total the | | |automatically deducted Medicaid or ARKids | | |First-B co-payments. | |30. RESERVED |Reserved for NUCC use. | |31. SIGNATURE OF PHYSICIAN|The provider or designated authorized | |OR SUPPLIER INCLUDING |individual must sign and date the claim | |DEGREES OR CREDENTIALS |certifying that the services were | | |personally rendered by the provider or | | |under the provider’s direction. | | |“Provider’s signature” is defined as the | | |provider’s actual signature, a rubber | | |stamp of the provider’s signature, an | | |automated signature, a typewritten | | |signature, or the signature of an | | |individual authorized by the provider | | |rendering the service. The name of a | | |clinic or group is not acceptable. | |32. SERVICE FACILITY |If other than home or office, enter the | |LOCATION INFORMATION |name and street, city, state, and zip code| | |of the facility where services were | | |performed. | | a. (blank) |Not required. | | b. (blank) |Not required. | |33. BILLING PROVIDER INFO |Billing provider’s name and complete | |& PH # |address. Telephone number is requested | | |but not required. | |a. (blank) |Not required. | |b. (blank) |Enter the 9-digit Arkansas Medicaid | | |provider ID number of the billing | | |provider. |

|242.400 Special Billing Procedures | | |242.401 National Drug Codes (NDCs) |11-1-15 |

Effective for claims with dates of service on or after January 1, 2008, Arkansas Medicaid implemented billing protocol per the Federal Deficit Reduction Act of 2005. This explains policy and billing protocol for providers that submit claims for drug HCPCS/CPT codes with dates of service on and after January 1, 2008.

The Federal Deficit Reduction Act of 2005 mandates that Arkansas Medicaid require the submission of National Drug Codes (NDCs) on claims submitted with Health Care Common Procedure Coding System, Level II/Current Procedural Terminology, 4th edition (HCPCS/CPT) codes for drugs administered. The purpose of this requirement is to assure that the State Medicaid Agencies obtain a rebate from those manufacturers who have signed a rebate agreement with the Centers for Medicare and Medicaid Services (CMS). A. Covered Labelers Arkansas Medicaid, by statute, will only pay for a drug procedure billed with an NDC when the pharmaceutical labeler of that drug is a covered labeler with Centers for Medicare and Medicaid Services (CMS). A “covered labeler” is a pharmaceutical manufacturer that has entered into a federal rebate agreement with CMS to provide each State a rebate for products reimbursed by Medicaid Programs. A covered labeler is identified by the first 5 digits of the NDC. To assure a product is payable for administration to a Medicaid beneficiary, compare the labeler code (the first 5 digits of the NDC) to the list of covered labelers which is maintained on the website at https://arkansas.magellanrx.com/provider/documents/. A complete listing of “Covered Labelers” is located on the website. See Diagram 1 for an example of this screen. The effective date is when a manufacturer entered into a rebate agreement with CMS. The Labeler termination date indicates that the manufacturer no longer participates in the federal rebate program and therefore the products cannot be reimbursed by Arkansas Medicaid on or after the termination date. Diagram 1

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In order for a claim with drug HCPCS/CPT codes to be eligible for payment, the detail date of service must be prior to the NDC termination date. The NDC termination date represents the shelf-life expiration date of the last batch produced, as supplied on the Centers for Medicare and Medicaid Services (CMS) quarterly update. The date is supplied to CMS by the drug manufacturer/distributor. Arkansas Medicaid will deny claim details with drug HCPCS/CPT codes with a detail date of service equal to or greater than the NDC termination date. When completing a Medicaid claim for administering a drug, indicate the HIPAA standard 11-digit NDC with no dashes or spaces. The 11- digit NDC is comprised of three segments or codes: a 5-digit labeler code, a 4-digit product code and a 2-digit package code. The 10- digit NDC assigned by the FDA printed on the drug package must be changed to the 11-digit format by inserting a leading zero in one of the three segments. Below are examples of the FDA assigned NDC on a package changed to the appropriate 11-digit HIPAA standard format. Diagram 2 displays the labeler code as five digits with leading zeros; the product code as four digits with leading zeros; the package code as two digits without leading zeros, using the “5-4-2” format. Diagram 2

|00123 |0456 |78 | |LABELER |PRODUCT |PACKAGE | |CODE |CODE |CODE | |(5 |(4 |(2 | |digits) |digits) |digits) |

NDCs submitted in any configuration other than the 11-digit format will be rejected/denied. NDCs billed to Medicaid for payment must use the 11-digit format without dashes or spaces between the numbers. See Diagram 3 for sample NDCs as they might appear on drug packaging and the corresponding format which should be used for billing Arkansas Medicaid: Diagram 3

|10-digit FDA NDC on |Required 11-digit NDC | |PACKAGE |(5-4-2) Billing Format | |12345 6789 1 |12345678901 | |1111-2222-33 |01111222233 | |01111 456 71 |01111045671 |

B. Drug Procedure Code (HCPCS/CPT) to NDC Relationship and Billing Principles HCPCS/CPT codes and any modifiers will continue to be billed per the policy for each procedure code. However, the NDC and NDC quantity of the administered drug is now also required for correct billing of drug HCPCS/CPT codes. To maintain the integrity of the drug rebate program, it is important that the specific NDC from the package used at the time of the procedure be recorded for billing. HCPCS/CPT codes submitted using invalid NDCs or NDCs that were unavailable on the date of service will be rejected/denied. We encourage you to enlist the cooperation of all staff members involved in drug administration to assure collection or notation of the NDC from the actual package used. It is not recommended that billing of NDCs be based on a reference list, as NDCs vary from one labeler to another, from one package size to another, and from one time period to another. Exception: There is no requirement for an NDC when billing for vaccines, radiopharmaceuticals and allergen immunotherapy.

II. Claims Filing

The HCPCS/CPT codes billing units and the NDC quantity do not always have a one-to-one relationship.

Example 1: The HCPCS/CPT code may specify up to 75 mg of the drug whereas the NDC quantity is typically billed in units, milliliters or grams. If the patient is provided 2 oral tablets, one at 25 mg and one at 50 mg, the HCPCS/CPT code unit would be 1 (1 total of 75 mg) in the example whereas the NDC quantity would be 1 each (1 unit of the 25 mg tablet and 1 unit of the 50 mg tablet). See Diagram 4.

Diagram 4

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Example 2: If the drug in the example is an injection of 5 ml (or cc) of a product that was 50 mg per 10 ml of a 10 ml single-use vial, the HCPCS/CPT code unit would be 1 (1 unit of 25 mg) whereas the NDC quantity would be 5 (5 ml). In this example, 5 ml or 25 mg would be documented as wasted. See Diagram 5.

Diagram 5

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A. Electronic Claims Filing – 837P (Professional) and 837I (Outpatient) Procedure codes that do not require paper billing may be billed electronically. Any procedure codes that have required modifiers in the past will continue to require modifiers. Arkansas Medicaid requires providers using Provider Electronic Solutions (PES) to use the required NDC format when billing HCPCS/CPT codes for administered drugs. B. Paper Claims Filing – CMS-1500 Arkansas Medicaid will require providers billing drug HCPCS/CPT codes including covered unlisted drug procedure codes to use the required NDC format. See Diagram 6 for CMS-1500. For professional claims, CMS-1500, list the qualifier of “N4”, the 11- digit NDC, the unit of measure qualifier (F2 – International Unit; GR – Gram; ML - Milliliter; UN – Unit), and the number of units of the actual NDC administered in the shaded area above detail field 24A, spaced and arranged exactly as in Diagram 6. Each NDC when billed under the same procedure code on the same date of service is defined as a “sequence.” When billing a single HCPCS/CPT code with multiple NDCs as detail sequences, the first sequence should reflect the total charges in detail field 24F and total HCPCS/CPT code units in detail field 24G. Each subsequent sequence number should show zeros in detail fields 24F and 24G. See Detail 1, sequence 2 in Diagram 6. The quantity of the NDC will be the total number of units billed for each specific NDC. See Diagram 6, first detail, sequences 1 and 2. Detail 2 is a Procedure Code that does not require an NDC. Detail 3, sequence 1 gives an example where only one NDC is associated with the HCPCS/CPT code. Diagram 6

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Procedure Code/NDC Detail Attachment Form—DMS-664

For drug HCPCS/CPT codes requiring paper billing (i.e., for manual review), complete every field of the DMS-664 “Procedure Code/NDC Detail Attachment Form.” Attach this form and any other required documents to your claim when submitting it for processing. See Diagram 7 for an example of the completed form. Section V of the provider manual includes this form.

Diagram 7

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III. Adjustments

Paper adjustments for paid claims filed with NDC numbers will not be accepted. Any original claim will have to be voided and a replacement claim will need to be filed. Providers have the option of adjusting a paper or electronic claim electronically.

IV. Remittance Advices

Only the first sequence in a detail will be displayed on the remittance advice reflecting either the total amount paid or the denial EOB(s) for the detail.

V. Record Retention

Each provider must retain all records for five (5) years from the date of service or until all audit questions, dispute or review issues, appeal hearings, investigations or administrative/judicial litigation to which the records may relate are concluded, whichever period is longer.

At times, a manufacturer may question the invoiced amount, which results in a drug rebate dispute. If this occurs, you may be contacted requesting a copy of your office records to include documentation pertaining to the billed HCPCS/CPT code. Requested records may include NDC invoices showing purchase of drugs and documentation showing what drug (name, strength and amount) was administered and on what date, to the beneficiary in question

|242.402 Billing of Multi-Use and Single-Use Vials |11-1-15 |

Arkansas Medicaid follows the billing protocol per the Federal Deficit Reduction Act of 2005 for drugs. A. Multiple units may be billed when applicable. Take-home drugs are not covered. Drugs loaded into an infusion pump are not classified as “take-home drugs.” Refer to payable CPT code ranges 96365 through 96379. B. When submitting Arkansas Medicaid drug claims, drug units should be reported in multiples of the dosage included in the HCPCS procedure code description. If the dosage given is not a multiple of the number provided in the HCPCS code description the provider shall round up to the nearest whole number in order to express the HCPCS description number as a multiple. 1. Single-Use Vials: If the provider must discard the remainder of a single-use vial or other package after administering the prescribed dosage of any given drug, Arkansas Medicaid will cover the amount of the drug discarded along with the amount administered. 2. Multi-Use Vials: Multi-use vials are not subject to payment for any discarded amounts of the drug. The units billed must correspond with the units administered to the beneficiary. 3. Documentation: The provider must clearly document in the patient’s medical record the actual dose administered in addition to the exact amount wasted and the total amount the vial is labeled to contain. 4. Paper Billing: For drug HCPCS/CPT codes requiring paper billing (i.e., for manual review), complete every field of the DMS-664 “Procedure Code/NDC Detail Attachment Form.” Attach this form and any other required documents to your claim when submitting it for processing.

Remember to verify the milligrams given to the patient and then convert to the proper units for billing.

Follow the Centers for Disease Control (CDC) requirements for safe practices regarding expiration and sterility of multi-use vials.

|242.410 Completion of Form - Medicare/Medicaid Deductible And |10-13-03 | |Coinsurance | |

If the Medicare fiscal intermediary is Arkansas Blue Cross/Blue Shield, the claim should be filed according to Medicare’s instructions and sent to the Medicare intermediary. The Medicaid provider number and the beneficiary ID number must be entered in Field 9 on the claim form. The claim will automatically cross to Medicaid. If Medicaid reimbursement has not been received within six weeks after receiving Medicare payment, refer to Section 302.100.

|242.420 Freight Charges, All Ages |10-13-03 |

Providers may include the freight charge on claims submitted to the Arkansas Medicaid Program for manual pricing and reimbursement of prosthetics services. If the freight charge is reflected as a charge on the manufacturer’s invoice, this will provide necessary documentation. However, if there is a separate freight invoice, the freight invoice must also be attached to the claim.

When a provider has ordered several items and is submitting a claim to the Medicaid Program for only certain items included on the invoice, the provider must determine and indicate on the invoice, the freight charges for those items being billed to Medicaid. Only the freight charge incurred for the covered Medicaid items may be included on the Medicaid claim. ----------------------- Bill on paper (Indicate specific name of formula on claims.)

Bill on paper (Indicate specific name of formula on claims.)

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