016.06.05 Ark. Code R. 041
Prosthetics providers must keep and properly maintain written records. At a minimum, the following records must be included in the provider?s files.
General records that must be available for review include:
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:
All records must be completed promptly, filed and retained for a period of five (5) years from the date of service or until all audit questions, appeal hearings, investigations or court cases are resolved, whichever is longer.
All documentation must be made available, upon request, to authorized representatives of the Arkansas Division of Medical Services, the state Medicaid Fraud Control Unit, representatives of the Department of Health and Human Services and its authorized agents or officials.
At the time of an audit by the Division of Medical Services Medicaid Field Audit Unit, all documentation must be available at the provider?s place of business during normal business hours. Requested documentation that is stored off-site must be made available to DMS personnel within 3 business days.
In the case of recoupment, there will be no more than thirty days allowed after the date of the recoupment notice in which additional documentation will be accepted. Additional documentation will not be accepted after the thirty-day period.
Failure to furnish records upon request may result in sanctions being imposed.
At least once every 6 months, the primary care physician must certify the medical necessity for prosthetics services and prescribe them by signing and dating a prescription and, when applicable, completing a Medical Equipment Request for Prior Authorization and Prescription Form (form DMS-679). View or print form DMS-679 and instructions for completion.
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:
As necessary, the prosthetics provider must:
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 Medical Equipment Request for Prior Authorization and Prescription Form (form DMS-679) to the Utilization Review Section. The primary care physician must initially review form DMS-679 and, based upon the physician?s certification of medical necessity, prescribe prosthetics services. Form DMS-679 must then be reviewed by the Utilization Review Section and prosthetics services must be prior authorized. If prosthetics services are prescribed, and when applicable, prior authorized, prosthetics services may be furnished for a maximum of 6 months from the date of the prescription.
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.
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.
Services that are not covered under the Arkansas Medicaid Prosthetics Program include but are not limited to:
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. 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 UR will be necessary only when the Benefit Extension Control Number expires or when a patient?s need for services unexpectedly exceeds the amount or number of services granted under the benefit extension.
Diapers and underpads are covered by the Arkansas Medicaid Program but are benefit limited and must be medically necessary.
Diaper services must be medically necessary. 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.
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.
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.
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.
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.
Prior authorization is not required for the initial one-month period of use of the monitor. If the apnea monitor is needed longer than an initial one-month period, prior authorization will be required.
Prior authorization of the apnea monitor is required after an infant has been monitored for one month. A new referral and prescription is required. Compliance during the initial thirty-day period and proof of medical necessity for the continuation of monitoring must be documented.
After the initial thirty-day period, the prescribing physician must sign form DMS-679?Medical Equipment Request for Prior Authorization and Prescription. 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 a neonatologist or pulmonologist.
As necessary, the PCP?s name and provider number must also be indicated on form DMS-679. The PCP's signature is not required on the initial certification but he or she must sign all re-certifications.
Documentation from the physician describing the education of the family regarding their understanding of the importance of the apnea monitor must be included after the initial one-month period.
The following criteria, which follow the guidelines set by the National Institute of Health Consensus Statement on Infantile Apnea on Home Monitoring, Consensus Development Conference Statement, September 29-October 1, 1986, will be utilized in evaluating the need for an apnea monitor after the initial one-month period:
Prior authorization for the apnea monitor must be submitted on form DMS-679, Medical Equipment Request for Prior Authorization and Prescription, to Utilization Review. View or print
form DMS-679 and instructions for completion. View or print Utilization Review Section contact information.
The augmentative communication device (ACD) is covered for individuals 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 can request an extension of benefits by submitting the DMS-699 form.
View or print form DMS-699.
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 individuals 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-679?Medical Equipment Request for Prior Authorization and Prescription. View or print form DMS-679 and instructions for completion.The form should be accompanied by:
This information must be submitted to the Utilization Review Section of the Division of Medical Services. View or print Utilization Review Section 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 Request for Extension of Benefits (form DMS-699), 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 Benefit Extension Requests, Utilization Review Section. View or print form DMS-699, titled Request for Extension of Benefits. View or print the Benefit Extension Requests Utilization Review Section contact information.
The provider will be notified in writing of the approval or denial of the request for extended benefits.
Arkansas Medicaid covers the automatic electronic blood pressure monitor for individuals under age 21 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 the Medical Equipment Request for Prior Authorization and Prescription form (form DMS-679) to the Utilization Review Section. View or print Form DMS-679 and instructions for completion. View or print Utilization Review Section contact information.
The request for an enteral nutrition pump is covered on a case-by-case basis for individuals 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 the Utilization Review Section of the Division of Medical Services using form DMS-679, Medical Equipment Request for Prior Authorization and Prescription. View or print Utilization Review Section contact information. View or print form DMS-679 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-679 and instructions for completion.
Requests for prior authorization for enteral pump repairs must be mailed to the Utilization Review Section, Division of Medical Services. Form DMS-679, Medical Equipment Request for Prior Authorization and Prescription, must be used to request prior authorization. View or print form DMS-679 and instructions for completion.
Arkansas Medicaid covers the home blood glucose monitor for pregnant women of all ages. Prior authorization is not required for use of this device.
Insulin pumps and supplies are covered by Arkansas Medicaid for individuals 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:
Prior authorization requests for the insulin pump and supplies must be submitted on Form DMS-679, Medical Equipment Request for Prior Authorization and Prescription, to Utilization Review.
View or print form DMS-679 and instructions for completion. View or print Utilization Review Section contact information.
The Arkansas Medicaid Program reimburses for the MIC-KEY Skin Level Gastrostomy Tube (Mic-Key button) and supplies for Medicaid-eligible individuals under age 21. Prior authorization (PA) from the Utilization Review Section is required.
The procedure codes may also be authorized for Medicaid-eligible children ages 0 through 5 years who receive their sole-source enteral formula through the Women, Infants and Children (WIC) Program. The Utilization Review Section must be contacted to receive the prior authorization.
When requesting prior authorization, form DMS-679, Medical Equipment Request for Prior Authorization and Prescription, must be completed and sent, along with sufficient medical documentation, to the Utilization Review Section.
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 the Utilization Review Section for any extensions using form DMS-679. View or print Utilization Review Section contact information. View or print form DMS-679 and instructions for completion.
Arkansas Medicaid covers specialized rehabilitative equipment for Medicaid-eligible individuals of all ages.
Some items of specialized equipment require prior authorization from the Utilization Review Unit.
View or print form DMS-679 and instructions for completion. View or print Utilization Review Section contact information.
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 Utilization Review Unit.
View or print form DMS-679 and instructions for completion. View or print Utilization Review Section contact information.
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.
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.
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.
The following restrictions apply to the coverage of orthotic appliances for individuals age 21 and over:
The appropriate forms (or the required information in a different format) must accompany the form DMS-679. View or print Medical Equipment Request for Prior Authorization and Prescription form DMS-679 and instructions for completion.
The forms and their titles are as follows:
1. DMS-646 | Evaluation Form Lower Limb. View or print form DMS-646. |
2. DMS-647 | Gait Analysis: Full Body. View or print form DMS-647. |
3. DMS-648 | Prosthetic-Orthotic Upper-Limb Amputee Evaluation. View or print form DMS-648. |
4. DMS-649 | Upper-Limb Prosthetic Prescription. View or print form DMS-649. |
5. DMS-650 | Prosthetic-Orthotic Lower-Limb Amputee Evaluation. View or print form DMS-650. |
6. DMS-651 | Lower-Limb Prosthetic Prescription. View or print form DMS-651. |
A prescription for oxygen must be accompanied by a current arterial blood gas (ABG) laboratory report from a certified laboratory or the patient?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 patient (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:
Pa02 with exercise less than 55 mm Hg
Symptomatic at rest, with Pa02 less than 60 mm Hg
Reviewed on an individual basis
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-679, Medical Equipment Request for Prior Authorization and Prescription, to the Utilization Review Section for individuals of all ages. View or print form DMS-679 and instructions for completion.
The original and the first copy of the Medical Equipment Request for Prior Authorization and Prescription Form (form DMS-679) must be forwarded to the Division of Medical Services, Utilization Review Section. View or print Utilization Review Section contact information.
The third copy should be retained in the provider?s records.
The Utilization Review Section reviews requests for prior authorization. If necessary, the Utilization Review Section may request additional information.
When a request is approved, a prior authorization control number will be assigned by the Utilization Review Section. 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 Utilization Review within 30 working days of receipt of the prior authorization request.
Prior authorization may only be approved for a maximum of six (6) months (180 days) for individuals 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 the Utilization Review Section.
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.
Providers should note the following authorization process exception.
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.
Denied requests will be returned to the provider within 30 working days of receipt of the prior authorization request, with the reason for denial indicated.
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.
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 Code | Required Modifier | Description |
L4205 | ? | Repair of orthotic appliances and prosthetic devices (non-EPSDT) |
L4210 | ? | |
L7510 | ? | |
L7520 | ? | |
L4205 | EP | Repair of orthotic appliances and prosthetic devices (EPSDT) |
L4210 | EP | |
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.
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.
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 the Utilization Review Section, Division of Medical Services (view or print Utilization Review Section contact information)on form DMS-679, titled Request for Prior Authorization and Prescription. (View or print form DMS-679 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.
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.
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.
Arkansas Medicaid has several methods of payment for all items covered by the Program. The following is a breakdown of the methods.
When billed either electronically or on paper, procedure codes found in this section must be billed 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.
Additionally, when billed on paper, procedure codes must be billed with a type of service (TOS) code ?6? for individuals under age 21 or TOS ?H? for individuals age 21 and over.
Modifiers in this section are indicated by the headings M1 and M2. Type of service is indicated by the heading TOS. Prior authorization requirements are shown under the heading PA. If prior authorization is needed, the information is indicated with a ?Y? in the column; if not, an ?N? is shown.
NOTE: Prosthetics providers may continue to use modifier 52 for claims with dates of service through October 31, 2005. Effective for claims with dates of service on and after November 1, 2005, modifier 52 will be replaced with modifier UB.
* Prior authorization is not required when another 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.
Respiratory and Diabetic Equipment, All Ages (section 242.110)
Procedure Code | M1 | M2 | TOS | Description | PA | Payment Method |
A4230 | NU | H | Infusion set for external insulin pump, nonneedle cannula type (each) | Y* | Purchase | |
A4231 | NU | H | Infusion set for external insulin pump, needle type (each) | Y* | Purchase | |
A4232 | NU | H | Syringe with needle for external insulin pump, sterile, 3 cc (each) | Y* | Purchase | |
A4627 | NU | UB | H | ***(Spacer bag or reservoir without mask, for use with metered dose inhaler) Spacer, bag or reservoir, with or without mask, for use with metered dose inhaler | N | Purchase |
A4627 | NU | H | ***(Spacer bag or reservoir with mask, for use with metered dose inhaler) Spacer, bag or reservoir, with or without mask, for use with metered dose inhaler | N | Purchase | |
A4632 | H | Replacement battery for external infusion pump, any type, each | Y* | Purchase | ||
A6021 | NU | H | Collagen dressing, pad size 16 sq. in. or less, each | Y* | Purchase | |
A6022 | NU | H | Collagen dressing, pad size more than 16 sq. in. but less than or equal to 48 sq. in., each | Y* | Purchase | |
A6023 | NU | H | Collagen dressing, pad size more than 48 sq. in., each | Y* | Purchase | |
A6024 | NU | H | Collagen dressing wound filler, per 6 in. | Y* | Purchase | |
A7034 | NU | RR | H | ***(CPAP Device Nasal Continuous 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 A7034 as the Global Monthly Rental Service. Nasal interface (mask or cannula type) used with positive airway pressure device, with or without head strap | Y* | Rental Only |
A7045 | NU | Exhalation port with or without swivel used with accessories for positive airway devices, replacement only | N | Purchase | ||
A9999 | NU | H | ***(Unlisted Durable Medical Equipment. The manufacturer?s invoice must be attached to the claim form.) Misc. DME supply or accessory, not otherwise specified | Y | Manually Priced | |
E0424 | Stationary compressed gaseous oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing | Y* | Rental Only | |||
E0430 | Portable gaseous oxygen system, purchase, includes regulator, flowmeter, humidifier, cannula or mask, and tubing | Y* | Rental Only | |||
E0435 | Portable liquid oxygen system, purchase; includes portable container, supply reservoir, flowmeter, humidifier, contents gauge, cannula or mask, tubing and refill adapter | Y* | Rental Only | |||
E0439 | Stationary liquid oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing | Y* | Rental Only | |||
E0441 | Oxygen contents, gaseous (for use with owned gaseous stationary systems or when both a stationary and portable gaseous system are owned), one month?s supply = I unit | Y | Purchase | |||
E0442 | Oxygen contents, liquid (for use with owned liquid stationary systems or when both a stationary and portable liquid system are owned), one month?s supply = 1 unit | Y | Purchase | |||
E0443 | Portable oxygen contents, gaseous (for use only with portable gaseous systems when no stationary gas or liquid system is used), one month?s supply=1 unit | Y* | Purchase | |||
E0444 | Portable oxygen contents, liquid (for use only with portable liquid systems when no stationary gas or liquid system is used), one month?s supply=1 unit | Y* | Purchase | |||
E0470 | RR | H | ***(BIPAP Device, Nasal Bi-level Positive Airway support system; 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 capability, without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device) | Y | Capped Rental | |
E0470 | NU EP | RR RR | H 6 | 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) | Y Y | Rental Only |
E0471 | NU EP | RR RR | H 6 | Respiratory assist device, bi-level pressure capacity, with backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device) | Y Y | Rental Only |
E0472 | NU EP | RR RR | H 6 | Respiratory assist device, bi-level pressure capacity, with backup rate feature, used with invasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device) | Y Y | Rental Only |
E0483 | NU | RR | H | ***(Bronchial Drainage System) High-frequency chest wall oscillation air-pulse generator system (includes hoses and vest), each | Y* | Rental Only |
E0483 | NU | UB | H | ***( Pulmonary Vest. The manufacturer invoice must be attached to the claim form.) High-frequency chest wall oscillation air-pulse generator system (includes hoses and vest), each | Y* | Purchase |
E0560 | Humidifier, durable for supplemental humidification during IPPB treatment or oxygen delivery | N | Purchase | |||
E0561 | NU EP | H 6 | Humidifier, non-heated, used w/positive airway pressure device | Y Y | Purchase | |
E0562 | NU EP | H 6 | Humidifier, heated, used w/positive airway pressure device | Y Y | Purchase | |
E0570 | Nebulizer, with compressor | Y* | Purchase | |||
E0575 | Nebulizer, ultrasonic, large volume | Y* | Capped Rental | |||
E0600 | Respiratory suction pump, home model, portable or stationary, electric | N | Rental Only | |||
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 | Y* | Rental Only | |
E0784 | NU | H | External ambulatory infusion pump, insulin | Y* | Purchase | |
E1340 | NU | H | ***(DME Repair: Parts Only Repairs will not be approved for more than the allowed purchase price of new equipment. The manufacturer?s invoice must be attached to the repair claim for all parts.) Repair or nonroutine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes | N | Manually Priced | |
E1340 | NU | U4 | H | ***(Maintenance for Capped Rental items) Repair or nonroutine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes | N | N/A |
E1340 | NU | U1 | H | ***(Labor Only; a maximum of twenty (20) units per date of service is allowable. 20 units = 5 hours of labor) Repair or nonroutine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes | N | Manually Priced |
E1340 | EP | U1 | 6 | ***(Labor Only; a maximum of twenty (20) units per date of service is allowable. 20 units = 5 hours of labor) Repair or nonroutine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes | N | Manually Priced |
E1390 | Oxygen concentrator, single delivery port, capable of delivering 85 % or greater oxygen concentration at the prescribed flow rate | Y* | Rental Only | |||
E1391 | NU | H | O2 concentrator, dual delivery port, capable of delivering 85% or [GREATER THAN] O2 concentration at the prescribed flow rate, each | Y | Purchase | |
E1391 | NU | I | O2 concentrator, dual delivery port, 85% or [GREATER THAN] O2 concentration at the prescribed flow rate, each | Y | Purchase |
Procedure codes found in this section must be billed either electronically or on paper with modifier KH to indicate an initial rental of an item. Modifiers are indicated below with the headings of M1 and M2.
Additionally, when billed on paper, procedure codes must be billed with a type of service (TOS) code ?I? for initial rental. Type of service is indicated by the heading of TOS.
Procedure codes shown in the list below are either covered for all ages (AA), for only individuals under age 21 (U21) or for only individuals age 21 and over (21+). A column in the list below defines the differences.
* Prior authorization is not required when another 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.
Procedure Code | M1 | M2 | TOS | Description | All U21 21+ |
A7034* | I | ***(CPAP Device Nasal Continuous Positive Airway Pressure (CPAP) Device; includes necessary accessory items. NOTE: For 21+, complete medical data pertinent to the request must be submitted with the prior authorization request.) Nasal interface (mask or cannula type) used with positive airway pressure device, with or without head strap | AA | ||
E0143* | I | Walker, folding, wheeled, adjustable or fixed height | 21+ | ||
E0166 | Commode chair, mobile, with detachable arms | U21 | |||
E0181 | Pressure pad, alternating with pump, heavy duty | U21 | |||
E0200 | Heat lamp, without stand (table model), includes bulb, or infrared element | U21 | |||
E0205 | Heat lamp, with stand includes bulb, or infrared element | U21 | |||
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 side rails, with mattress | U21 | |||
E0250 | I | Hospital bed, fixed height, with any type side rails, with mattress | 21+ | ||
E0255* | Hospital bed, variable height; hi-lo, with any type side rails, with mattress | U21 | |||
E0255 | KH | I | Hospital bed, variable height; hi-lo, with any type side rails, with mattress | 21+ | |
E0260* | I | Hospital bed, semi-electric (head and foot adjustment), with any type side rails with mattress | U21 | ||
E0260* | KH | I | Hospital bed, semi-electric (head and foot adjustment), with any type side rails with mattress | 21+ | |
E0271 | Mattress, inner spring | U21 | |||
E0272 | Mattress, foam rubber | U21 | |||
E0303 | I | Hospital bed, heavy duty, extra wide, with weight capacity [GREATER THAN] 350 but [LESS THAN] or = 600, any type side rails, w/mattress | AA | ||
E0424 | Stationary. compressed gaseous oxygen system, rental; includes container, contents, regulator flowmeter, humidifier, nebulizer cannula or mask, and tubing | AA | |||
E0430* | Portable gaseous oxygen system, purchase, includes regulator, flowmeter, humidifier, cannula, or mask, and tubing | AA | |||
E0435* | Portable liquid oxygen system, purchase; includes portable container, supply reservoir, flowmeter, humidifier, contents gauge, cannula or mask, tubing and refill adapter | AA | |||
E0439 | Stationary liquid oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing | AA | |||
E0480 | Percussor, electric or pneumatic, home model | U21 | |||
E0445* | ***(Pulse oximeter, including 4 disposable probes) Oximeter for measuring blood oxygen levels noninvasively | U21 | |||
E0565* | Compressor, air power source for equipment which is not self-contained or cylinder driven | U21 | |||
E0575* | Nebulizer, ultrasonic, large volume | AA | |||
E0585 | Nebulizer, with compressor and heater | U21 | |||
E0600 | Respiratory suction pump, home model, portable or stationary, electric | AA | |||
E0606 | Vaporizer, room type | U21 | |||
E0630* | Patient lift, hydraulic, with seat or sling | U21 | |||
E0630 | KH | I | Patient lift, hydraulic, with seat or sling | 21+ | |
E0650* | Pneumatic compressor, nonsegmental home model | U21 | |||
E0667* | Segmental pneumatic appliance for use with pneumatic compressor, full leg | U21 | |||
E0668* | Segmental pneumatic appliance for use with pneumatic compressor, full arm | U21 | |||
E0691 | Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; treatment area two square feet or less | U21 | |||
E0692 | I | Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; four foot panel | U21 | ||
E0693 | I | Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; six foot panel | U21 | ||
E0694 | I | Ultraviolet multidirectional light therapy system in six foot cabinet includes bulbs/lamps, timer and eye protection | U21 | ||
E0720* | TENS, two lead, localized stimulation | U21 | |||
E0730* | Transcutaneous electrical nerve stimulation device four or more leads, for multiple nerve stimulation | U21 | |||
E0730 | KH | I | Transcutaneous electrical nerve stimulation device four or more leads, for multiple nerve stimulation | 21+ | |
E0745* | I | Neuromuscular stimulator, electronic shock unit | U21 | ||
E0747* | Osteogenesis stimulator, electrical noninvasive, other than spinal applications | U21 | |||
E0779* | I | ***(Ambulatory infusion device, payable only 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 | AA | ||
E0910 | Trapeze bars, also known as Patient Helper, attached to bed, with grab bar | U21 | |||
E0910 | KH | I | Trapeze bars, also known as Patient Helper, attached to bed, with grab bar | 21+ | |
E0920 | Fracture frame, attached to bed, includes weights | U21 | |||
E0930 | Fracture frame, freestanding, includes weights | U21 | |||
E0935* | Passive motion exercise device | U21 | |||
E0940 | Trapeze bar, freestanding, complete with grab bar | U21 | |||
E0941 | Gravity assisted traction device, any type | U21 | |||
E1130* | Standard wheelchair, fixed full-length arms, fixed or swing?away, detachable footrests | U21 | |||
E1130* | KH | I | Standard wheelchair, fixed full-length arms, fixed or swing?away, detachable footrests | 21+ | |
E1224* | Wheelchair with detachable arms, elevating legrests | U21 | |||
E1224* | I | Wheelchair with detachable arms, elevating legrests | 21+ | ||
E1390 | Oxygen concentrator, single delivery port, capable of delivering 85% or greater oxygen concentration at the prescribed flow rate | AA |
Providers will be reimbursed for a minimum of 30 days of rental when the equipment is used less than 30 days. Initial rental codes should only 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 and type of service for the same time period.
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.
Additionally, when billed on paper, procedure codes must be billed with a type of service (TOS) code ?H? for individuals of all ages. Modifiers in the section are indicated by the headings M1 and M2. Type of service is indicated by the heading TOS. Prior authorization is indicated by the heading PA.
Procedure Code | M1 | M2 | TOS | Description | PA | Payment Method |
E0607 | NU | U1 | H | Home Blood Glucose Monitor | N | Purchase |
A4253 | NU | U1 | H | Blood glucose test or reagent strips for home glucose monitor, per 50 strips | N | Purchase |
A4259 | NU | U2 | H | Lancets, per box of 100 | N | Purchase |
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 modifier NU.
Additionally, when billed on paper, procedure codes must be billed with a type of service (TOS) code ?H? for individuals of all ages.
Modifiers in this section are indicated by the headings M1 and M2. Type of service is indicated by the heading TOS.
NOTE: Prosthetics providers may continue to use modifier 52 for claims with dates of service through October 31, 2005. Effective for claims with dates of service on and after November 1, 2005, modifier 52 will be replaced with modifier UB.
Medical Supplies, All Ages (section 242.120)
Procedure Code | M1 | M2 | TOS | Description |
A4206 | NU | H | Syringe with needle, sterile, 1 cc, ea | |
A4207 | NU | Syringe with needle, sterile, 2 cc, ea | ||
A4209 | NU | Syringe with needle, sterile, 5 cc or greater, ea | ||
A4216 | NU | H | Sterile water/saline, 10 ml | |
A4217 | NU | H | 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 | Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips | ||
A4253 | NU | UB | H | 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 pound | ||
A4310 | NU | Insertion tray without drainage bag and without catheter (accessories only) | ||
A4311 | NU | Insertion tray without drainage bag with indwelling catheter, Foley type, two-way latex with coating (Teflon, silicone, silicone elastomer or hydrophilic, etc.) | ||
A4312 | NU | Insertion tray without drainage bag with indwelling catheter, Foley type, two-way, all silicone | ||
A4313 | NU | Insertion tray without drainage bag with indwelling catheter, Foley type, three-way, for continuous irrigation | ||
A4314 | NU | Insertion tray with drainage bag with indwelling catheter, Foley type, two-way latex with coating (Teflon, silicone, silicone elastomer or hydrophilic, etc. | ||
A4315 | NU | Insertion tray with drainage bag with indwelling catheter, Foley type, two-way, all silicone | ||
A4316 | NU | Insertion tray with drainage bag with indwelling catheter, Foley type, three-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 specialty type with intergral collection chamber, 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, two-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, two-way, all silicone, each | ||
A4346 | NU | Indwelling catheter, Foley type, three-way for continuous irrigation, each | ||
A4348 | NU | Male external catheter with integral collection compartment, extended wear, each (e.g., 2 per month) | ||
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; 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 | U2 | H | Intermittent urinary catheter, with insertion supplies (tray) |
A4354 | NU | Insertion tray with drainage bag but without catheter | ||
A4355 | NU | Irrigation tubing set for continuous bladder irrigation through a three-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 | ||
A4359 | NU | Urinary suspensory without leg bag, 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 ounce | ||
A4365 | NU | H | Adhesive remover wipes, any type, per 50 | |
A4367 | NU | Ostomy belt, each | ||
A4368 | NU | H | Ostomy filter, any type, each | |
A4369 | NU | Ostomy skin barrier, liquid, (spray, brush, etc), per oz | ||
A4371 | NU | Ostomy skin barrier, power, per oz | ||
A4394 | NU | H | Ostomy deodorant for use in ostomy pouch, liquid, per fluid ounce | |
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 ounce | ||
A4404 | NU | Ostomy ring, each | ||
A4405 | NU | Ostomy skin barrier, non-pectin based, paste, per ounce | ||
A4406 | NU | Ostomy skin barrier, pectin based, paste, per ounce | ||
A4414 | NU | Ostomy skin barrier, with flange (solid, flexible or accordion), without built-in convexity, 4 x 4 inches or smaller, each | ||
A4450 | NU | U1 | Tape, non-waterproof, per 18 square inches | |
A4450 | NU | H | Tape, non-waterproof, per 18 square inches | |
A4452 | NU | Tape, waterproof, per 18 square inches | ||
A4455 | NU | Adhesive remover or solvent (for tape, cement or other adhesive), per ounce | ||
A4483 | NU | H | Moisture exchanger, disposable, for use with invasive mechanical ventilation | |
A4558 | NU | Conductive paste or gel | ||
A4561 | NU | U1 | Pessary, rubber, any type | |
A4562 | NU | Pessary, non rubber, any type | ||
A4623 | NU | Tracheostomy, inner cannula | ||
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 (one piece), each | ||
A5052 | NU | Ostomy pouch, closed; without barrier attached (one piece), each | ||
A5053 | NU | Ostomy pouch, closed; for use on faceplate, each | ||
A5054 | NU | Ostomy pouch, closed; for use on barrier with flange (two piece), each | ||
A5055 | NU | Stoma cap | ||
A5061 | NU | U1 | Ostomy pouch, drainable; with barrier attached (one piece), each | |
A5062 | NU | Ostomy pouch, drainable; without barrier attached (one piece), each | ||
A5063 | NU | Ostomy pouch, drainable; for use on barrier with flange (two piece system), each | ||
A5071 | NU | Ostomy pouch, urinary; with barrier attached (one piece), each | ||
A5072 | NU | Ostomy pouch, urinary; without barrier attached (one piece), each | ||
A5073 | NU | Ostomy pouch, urinary; for use on barrier with flange (two 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 | ||
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 | ||
A5119 | NU | Skin barrier; wipes, box per 50 | ||
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. | ||
A6154 | NU | Wound pouch, each | ||
A6196 | NU | H | Alginate or other fiber gelling dressing, wound cover, pad size 16 sq. in. or less, each dressing | |
A6197 | NU | UB | H | Alginate or other fiber gelling dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in, each dressing |
A6197 | NU | UB | H | Alginate or other fiber gelling dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in, each dressing (1 linear yard) |
A6198 | NU | H | Alginate or other fiber gelling dressing, wound cover, pad size more than 48 sq. in., each dressing | |
A6203 | NU | H | Composite dressing, pad size 16 sq. in. or less, with any size adhesive border, each dressing | |
A6204 | NU | H | Composite dressing, pad size more than 16 sq. in. but less than 48 sq. in., with any size adhesive border, each dressing | |
A6205 | NU | H | Composite dressing, pad size more than 48 sq. in., with any size adhesive border, each dressing | |
A6211 | NU | H | Foam dressing, wound cover, pad size more than 48 sq. in., without adhesive border, each dressing | |
A6212 | NU | H | Foam dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive border, each dressing | |
A6213 | NU | H | Foam dressing, wound cover, 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 | H | Gauze, non-impregnated, non-sterile, pad size 16 sq. in. or less, without adhesive border, each dressing | |
A6219 | NU | H | Gauze, non-impregnated, 16 sq. in. or less with any size adhesive border, each dressing | |
A6220 | NU | H | Gauze, non-impregnated, pad more than 16 sq. in., but less than or equal to 48 sq. in., with any size adhesive border, each dressing | |
A6221 | NU | H | Gauze, non-impregnated, pad size more than 48 sq. in., with any size adhesive border, each dressing | |
A6228 | NU | H | Gauze, impregnated, water or normal saline, pad, size 16 sq. in. or less, without adhesive border, each dressing | |
A6229 | NU | H | Gauze, impregnated, water or normal saline, pad size more than 16 sq. in., but less than or equal to 48 sq. in., without adhesive border, each dressing | |
A6230 | NU | H | Gauze, impregnated, water or normal saline, pad more than 48 sq. in., without adhesive border, each dressing | |
A6234 | NU | U1 | Hydrocolloid dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing | |
A6234 | NU | H | Hydrocolloid dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing | |
A6235 | NU | H | Hydrocolloid dressing, wound cover, pad size more than 16 sq. in., but less than or equal to 48 sq. in., without adhesive border, each dressing | |
A6236 | NU | H | Hydrocolloid dressing, wound cover, pad size more than 48 sq. in., without adhesive border, each dressing | |
A6237 | NU | H | Hydrocolloid dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive border, each dressing | |
A6238 | NU | H | Hydrocolloid dressing, wound cover, 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 | H | Hydrocolloid dressing, wound cover, 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 | H | Hydrocolloid dressing, wound cover, pad size more than 48 sq. in., with any size adhesive border, each dressing | |
A6241 | NU | Hydrocolloid dressing, wound filler, dry form, per gram | ||
A6242 | NU | Hydrocolloid dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing | ||
A6242 | NU | U1 | Hydrocolloid dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing | |
A6242 | NU | H | Hydrogel dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing | |
A6243 | NU | H | Hydrogel dressing, wound cover, pad size more than 16 sq. in., but less than or equal to 48 sq. in., without adhesive border, each dressing | |
A6244 | NU | H | Hydrogel dressing, wound cover, pad size more than 48 sq. in. without adhesive border, each dressing | |
A6245 | NU | H | Hydrogel dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive border, each dressing | |
A6246 | NU | H | Hydrogel dressing, wound cover, 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 | H | Hydrogel dressing, wound cover, pad size more than 48 sq. in. with any size adhesive border, each dressing | |
A6248 | NU | Hydrogel dressing, wound filler, gel, per fluid ounce | ||
A6248 | NU | U1 | Hydrogel dressing, wound filler, gel, per fluid ounce | |
A6248 | NU | H | Hydrogel dressing, wound filler, gel, per fluid ounce | |
A6257 | NU | H | Transparent film, 16 sq. in. or less, each dressing | |
A6258 | NU | H | Transparent film, more than 16 sq. in., but less than or equal to 48 sq. in., each dressing | |
A6259 | NU | H | Transparent film, more than 48 sq. in., each dressing | |
A6403 | NU | H | Gauze, non-impregnated, sterile, pad size more than 16 sq. in. but less than 48 sq. in., without adhesive border, each dressing | |
A6404 | NU | H | Gauze, non-impregnated, sterile, pad size more than 48 sq. in., without adhesive border, each dressing | |
A6441 | NU | H | Padding bandage, non-elastic, non-woven/non-knitted, width [GREATER THAN] or = 3 inches & [LESS THAN] 5 in, per yd | |
A6442 | NU | Conforming bandage, non-elastic, knitted/woven, non-sterile, width [LESS THAN] 3 in, per yd | ||
A6443 | NU | H | Conforming bandage, non-elastic, knitted/woven, non-sterile, width [GREATER THAN] or = 3 in & [LESS THAN] 5 in, per yd | |
A6444 | NU | H | Conforming bandage, non-elastic, knitted/woven, non-sterile, width [GREATER THAN] or = 5 in, per yd | |
A6445 | NU | Conforming bandage, non-elastic, knitted/woven sterile, width [LESS THAN]3 in, per yd | ||
A6446 | NU | H | Conforming bandage, non-elastic, knitted/woven, sterile, width [GREATER THAN] or = 3 in & [LESS THAN] 5 in, per yd | |
A6447 | NU | H | Conforming bandage, non-elastic, knitted/woven, sterile, width [GREATER THAN] or = 5 in, per yd | |
A6448 | NU | Light compression bandage, elastic, knitted/woven width[LESS THAN]3in, per yd | ||
A6449 | NU | H | Light compression bandage, elastic, knitted/woven, width [GREATER THAN] or = 3 in & [LESS THAN] 5 in, per yd | |
A6450 | NU | H | Light compression bandage, elastic, knitted/woven, width [GREATER THAN] or = 5 in, per yd | |
A6451 | NU | H | Moderate compress bandage, elastic, knitted/woven load resistance of 1.25 to 1.34 foot pounds at 50% maximum stretch, width [GREATER THAN] or = 3 in & [LESS THAN] 5 in, per yd | |
A6452 | NU | H | High compress bandage, elastic, knitted/woven, load resistance greater than or equal to 1.35 foot pounds at 50 % maximum stretch, width [GREATER THAN] or = 3 in & [LESS THAN] 5 in, per yd | |
A6453 | NU | Self-adherent bandage, elastic, non-knitted/non-woven, width[LESS THAN]3in, per yd | ||
A6454 | NU | Self-adherent bandage, elastic, non-knitted/non-woven, width [GREATER THAN] or = 3 in & [LESS THAN] 5 in, per yd | ||
A6455 | NU | Self-adherent bandage, elastic, non-knitted/non-woven, width [GREATER THAN] or = 5 in, per yd | ||
A65011 | NU | Compression burn garment, body suit (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 | ||
A7520 | NU | Trachestomy/Laryngectomy tube, non-cuffed, PVC, silicone or equal, each | ||
A7521 | Trachestoomy/Laryngectomy tube, cuffed, PVC, silicone or equal, each | |||
A7522 | Trachestomy/Laryngectomy tube, stainless steel or equal, (sterilizable and reusable), each | |||
A7524 | PO-Tracheostoma stent/stud/button, each | |||
A7525 | Tracheostomy mask, each | |||
B4086 | NU | Gastrostomy/jejunostomy tube, any material, any type, (standard or low profile), each | ||
E0776 | NU | IV pole |
Food thickeners, including ?Thick-It,? ?Thick-It II,? ?Simply Thick? and ?Thick and Easy,? are not subject to the $250 medical supply benefit limit.
When food thickeners are to be administered enterally, the modifier ?BA? must be used in conjunction with the procedure code.
When food thickeners are billed, total units are to be calculated to the nearest full ounce. Partial units may not be rounded up. When a date span is billed, the product cannot be billed until the end date has elapsed.
The maximum number of units allowed for food thickeners is 16 units per date of service.
Procedure Code | M1 | M2 | TOS | Description |
B4100 | H | Food thickener, administered orally, per oz. | ||
B4100 | BA | H | Food thickener, administered enterally, per oz. |
The gradient compression stocking (Jobst) is payable for individuals of all ages. However, before supplying the item, the Jobst stocking must be prior authorized by Utilization Review. View or print form DMS-679 and instructions for completion.Documentation accompanying form DMS-679 must indicate that the patient 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 Code | M1 | M2 | TOS | Description Maximum Units |
L8239 | NU | H | Gradient compression stocking, NOS Maximum 2 units per (Jobst); 1 unit = 1 stocking date of service |
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.
Additionally, when billed on paper, procedure codes must be billed with a type of service (TOS) code ?6? for individuals under age 21 or TOS ?H? for individuals age 21 and over.
Modifiers in this section are indicated by the headings M1 and M2. Type of service is indicated by the heading TOS. Prior authorization 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.
Diapers and Underpads, 3 Years Old and Older (section 242.130)
Procedure Code | M1 | M2 | TOS | Description | PA | Payment Method |
A4335 | EP | 6 | ***(Small Child-Size Diaper) Incontinence supply; miscellaneous | N | Purchase | |
A4335 | EP | U1 | 6 | ***(Medium Child-Size Diaper) Incontinence supply; miscellaneous | N | Purchase |
A4335 | EP | U2 | 6 | ***(Large Child-Size Diaper) Incontinence supply; miscellaneous | N | Purchase |
A4335 | NU EP | U1 U3 | H 6 | AIncontinence supply; miscellaneous (Under-Garment One size fits all) | N | Purchase |
A4554 | NU | H | Disposable underpads, all sizes (e.g., Chux?s) | N | Purchase | |
T4521 | NU | H | Adult-sized disposable incontinence product, brief/diaper, small, each | N | Purchase | |
T4522 | NU | H | Adult-sized disposable incontinence product, brief/diaper, medium, each | N | Purchase | |
T4523 | NU | H | Adult-sized disposable incontinence product, brief/diaper, large, each | N | Purchase | |
T4524 | NU | H | Adult-sized disposable incontinence product, brief/diaper, extra large, each | N | Purchase | |
T4526 | NU EP | H 6 | Adult-sized disposable incontinence product, protective underwear/pull-on, medium size, each | N | Purchase | |
T4527 | NU EP | H 6 | Adult-sized disposable incontinence product, protective underwear/pull-on, large size, each | N | Purchase | |
T4528 | NU EP | H 6 | Adult-sized disposable incontinence product, protective underwear/pull-on, extra large size, each | N | Purchase | |
T4529 | EP | 6 | Pediatric-sized disposable incontinence product, brief/diaper, small/medium size, each | N | Purchase | |
T4529 | EP | U1 | 6 | Pediatric-sized disposable incontinence product, brief/diaper, small/medium size, each | N | Purchase |
T4530 | EP | 6 | Pediatric-sized disposable incontinence product, brief/diaper, large size, each | N | Purchase | |
T4531 | EP | 6 | Pediatric-sized disposable incontinence product, brief/diaper, reusable, small/medium size, each | N | Purchase | |
T4531 | EP | U1 | 6 | Pediatric-sized disposable incontinence product, brief/diaper, reusable, small/medium size, each | N | Purchase |
T4532 | EP | 6 | Pediatric-sized disposable incontinence product, brief/diaper, reusable, large size, each | N | Purchase | |
T4532 | EP | U1 | 6 | Pediatric-sized disposable incontinence product, brief/diaper, reusable, large size, each | N | Purchase |
T4533 | EP | 6 | Youth-sized disposable incontinence product, brief/diaper, each | N | Purchase | |
T4535 | NU EP | H 6 | Disposable liner/shield/guard/pad/undergarment for incontinence, each | N | Purchase | |
T4535 | NU EP | U1 U1 | H 6 | Disposable liner/shield/guard/pad/undergarment for incontinence, each | N | Purchase |
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 212.500 of this manual for coverage information on diapers and underpads.
The procedure code found in this section must be billed either electronically or on paper using modifier NU for individuals of all ages.
Additionally, when billed on paper, the procedure code must be billed with a type of service (TOS) ?H? for individuals of all ages.
Modifiers in this section are indicated by the headings M1 and M2. Type of service is indicated by the heading TOS. Prior authorization requirements are shown under the heading PA. If prior authorization is needed, that information is indicated with a ?Y? in the column; if not, an ?N? is shown.
*Prior authorization is not required when another insurance pays at least 50% of the Medicaid maximum allowable reimbursement amount.
Procedure Code | M1 | M2 | TOS | Description | PA | Payment Method |
A4670 | NU | H | Automatic blood pressure monitor | Y* | Rental Only |
Included with the rental of this monitor, the provider will need to supply one (1) disposable blood pressure cuff each month.
Beneficiaries Under 21 Years of Age
The coverage listed is payable only if the service is prescribed as a result of a Child Health Services (EPSDT) screening/referral.
NOTE: WIC must be accessed first for individuals age 0 through the fifth birthday.
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.
Additionally, when billed on paper, procedure codes must be billed with a type of service (TOS) code ?6? for individuals under age 21.
Modifiers in this section are indicated by the headings M1 and M2. Type of service is indicated by the heading TOS. Modifier ?BO? is used to bill for oral usage.
Nutritional Formulae, for Child Health Services (EPSDT) Beneficiaries Under 21 Years of Age (section 242.150)
Procedure Code | M1 | M2 | M3 | T O S | Description | Covered Formulae |
B4149 B4149 | EP EP | BO | 6 6 | Enteral formula, blenderized natural foods with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit | Compleat | |
B4150 B4150 | EP EP | BO | 6 6 | Enteral formula, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit | See list below | |
Covered Formulae: | ||||||
Boost | Fibersource HN | Nutren 1.0 with Fiber | ||||
Boost with Fiber | Fortison | Osmolite | ||||
Carnation Instant Breakfast ? | Intraolite | Osmolite 1.0 CAL | ||||
Lactose Free | Isocal | Osmolite HN | ||||
Ensure | Isocal HN | Portagen | ||||
Ensure Fiber with FOS | IsoSource | Probalance | ||||
Ensure High Protein | IsoSource HN | Promote | ||||
Ensure HN | Jevity 1.0 CAL | Promote with Fiber | ||||
Ensure Powder | Nutrapack | Resource | ||||
Fibersource | Nutren 1.0 | Ultracal | ||||
B4150 | EP | U1 | BO | 6 | Enteral formula, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit | Boost Pudding Ensure Pudding |
B4152 B4152 | EP EP | BO | 6 6 | Enteral formula, nutritionally complete, calorically dense (equal to or greater than 1.5 Kcal/ml), with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit | Boost Plus Carnation Instant Breakfast ? Lactose Free Plus Comply Deliver 2.0 Ensure Plus Ensure Plus HN Nutren 1.5 Nutren 2.0 Resource Plus Scandishake Two-Cal HN | |
B4153 B4153 | EP EP | BO | 6 6 | Enteral formula, nutritionally complete, hydrolyzed proteins (amino acids and peptide chain), includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit | Alitraq Criticare HN Isotein HN Peptamen Peptamen 1.5 Peptamen VHP Peptamen with Prebio 1 Perative Tolerex Vital HN Vivonex Plus Vivonex TEN | |
B4154 B4154 | EP EP | BO | 6 6 | Enteral formula, nutritionally complete, for special metabolic needs, includes inherited disease of metabolism, includes altered composition of proteins, fats, carbohydrates, vitamins and/or minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit | See list below | |
Covered formulae: | ||||||
Advera | Impact with Fiber | Pulmocare | ||||
AminAid | IsoSource VHN | Resource Diabetic | ||||
Choice DM | Ketocal | Respalor | ||||
Forta Drink | Lipisorb | Similac 60/40 | ||||
Glucerna | Lofenalac | Suplena | ||||
Glytrol | Nepro | Traumacal | ||||
Hepatic Aid | NutriHep | Trumaid Powder | ||||
Impact | Protain XL | |||||
B4155 B4155 Bill on pape specific nam formula on | EP EP r (Indi e of claims | BO cate .) | 6 6 | Enteral formula, nutritionally incomplete/modular nutrients, includes 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 | Casec Powder Fructose Powder MCT Oil Moducal Polycose Liquid Promod Provimin Sumacal | |
B4155 B4155 | EP EP | U1 U1 | BO | 6 6 | Enteral formula, nutritionally incomplete/modular nutrients, includes 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 | Polycose Powder Dextrose Scandical |
B4155 B4155 | EP EP | U2 U2 | BO | 6 6 | Enteral formula, nutritionally incomplete/modular nutrients, includes 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 | Microlipids |
B4155 B4155 | EP EP | U3 U3 | BO | 6 6 | Enteral formula, nutritionally incomplete/modular nutrients, includes 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 | Product 80056 PKU 1, 2 and 3 RCF Try 1 and 2 |
B4158 B4158 | EP EP | BO | 6 6 | Enteral formula, for pediatrics, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 calories = 1 unit | Enfamil Enfamil AR Lipil Enfamil Lactofree Enfamil Lactofree Lipil Enfamil Lipil Low Iron Enfamil Lipil with Iron Enfamil Next Step Lipil Nutren Jr. Nutren JF with Fiber Resource for Kids Resource Just for Kids with Fiber | |
B4159 B4159 | EP EP | BO | 6 6 | Enteral formula, for pediatrics, nutritionally complete soy base with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 calories = 1 unit | Enfamil Next Step Prosobee Lipil Enfamil Prosobee Lipil Isomil Isomil Advance Soy with Iron Prosobee | |
B4160 B4160 | EP EP | BO | 6 6 | Enteral formula, for pediatrics, nutritionally calorically dense (equal to or greater than 0.7 Kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit | Enfamil Enfacare Lipil Powder Kindercal Pediasure Pediasure with Fiber | |
B4160 B4160 | EP EP | U1 U1 | BO | 6 6 | Enteral formula, for pediatrics, nutritionally calorically dense (equal to or greater than 0.7 Kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit | Enfamil Premature Lipil 24 Cal Low Iron Enfamil Premature Lipil 24 Cal with Iron Similac Neosure Similac Neosure Advance Special Care Advance 20 Special Care Advance 20 with Iron Special Care Advance 24 Special Care Advance 24 with Iron |
B4161 B4161 | EP EP | BO | 6 6 | Enteral formula, for pediatrics, hydrolyzed/amino acids and peptide chain proteins, includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit | Alimentum Enfamil Nutramigen Lipil Enfamil Pregestimil Neocate Infant Formula Neocate Jr Neocate One + (Pediatric E028) Liquid Neocate One + Powder Nutramigen Peptamen Jr Pregestimil Similac Alimentum Advance with Iron Vivonex Pediatric | |
B4162 B4162 | EP EP | BO | 6 6 | Enteral formula, for pediatrics, special metabolic needs for inherited disease of metabolism, includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit | See list below | |
Covered Formulae: | ||||||
Calcilo XD | Low Phe Try Diet Powder | Periflex | ||||
Cyclinex-1 | Maxamaid MSUD | Phenex-1 | ||||
Cyclinex-2 | Maxamaid XLYS-TRY | Phenex-2 | ||||
Hominex-1 | Maxamaid Xp | Phenyl Free 1 | ||||
Hominex-2 | Maxamaid Xphen Try | Phenyl Free 2 | ||||
I-Valex-1 | Maxamum MSUD | Propimex-1 | ||||
I-Valex-2 | Maxamum XP | Propimex-2 | ||||
Ketonex-1 | MSUD Analog | XP Analog | ||||
Ketonex-2 | MSUD 1 and 2 | Xphen, Try Analog | ||||
B4162 B4162 | EP EP | U1 U1 | BO | 6 6 | Enteral formula, for pediatrics, special metabolic needs for inherited disease of metabolism, includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit | XMTVI Maximaid |
One unit of service equals 100 calories with a maximum of 30 units per day reimbursable. Supplies provided in conjunction with the nutritional formula through the prosthetics programs must be billed under the prosthetics medical supply code. These formulae are covered as nutritional supplements rather than 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 should not be filed until the ?through? date has elapsed. Claims may be submitted on either a weekly or monthly basis.
NOTE: If a specific formula is not listed but is the same as a formula listed, it may be billed using the procedure code for the comparable formula. It is the responsibility of the provider to prove comparability when audited.
The procedure code found in this section must be billed with modifier EP. Additionally, when billed on paper, the procedure code must be billed with a type of service (TOS) code ?6.? Pedia-Pop is only for oral consumption, and only in frozen form.
Modifiers in this section are indicated by the headings M1 and M2. Type of service is indicated by the heading TOS.
Procedure Code | M1 | M2 | TOS | Description | Maximum Units |
Z2487 | EP | 6 | Pedia-Pop; 1 unit = 1 box | 2 units per date of service |
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.
Additionally, when billed on paper, procedure codes must be billed with a type of service (TOS) code ?6? for individuals under age 21.
The procedure codes will require prior authorization from the Utilization Review Section of the Division of Medical Services.
Modifiers in this section are indicated by the headings M1 and M2. Type of service is indicated by the heading TOS. Prior authorization requirements are shown under the heading PA. If prior authorization is needed, that information is indicated with a ?Y? in the column; if not, an ?N? is shown.
***(?) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product.
Procedure Code | M1 | M2 | TOS | Description | Maximum Units | PA | Payment Method |
B4035 | EP | 6 | Enteral feeding supply kit, pump fed, per day (1 unit = 1 day) | 1 per day | Y | Purchase | |
B9000 | EP | 6 | Enteral nutrition infusion pump ? without alarm (1 day = 1 unit) | 1 per day | Y | Rent to Purchase | |
B9002 | EP | 6 | Enteral nutrition infusion pump ? with alarm (1 day = 1 unit) | 1 per day | Y | Rent to Purchase | |
E1340 | EP | U2 | 6 | ***(Repair - Enteral nutrition infusion pump) Repair or nonroutine service for durable medical equipment requiring the skill of a technician, labor component | Y |
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. 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.
and Supplies for Individuals Under Age 21
Procedure codes found in this section must be billed with modifier EP for beneficiaries under 21 years of age. Additionally, when billed on paper, procedure codes must be billed with a type of service (TOS) code ?6? for individuals under age 21.
Procedure Code | M1 | M2 | PA | Description | Payment Method |
B9998 | Y | MIC-KEY Kit | Purchase | ||
B9998 | EP | U1 | Y | SECUR-LOK Extension Set with 2 Port ?Y? and Clamp 12? Length | Purchase |
B9998 | EP | U2 | Y | SECUR-LOK Extension Set with 2 Port ?Y? and Clamp 24? Length | Purchase |
B9998 | EP | U3 | Y | Bolus Extension Set with Single Port Clamp 12? Length | Purchase |
B9998 | EP | U4 | Y | Bolus Extension Set with Single Port Clamp 24? Length | Purchase |
B9998 | EP | U5 | Y | Bolus SECUR-LOK Extension Set Single Port w/Clamp 12? Length | Purchase |
B9998 | EP | U6 | Y | Bolus SECUR-LOK Extension Set Single Port w/Clamp 24? Length | Purchase |
B9998 | EP | U7 | Y | Microvasive Adapter | Purchase |
B9998 | EP | U8 | Y | Microvasive Decompression Tube | Purchase |
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. Modifier UE must be used to bill for used equipment.
Additionally, when billed on paper, procedure codes must be billed with a type of service (TOS) code ?6? for individuals under age 21 and TOS ?H? for individuals age 21 and over. TOS ?U? must be used to bill for used equipment.
Modifiers in this section are indicated by the headings M1 and M2. Type of service is indicated by the heading TOS. Prior authorization requirements are shown under the heading PA. If prior authorization is needed, that information is indicated with a ?Y? in the column; if not, an ?N? is shown.
* The purchase of wheelchairs for individuals age 21 and over is limited to one per five-year period.
*** This procedure code may not be billed for TOS ?U? (used equipment).
* Prior authorization is not required when another 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.
Durable Medical Equipment, All Ages (section 242.160)
Procedure Code | M1 | M2 | T O S | PA | Description | Payment Method |
A4635 | NU EP UE | H 6 U | N | Underarm pad, crutch, replacement, each | Purchase | |
A4636 | NU EP UE | H 6 U | N | Replacement, handgrip, cane, crutch, or walker, each | Purchase | |
A4637 | H 6 U | N | Replacement, tip, cane, crutch, walker, each | Purchase | ||
E0100 | H 6 U | N | Cane, includes canes of all materials, adjustable or fixed, with tip | Purchase | ||
E0105 | H 6 U | N | Cane, quad or three-prong, includes canes of all materials, adjustable or fixed, with tips | Purchase | ||
E0110 | H 6 U | N | Crutches, forearm, includes crutches of various materials, adjustable or fixed, pair, complete with tips and handgrips | Purchase | ||
E0111 | NU EP UE | U1 | H 6 U | N | Crutch, forearm, includes crutches of various materials, adjustable or fixed, each, with tip and handgrip | Purchase |
E0112 | H 6 U | N | Crutches, underarm, wood, adjustable or fixed, pair, with pads, tips and handgrips | Purchase | ||
E0113 | H 6 U | N | Crutch, underarm, wood, adjustable or fixed, each, with pad, tip and handgrip | Purchase | ||
E0114 | H 6 U | N | Crutches, underarm, other than wood, adjustable or fixed, pair, with pads, tips and handgrips | Purchase | ||
E0116 | NU EP UE | H 6 U | N | Crutch, underarm, other than wood, adjustable or fixed, each, with pad, tip and handgrip | Purchase | |
E0130 | H 6 U | N | Walker, rigid (pickup), adjustable or fixed height | Purchase | ||
E0135 | H 6 U | N | Walker, folding (pickup), adjustable or fixed height | Purchase | ||
E0140 | NU EP | H 6 | N | Walker, w/trunk support, adjustable or fixed height, any type | Purchase | |
E0141 | H 6 U | N | Walker, rigid, wheeled, adjustable or fixed height | Purchase | ||
E0143 | H 6 U | N | Walker, folding, wheeled, adjustable or fixed height | Purchase | ||
E0147 | NU EP UE | H 6 U | N | Walker, heavy duty, multiple braking system, variable wheel resistance | Purchase | |
E0153 | H 6 U | N | Platform attachment, forearm crutch, each | Purchase | ||
E0154 | H 6 U | N | Platform attachment, walker, each | Purchase | ||
E0155 | H 6 U | N | Wheel attachment, rigid pick-up walker, per pair seat attachment, walker | Purchase | ||
E0156 | NU EP | H 6 | N | Seat attachment, walker | Purchase | |
E0157 | H 6 U | N | Crutch attachment, walker, each | Purchase | ||
E0158 | H 6 U | N | Leg extensions for walker, per set of four (4) | Purchase | ||
E0159 | NU EP | H 6 | N | Brake attachment for wheeled walker, replacement, each | Purchase | |
E0160 | H 6 U | N | Sitz type bath or equipment, portable, used with or without commode | Purchase | ||
E0161 | H 6 U | N | Sitz type bath or equipment, portable, used with or without commode, with faucet attachment(s) | Purchase | ||
E0163 | NU EP UE | H 6 U | N | Commode chair, stationary, with fixed arms | Purchase | |
E0164 | H 6 U | N | Commode chair, mobile, with fixed arms | Purchase | ||
E0166 | H 6 U | N | PO-Commode chair, mobile, w/detachable arms | Capped Rental | ||
E0166 | NU EP UE | U2 U2 U2 | H 6 U | N | PO-Commode chair, mobile, w/detachable arms | Purchase |
E0167 | H 6 U | N | Pail or pan for use with commode chair | Purchase | ||
E0175 | NU EP UE | H 6 U | N | Foot rest, for use with commode chair, each | Purchase | |
E0180 | NU EP UE | H 6 U | N | Pressure pad, alternating with pump | Purchase | |
E0181 | H 6 U | N | Pressure pad, alternating with pump, heavy duty | Capped Rental | ||
E0182 | U1 | H 6 U | N | Pump for alternating pressure pad | Purchase | |
E0184 | H 6 U | N | Dry pressure mattress | Purchase | ||
E0185 | H 6 U | N | Gel or gel-like pressure pad for mattress, standard mattress length and width | Purchase | ||
E0186 | NU EP | H 6 | Y | Air pressure mattress | Purchase | |
E0187 | NU EP | H 6 | Y | Water pressure mattress | Purchase | |
E0189 | NU EP UE | H 6 U | N | Lambswool sheepskin pad, any size | Purchase | |
E0190 | NU UE | H U | N | Positioning cushion/pillow/wedge, any shape or size | Purchase | |
E0190 | EP EP EP EP EP EP EP EP EP EP EP EP EP | U1 U2 U3 U4 U5 U6 U7 U8 U9 KA/U1 KA/U2 KA/U3 | 6 6 6 6 6 6 6 6 6 6 6 6 6 | N | Positioning cushion/pillow/wedge, any shape or size | Purchase |
E0191 | H 6 U | N | Heel or elbow protector, each | Purchase | ||
E0196 | NU EP | H 6 | N | Gel pressure mattress | Purchase | |
E0197 | NU EP UE | H 6 U | N | Air pressure pad for mattress, standard mattress length and width | Purchase | |
E0198 | NU EP | H 6 | Y | Water pressure pad for mattress, standard mattress length and width | Purchase | |
E0200 | NU EP UE | H 6 U | N | Heat lamp, without stand (table model), includes bulb, or infrared element | Capped Rental | |
E0202 | NU EP UE | H 6 U | N | Phototherapy (bilirubin) light with photometer | Rental Only | |
E0205 | NU EP UE | H 6 U | N | Heat lamp, with stand includes bulb, or infrared element | Capped Rental | |
E0217 | NU EP UE | H 6 U | N | Water circulating heat pad with pump | Capped Rental | |
E0225 | NU EP UE | H 6 U | N | Hydrocollator unit, includes pad | Capped Rental | |
E0235 | NU EP UE | H 6 U | N | Paraffin bath unit, portable (see medical supply code A4265 for paraffin) | Purchase | |
E0236 | NU EP UE | H 6 U | N | Pump for water circulating pad | Capped Rental | |
E0238 | NU EP UE | H 6 U | N | Nonelectric heat pad, moist | Purchase | |
E0239 | NU EP UE | H 6 U | N | Hydrocollator unit, portable | Capped Rental | |
E0240 | NU EP NU EP NU EP NU EP | U1 U1 U2 U2 U3 U3 | H 6 H 6 H 6 H 6 | N | Bath/shower chair w/wo wheels, any size | Purchase |
E0244 | NU EP | H 6 | Y | Raised toilet seat | Purchase | |
E0245*** | NU EP | U1 U1 | H 6 | N | ***(Bath Frame Support, Large) Tub stool or bench | Purchase |
E0247 | NU EP NU EP | U1 U1 | H 6 H 6 | N | Transfer bench, tub/toilet, w/wo commode opening | Purchase |
E0248 | NU EP NU EP | U1 U1 | H 6 H 6 | N | Transfer bench, heavy duty, tub/toilet w/wo commode opening | Purchase |
E0249 | NU EP UE | H 6 U | N | Pad for water circulating heat unit | Purchase | |
E0250 | UE | U | Y* | Hospital bed, fixed height, with any type side rails, with mattress | Capped Rental | |
E0250 | NU EP | H 6 | Y* | ***(Hospital bed, with side rails, fixed height, with mattress, purchase) Hospital bed, fixed height, with any type side rails, with mattress | Purchase | |
E0255 | UE | U | Y* | Hospital bed, variable height; hi-lo, with any type side rails, with mattress | Capped Rental | |
E0255 | NU EP | U1 | H 6 | Y* | ***(Hospital bed, with side rails, variable height; hi-lo, with mattress, purchase) Hospital bed, variable height; hi-lo, with any type side rails, with mattress | Purchase |
E0260 | NU EP UE | RR RR | H 6 U | Y* | Hospital bed, semi-electric, head and foot adjustment, with any type side rails with mattress | Capped Rental |
E0260 | NU EP | H 6 | Y* | ***(Hospital bed, with side rails, semi-electric, head and foot adjustments, with mattress, purchase) Hospital bed, semi-electric, head and foot adjustment, with any type side rails with mattress | Purchase | |
E0271 | NU EP UE | H 6 U | N | Mattress, inner spring | Capped Rental | |
E0272 | NU EP UE | H 6 U | N | Mattress, foam rubber | Capped Rental | |
E0273 | NU EP UE | H 6 U | N | Bed board | Purchase | |
E0275 | NU EP UE | H 6 U | N | Bed pan, standard, metal or plastic | Purchase | |
E0276 | NU EP UE | H 6 U | N | Bed pan, fracture, metal or plastic | Purchase | |
E0280 | NU EP UE | H 6 U | N | Bed cradle, any type | Purchase | |
E0300 | EP EP | RR | 6 6 | Y Y | Pediatric crib, hospital grade, fully enclosed | Purchase Rental Only |
E0303 | NU EP UE | H 6 U | Y Y Y | Hospital bed, heavy duty, extra wide, with weight capacity [GREATER THAN] 350 but [LESS THAN] or = 600, any type side rails, w/mattress | Rental Only (Rent to Purchase) | |
E0325 | NU NU EP UE | U1 | H H 6 U | N | Urinal; male, jug-type, any material | Purchase |
E0326 | NU EP UE | H 6 U | N | Urinal; female, jug-type, any material | Purchase | |
E0445*** | NU EP | H 6 | Y* | ***(Pulse oximeter, including 4 disposable probes) Oximeter for measuring blood oxygen levels non-invasively | Rental Only | |
E0480 | NU EP UE | H 6 U | N | Percussor, electric or pneumatic, home model | Capped Rental | |
E0565 | NU EP UE | H 6 U | Y* | Compressor, air power source for equipment which is not self-contained or cylinder driven | Capped Rental | |
E0570 | NU EP UE | H 6 U | Y | Nebulizer, with compressor | Purchase | |
E0585 | NU EP UE | H 6 U | N | Nebulizer, with compressor and heater | Capped Rental | |
E0605 | NU EP UE | H 6 U | N | Vaporizer, room type | Purchase | |
E0606 | NU EP UE | H 6 U | N | Postural drainage board | Capped Rental | |
E0607*** | NU EP | H 6 | N | Home blood glucose monitor | Purchase | |
E0621 | NU | H | N | Sling or seat, patient lift, canvas or nylon | Purchase | |
E0630 | NU EP UE | H 6 U | Y* | Patient lift, hydraulic, with seat or sling | Capped Rental | |
E0650 | NU EP UE | H 6 U | Y* | Pneumatic compressor, nonsegmental home model | Capped Rental | |
E0667 | NU EP UE | H 6 U | Y* | Segmental pneumatic appliance for use with pneumatic compressor, full leg | Capped Rental | |
E0668 | NU EP UE | H 6 U | Y* | Segmental pneumatic appliance for use with pneumatic compressor, full arm | Capped Rental | |
E0691 | NU EP UE | H 6 U | N | Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; treatment area two square feet or less | Rental Only | |
E0692 | NU EP | H 6 | N | Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; four foot panel | Rental Only | |
E0693 | NU EP | H 6 | N | Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; six foot panel | Rental Only | |
E0694 | NU EP | H 6 | N | Ultraviolet multidirectional light therapy system in six foot cabinet includes bulbs/lamps, timer and eye protection | Rental Only | |
E0720 | NU EP UE | H 6 U | Y* | TENS, two lead, localized stimulation | Capped Rental | |
E0730 | NU EP UE | H 6 U | Y* | Transcutaneous electrical nerve stimulation device four or more leads, for multiple nerve stimulation | Capped Rental | |
E0740 | NU EP UE | H 6 U | N | Incontinence treatment system, pelvic floor stimulator, monitor, sensor and/or trainer | Purchase | |
E0745 | NU EP UE | H 6 U | Y* | Neuromuscular stimulator, electronic shock unit | Capped Rental | |
E0747 | NU EP UE | H 6 U | Y* | Osteogenesis stimulator, electrical noninvasive, other than spinal applications | Rental Only | |
E0748 | NU EP | H 6 | N | Osteogenesis stimulator, electrical noninvasive, spinal applications | Purchase | |
E0749 | NU EP UE | H 6 U | Y* | Osteogenesis stimulator, electrical, surgically implanted | Purchase | |
E0779 | NU | H | Y* | ***(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 | Rental Only | |
E0840 | NU EP UE | H 6 U | N | Traction frame, attached to headboard, cervical traction | Purchase | |
E0850 | NU EP UE | H 6 U | N | Traction stand, freestanding, cervical traction | Purchase | |
E0860 | NU EP UE | H 6 U | N | Traction equipment, overdoor, cervical | Purchase | |
E0870 | NU EP UE | H 6 U | N | Traction frame, attached to footboard, extremity traction (e.g., Buck?s) | Purchase | |
E0880 | NU EP UE | H 6 U | N | Traction stand, freestanding, extremity traction (e.g., Buck?s) | Purchase | |
E0890 | NU EP UE | H 6 U | N | Traction frame, attached to footboard, pelvic traction | Purchase | |
E0900 | NU EP UE | H 6 U | N | Traction stand, freestanding, pelvic traction (e.g., Buck?s) | Purchase | |
E0910 | NU EP UE | H 6 U | N | Trapeze bars, also known as Patient Helper, attached to bed, with grab bar | Capped Rental | |
E0920 | NU EP UE | H 6 U | N | Fracture frame, attached to bed, includes weights | Capped Rental | |
E0930 | NU EP UE | H 6 U | N | Fracture frame, freestanding, includes weights | Capped Rental | |
E0935 | NU EP UE | H 6 U | Y* | Passive motion exercise device | Capped Rental | |
E0940 | NU EP UE | H 6 U | N | Trapeze bar, freestanding, complete with grab bar | Capped Rental | |
E0941 | NU EP UE | H 6 U | N | Gravity assisted traction device, any type | Capped Rental | |
E0942 | NU EP UE | H 6 U | N | Cervical head harness/halter | Purchase | |
E0944 | NU EP UE | H 6 U | N | Pelvic belt/harness/boot | Purchase | |
E0945 | NU EP UE | H 6 U | N | Extremity belt/harness | Purchase | |
E0946 | NU EP UE | H 6 U | N | Fracture frame, dual with cross bars, attached to bed (e.g., Balken, Four Poster) | Purchase | |
E0947 | NU EP UE | H 6 U | N | Fracture frame, attachments for complex pelvic traction | Purchase | |
E0948 | NU EP UE | H 6 U | N | Fracture frame, attachments for complex cervical traction | Purchase | |
E0950 | NU EP UE | H 6 U | N | Wheelchair accessory, tray, each | Purchase | |
E1130* | NU EP UE | H 6 U | Y* | Standard wheelchair, fixed full-length arms, fixed or swing?away, detachable footrests | Capped Rental | |
E1140* | NU EP UE | H 6 U | Y* | Wheelchair, detachable arms, desk or full-length, swing?away, detachable footrests | Capped Rental | |
E1150* | NU EP UE | H 6 U | Y* | Wheelchair; detachable arms, desk or full-length, swing?away, detachable, elevating legrests | Capped Rental | |
E1160* | NU EP UE | H 6 U | Y* | Wheelchair; fixed full-length arms, swing?away, detachable, elevating legrests | Capped Rental | |
E1224* | NU EP UE | H 6 U | Y* | Wheelchair with detachable arms, elevating leg rests | Capped Rental | |
E1340 | NU | H | N | ***(DME Repairs/Parts Only Repairs will not be approved for more than the allowed purchase price of new equipment. The manufacturer?s invoice must be attached to the repair claim for all parts.) Repair or nonroutine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes | Manually Priced | |
E1340*** | NU EP | U1 U1 | H 6 | N | ***(Labor Only; a maximum of twenty [20] units [20 units = 5 hours of labor] per date of service is allowable.) Repair or non-routine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes | Manually Priced |
E1399 | NU | H | N | Durable medical equipment, miscellaneous | Manually Priced | |
S8096*** | NU EP | H 6 | N | ***(Peak flow meter used by asthmatic patients) Portable peak flow meter | Purchase |
Procedure codes E0250*, E0255* and E0260* must be billed when hospital beds are purchased for eligible Medicaid beneficiaries of all ages.
The hospital beds must be new, not used. When billed electronically, the above procedure codes must be billed with modifier NU for individuals age 21 and over or modifier EP for individuals under the age of 21. A type of service code ?6? must be used for billing paper claims for beneficiaries under age 21 and type of service code ?H? for beneficiaries age 21 and over. The codes all require prior authorization. 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*remain payable and must 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.
Procedure codes found in this section must be billed either electronically or on paper with modifier UE for used equipment.
Additionally, when billing on paper, bill for beneficiaries age 21 and over using these procedure codes with a type of service code ?U,? for used equipment.
Modifiers in this section are indicated by the headings M1 and M2. Type of service is indicated by the heading TOS. Prior authorization requirements are shown under the heading PA. If prior authorization is needed, that information is indicated with a ?Y? in the column; if not, an ?N? is shown.
* The purchase of wheelchairs for individuals age 21 and over is limited to one per five-year period.
* Prior authorization is not required when another 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.
Used Durable Medical Equipment, Age 21 and Over (section 242.161)
Procedure Code | M1 | M2 | TOS | Description | PA | Payment Method |
E0105 | UE | U | Cane, quad or three-prong, includes canes of all materials, adjustable or fixed, with tips | N | Purchase | |
E0143 | UE | U | ***(Walker, folding, wheeled, with seat) Walker, folding, wheeled, adjustable or fixed height | N | Capped Rental | |
E0143 | UE | U | Walker, folding, wheeled, adjustable or fixed height | N | Purchase | |
E0163 | UE | U | Commode chair, stationary with fixed arms | N | Purchase | |
E0180 | UE | U | Pressure pad, alternating with pump | N | Purchase | |
E0191 | UE | U | Heel or elbow protector, each | N | Purchase | |
E0192 | UE | U | Low pressure and positioning equalization pad for wheelchair | N | Purchase | |
E0202 | UE | U | Phototherapy (bilirubin) light with photometer | N | Rental Only | |
E0255 | UE | U | ***(Hospital bed, with side rails, variable height; hi-lo, with mattress) Hospital bed, variable height; hi-lo, with any type side rails, with mattress | Y | Capped Rental | |
E0260 | UE | U | ***(Hospital bed, with side rails, semi-electric; head and foot adjustment, with mattress) Hospital bed, semi-electric, head and foot adjustment, with any type side rails with mattress | Y* | Capped Rental | |
E0630 | UE | U | Patient lift, hydraulic, with seat or sling | Y* | Capped Rental | |
E0730 | UE | U | Transcutaneous electrical nerve stimulation device, four or more leads, for multiple nerve stimulation | Y* | Capped Rental | |
E0910 | UE | U | ***(Trapeze bars, attached to bed, complete with grab bar) Trapeze bars, also known as Patient Helper, attached to bed, with grab bar | N | Capped Rental | |
E1130* | UE | U | Standard wheelchair; fixed full-length arms, fixed or swing-away, detachable footrests | Y* | Capped Rental | |
E1224* | UE | U | ***(Footrest wheelchair with detachable arms, elevating legrests) Wheelchair with detachable arms, elevating legrests | Y* | Capped Rental |
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.
Additionally, when billed on paper, procedure codes must be billed with a type of service (TOS) code ?6? for individuals under 21 years of age or TOS ?U? for used equipment.
Modifiers in this section are indicated by the headings M1 and M2. Type of service is indicated by the heading TOS. Prior authorization requirements are shown under the heading PA. If prior authorization is needed, that information is indicated with a ?Y? in the column; if not, an ?N? is shown.
Sections 212.300 and 222.200 contain information regarding specific coverage and restrictions.
* Prior authorization is not required when another 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.
National Code | M1 | M2 | TOS | Local Code | Description | PA | Payment Method |
E0618 | EP | 6 | Apnea monitor, without recording feature | Y (on 31st day)* | Rental Only (Daily Rental) | ||
E0619 | EP | 6 | Apnea monitor, with recording feature | Y (on 31st day)* | Rental Only (Daily Rental) | ||
E0619 | ***(Initial setup of apnea monitor, includes 30 days rental) Apnea monitor, with recording feature | N | First 30 Days Rental | ||||
Bill on paper | 6 | Z1684 | Technical and lab services for setting up pneumogram or event recording (not including professional services) | N | Purchase |
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.
Additionally, when billed on paper, procedure codes must be billed with a type of service (TOS) code ?6? for individuals under age 21 or TOS code ?H? for individuals age 21 and over.
Modifiers in this section are indicated by the headings M1 and M2. Type of service is indicated by the heading TOS.
Prior authorization requirements are shown under the heading PA. If prior authorization is needed for individuals age 21 and over, 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 over.
NOTE: Prosthetics providers may continue to use modifier 52 for claims with dates of service through October 31, 2005. Effective for claims with dates of service on and after November 1, 2005, modifier 52 will be replaced with modifier UB.
** 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.
Orthotic Appliances, All Ages (section 242.180)
Procedure Code | M1 | M2 | TOS | Description | All U21 21+ | PA 21+ | Payment Method |
A5500 | NU | H | For diabetics only, fitting (including follow-up) custom preparation and supply of off-the-shelf depth-inlay shoe manufactured to accommodate multi-density insert(s), per shoe | 21+ | Y | Purchase | |
A5501 | NU | H | For diabetics only, fitting (including follow-up) custom preparation and supply of molded from cast(s) of patient?s foot (custom molded shoe), per shoe | 21+ | Y | Purchase | |
A5503 | NU | H | For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with roller or rigid rocker bottom, per shoe | 21+ | Y | Purchase | |
A5504 | NU | H | For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with wedge(s), per shoe | 21+ | Y | Purchase | |
A5505 | NU | H | For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with metatarsal bar, per shoe | 21+ | Y | Purchase | |
A5506 | NU | H | For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with off-set heel(s), per shoe | 21+ | Y | Purchase | |
A5507 | NU | H | For diabetics only, not otherwise specified modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe, per shoe | 21+ | Y | Purchase | |
A5509 | NU | H | For diabetics only, direct formed, molded to foot with external heat source (i.e., heat gun) multiple density inserts(s), prefabricated, per shoe | 21+ | Y | Purchase | |
A5510 | NU | H | For diabetics only, direct formed, compression molded to patient?s foot without external heat source, multiple-density insert(s) prefabricated, per shoe | 21+ | Y | Purchase | |
A5511 | NU | H | For diabetics only, custom-molded from model of patient?s foot multiple-density insert(s) custom-fabricated, per shoe | 21+ | Y | Purchase | |
K0630 | NU EP | H 6 | SO, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, prefabricated, includes fitting and adjustment | All | N | Purchase | |
K0631 | NU EP | H 6 | SO, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricated | All | N | Purchase | |
K0632 | NU EP | H 6 | SO, flexible, provides pelvic-sacral support, with rigid or semi-rigid panels over sacrum and abdomen, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, prefabricated, includes fitting and adjustment | All | N | Purchase | |
K0634 | NU EP | H 6 | LO, flexible, provides lumbar support, posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include pendulous abdomen design, shoulder straps, stays, prefabricated, includes fitting and adjustment | All | N | Purchase | |
K0635 | NU EP | H 6 | LO, sagittal control, with rigid posterior panel(s), includes straps, posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment | All | N | Purchase | |
K0636 | NU EP | H 6 | LO, sagittal control, with rigid anterior and posterior panel(s), includes straps, posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment | All | N | Purchase | |
K0637 | NU EP | H 6 | LSO, flexible, provides lumbo-sacral support, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include stays, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment | All | N | Purchase | |
K0638 | NU EP | H 6 | LSO, flexible, provides lumbo-sacral support, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include stays, shoulder straps, pendulous abdomen design, custom fabricated | All | N | Purchase | |
K0639 | NU EP | H 6 | LSO, sagittal control, with rigid posterior panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment | All | N | Purchase | |
K0640 | NU EP | H 6 | LSO, sagittal control, with rigid anterior and posterior panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment | All | N | Purchase | |
K0641 | NU EP | H 6 | LSO, sagittal control, with rigid anterior and posterior panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, custom fabricated | All | N | Purchase | |
K0642 | NU EP | H 6 | LSO, sagittal-coronal control, with rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment | All | N | Purchase | |
K0643 | NU EP | H 6 | LSO, sagittal-coronal control, with rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, custom fabricated | All | N | Purchase | |
K0644 | NU EP | H 6 | LSO, sagittal-coronal control, lumbar flexion, rigid posterior frame/panel(s), lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, prefabricated, includes fitting and adjustment | All | N | Purchase | |
K0645 | NU EP | H 6 | LSO, sagittal-coronal control, lumbar flexion, rigid posterior frame/panel(s), lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, custom fabricated | All | N | Purchase | |
K0646 | NU EP | H 6 | LSO, sagittal-coronal control, with rigid anterior and posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment | All | N | Purchase | |
K0647 | NU EP | H 6 | LSO, sagittal-coronal control, with rigid anterior and posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, custom fabricated | All | N | Purchase | |
K0648 | NU EP | H 6 | LSO, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xiphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength provided by overlapping rigid plastic and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, prefabricated, includes fitting and adjustment | All | N | Purchase | |
K0649 | NU EP | H 6 | LSO, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xiphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength provided by overlapping rigid plastic and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, custom fabricated | All | N | Purchase | |
L0100 | NU EP | H 6 | Cranial orthosis (helmet), with or without soft interface, molded to patient model | All | N | Purchase | |
L0110 | NU EP | H 6 | Cranial orthosis (helmet), with or without soft interface, non-molded | All | N | Purchase | |
L0120 | NU EP | H 6 | Cervical, flexible, nonadjustable (foam collar) | All | N | Purchase | |
L0130 | NU EP | H 6 | Cervical, flexible, thermoplastic collar, molded to patient | All | N | Purchase | |
L0140 | NU EP | H 6 | Cervical, semi-rigid, adjustable (plastic collar) | All | N | Purchase | |
L0150 | NU EP | H 6 | Cervical, semi-rigid, adjustable molded chin cup (plastic collar with mandibular/occipital piece) | All | N | Purchase | |
L0160 | NU EP | H 6 | Cervical, semi-rigid wire frame occipital/mandibular support | All | N | Purchase | |
L0170 | NU EP | H 6 | Cervical, collar, molded to patient model | All | N | Purchase | |
L0172 | NU EP | H 6 | Cervical, collar, semi-rigid thermoplastic foam, two piece | All | N | Purchase | |
L0174 | NU EP | H 6 | Cervical, collar, semi-rigid thermoplastic foam, two piece with thoracic extension | All | N | Purchase | |
L0180 | NU EP | H 6 | Cervical, multiple post collar, occipital/mandibular supports, adjustable | All | N | Purchase | |
L0190 | NU EP | H 6 | Cervical, multiple post collar, occipital/mandibular supports, adjustable cervical bars (Somi, Guilford, Taylor types) | All | N | Purchase | |
L0200 | NU EP | H 6 | Cervical, multiple post collar, occipital/mandibular supports, adjustable cervical bars, and thoracic extension | All | N | Purchase | |
L0210 | NU EP | H 6 | Thoracic, rib belt | All | N | Purchase | |
L0220 | NU EP | H 6 | Thoracic, rib belt, custom fabricated | All | N | Purchase | |
L0450 | NU EP | H 6 | TLSO, flexible, provides trunk support, upper thoracic region, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, prefabricated, includes fitting and adjustment | All | N | Purchase | |
L0452 | NU EP | H 6 | TLSO, flexible, provides trunk support, upper thoracic region, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, custom fabricated | All | N | Purchase | |
L0454 | NU EP | H 6 | TLSO, flexible, provides trunk support, extends from sacrococcygeal junction to above T-9 vertebra, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, prefabricated, includes fitting and adjustment | All | N | Purchase | |
L0456 | NU EP | H 6 | TLSO, flexible, provides trunk support, thoracic region, rigid posterior panel and soft anterior apron, extends from sacrococcygeal junction and terminates just inferior to the scapular spine, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks, includes straps and closures, prefabricated, includes fitting and adjustment | All | Y | Purchase | |
L0458 | NU EP | H 6 | TLSO, triplanar control, modular segmented spinal system, two rigid plastic shells, posterior extends from sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal, coronal and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment | All | Y | Purchase | |
L0460 | NU EP | H 6 | TLSO, triplanar control modular segmented spinal system, two rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, including straps and closures, prefabricated, includes fitting and adjustment | All | Y | Purchase | |
L0462 | NU EP | H 6 | TLSO, triplanar control modular segmented spinal system, three rigid plastic shells, posterior extends from sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, including straps and closures, prefabricated, includes fitting and adjustment | All | Y | Purchase | |
L0464 | NU EP | H 6 | TLSO, triplanar control modular segmented spinal system, four rigid plastic shells, posterior extends from sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in sagittal, coronal and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, including straps and closures, prefabricated, includes fitting and adjustment | All | Y | Purchase | |
L0466 | NU EP | H 6 | TLSO, sagittal control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, restricts gross trunk motion in sagittal plane, produces intracavitary pressure to reduce load on intervertebral disks, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment | All | Y | Purchase | |
L0468 | NU EP | H 6 | TLSO, sagittal-coronal control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, extends from sacrococcygeal junction over scapulae, lateral strength provided by pelvic, thoracic, and lateral frame pieces, restricts gross trunk motion in sagittal and coronal planes, produces intracavitary pressure to reduce load on intervertebral disks, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment | All | Y | Purchase | |
L0470 | NU EP | H 6 | TLSO, triplanar control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, extends from sacrococcygeal junction to scapula, lateral strength provided by pelvic, thoracic, and lateral frame pieces, rotational strength provided by subclavicular extensions, restricts gross trunk motion in sagittal, coronal and transverse planes, produces intracavitary pressure to reduce load on intervertebral disks, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment | All | Y | Purchase | |
L0472 | NU EP | H 6 | TLSO, triplanar control, hyperextension, rigid anterior and lateral frame extends from symphysis pubis to sternal notch with two anterior components (one pubic and one sternal) posterior and lateral pads with straps and closures, limits spinal flexion, restricts gross trunk motion in sagittal, coronal and transverse planes, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment | All | Y | Purchase | |
L0474 | NU EP | H 6 | TLSO, triplanar control, rigid posterior frame with multiple straps, closures and padding, extends from sacrococcygeal junction to scapula, lateral strength provided by pelvic, thoracic, and lateral frame pieces, rotational strength provided by subclavicular extensions, restricts gross trunk motion in sagittal, coronal and transverse planes, produces intracavitary pressure to reduce load on the intervertebral disks, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment | All | Y | Purchase | |
L0480 | NU EP | H 6 | TLSO, triplanar control, one-piece rigid plastic shell without interface liner, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated | All | Y | Purchase | |
L0482 | NU EP | H 6 | TLSO, triplanar control, one-piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated | All | Y | Purchase | |
L0484 | NU EP | H 6 | TLSO, triplanar control, two-piece rigid plastic shell without interface liner, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, lateral strength is enhanced by overlapping plastic, restricts gross trunk motion in the sagittal, coronal and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated | All | Y | Purchase | |
L0486 | NU EP | H 6 | TLSO, triplanar control, two-piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, lateral strength is enhanced by overlapping plastic, restricts gross trunk motion in the sagittal, coronal and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated | All | Y | Purchase | |
L0488 | NU EP | H 6 | TLSO, triplanar control, one-piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal and transverse planes, prefabricated, includes fitting and adjustment | All | Y | Purchase | |
L0490 | NU EP | H 6 | TLSO, sagittal-coronal control, one-piece rigid plastic shell with overlapping reinforced anterior, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates at or before the T9 vertebra, anterior extends from symphysis pubis to xiphoid, anterior opening, restricts gross trunk motion in sagittal and coronal planes, prefabricated, includes fitting and adjustment | All | Y | Purchase | |
L0700 | NU EP | H 6 | Cervical-thoracic-lumbar-sacral orthoses (CTLSO), anterior-posterior-lateral control, molded to patient model (Minerva type) | All | Y | Purchase | |
L0710 | NU EP | H 6 | CTLSO, anterior-posterior-lateral control, molded to patient model, with interface material (Minerva type) | All | Y | Purchase | |
L0810 | NU EP | H 6 | Halo procedure, cervical halo incorporated into jacket vest | All | Y | Purchase | |
L0820 | NU EP | H 6 | Halo procedure, cervical halo incorporated into plaster body jacket | All | Y | Purchase | |
L0830 | NU EP | H 6 | Halo procedure, cervical halo incorporated into Milwaukee type orthosis | All | Y | Purchase | |
L0860 | NU EP | H 6 | Addition to halo procedure, magnetic resonance image compatible system | All | Y | Purchase | |
L0960 | NU EP | H 6 | Torso support, post surgical support, pads for post surgical support | All | N | Purchase | |
L0970 | NU EP | H 6 | TLSO, corset front | All | N | Purchase | |
L0972 | NU EP | H 6 | LSO, corset front | All | N | Purchase | |
L0974 | NU EP | H 6 | TLSO, full corset | All | N | Purchase | |
L0976 | NU EP | H 6 | LSO, full corset | All | N | Purchase | |
L0978 | NU EP | H 6 | Axillary crutch extension | All | N | Purchase | |
L0980 | NU EP | H 6 | Peroneal straps, pair | All | N | Purchase | |
L0982 | NU EP | H 6 | Stocking supporter grips, set of four (4) | All | N | Purchase | |
L0984 | NU | H | Protective body sock, each | 21+ | N | Purchase | |
L1000 | NU EP | H 6 | CTLSO (Milwaukee), inclusive of furnishing initial orthosis, including model | All | Y | Purchase | |
L1010 | NU EP | H 6 | TLSO or scoliosis orthosis, axilla sling | All | N | Purchase | |
L1020 | NU EP | H 6 | Addition to CTLSO or scoliosis orthosis, kyphosis pad | All | N | Purchase | |
L1025 | NU EP | H 6 | Addition to CTLSO or scoliosis orthosis, kyphosis pad, floating | All | N | Purchase | |
L1030 | NU EP | H 6 | Addition to CTLSO or scoliosis orthosis, lumbar bolster pad | All | N | Purchase | |
L1040 | NU EP | H 6 | Addition to CTLSO or scoliosis orthosis, lumbar or lumbar rib pad | All | N | Purchase | |
L1050 | NU EP | H 6 | Addition to CTLSO or scoliosis orthosis, sternal pad | All | N | Purchase | |
L1060 | NU EP | H 6 | Addition to CTLSO or scoliosis orthosis, thoracic pad | All | N | Purchase | |
L1070 | NU EP | H 6 | Addition to CTLSO or scoliosis orthosis, trapezius sling | All | N | Purchase | |
L1080 | NU EP | H 6 | Addition to CTLSO or scoliosis orthosis, outrigger | All | N | Purchase | |
L1085 | NU EP | H 6 | Addition to CTLSO or scoliosis orthosis, outrigger, bilateral with vertical extensions | All | N | Purchase | |
L1090 | NU EP | H 6 | Addition to CTLSO or scoliosis orthosis, lumbar sling | All | N | Purchase | |
L1100 | NU EP | H 6 | Addition to CTLSO or scoliosis orthosis, ring flange, plastic or leather | All | N | Purchase | |
L1110 | NU EP | H 6 | Addition to CTLSO or scoliosis orthosis, ring flange, plastic or leather, molded to patient model | All | N | Purchase | |
L1120 | NU EP | H 6 | Addition to CTLSO, scoliosis orthosis, cover for upright, each | All | N | Purchase | |
L1200 | NU EP | H 6 | Thoracic-lumbar-sacral-orthosis (TLSO), inclusive of furnishing initial orthosis only | All | Y | Purchase | |
L1210 | NU EP | H 6 | Addition to TLSO (low profile), lateral thoracic extension | All | N | Purchase | |
L1220 | NU EP | H 6 | Addition to TLSO (low profile), anterior thoracic extension | All | N | Purchase | |
L1230 | NU EP | H 6 | Addition to TLSO (low profile), Milwaukee type superstructure | All | N | Purchase | |
L1240 | NU EP | H 6 | Addition to TLSO (low profile), lumbar derotation pad | All | N | Purchase | |
L1250 | NU EP | H 6 | Addition to TLSO (low profile), anterior ASIS pad | All | N | Purchase | |
L1260 | NU EP | H 6 | Addition to TLSO (low profile), anterior thoracic derotation pad | All | N | Purchase | |
L1270 | NU EP | H 6 | Addition to TLSO (low profile), abdominal pad | All | N | Purchase | |
L1280 | NU EP | H 6 | Addition to TLSO (low profile), rib gusset (elastic), each | All | N | Purchase | |
L1290 | NU EP | H 6 | Addition to TLSO (low profile), lateral trochanteric pad | All | N | Purchase | |
L1300 | NU EP | H 6 | Other scoliosis procedure, body jacket molded to patient model | All | Y | Purchase | |
L1310 | NU EP | H 6 | Other scoliosis procedure, postoperative body jacket | All | Y | Purchase | |
L1499 | NU EP | H 6 | Spinal orthosis, not otherwise specified. ***The manufacturer?s invoice must be attached to all claims. | All | Y | Manually Priced | |
L1500 | NU EP | H 6 | THKAO, mobility frame (Newington, Parapodium types) | All | Y | Purchase | |
L1510 | NU EP | H 6 | THKAO, standing frame, with or without tray and accessories | All | Y | Purchase | |
L1520 | NU EP | H 6 | THKAO, swivel walker | All | Y | Purchase | |
L1600 | NU EP | H 6 | HO, abduction control of hip joints, flexible, Frejka type with cover, prefabricated, includes fitting and adjustment | All | N | Purchase | |
L1610 | NU EP | H 6 | HO, abduction control of hip joints, flexible (Frejka cover only), prefabricated, includes fitting and adjustment | All | N | Purchase | |
L1620 | NU EP | H 6 | HO, abduction control of hip joints, flexible (Pavlik harness), prefabricated, includes fitting and adjustment | All | N | Purchase | |
L1630 | NU EP | H 6 | HO, abduction control of hip joints, semi-flexible (Von Rosen type), custom fabricated | All | N | Purchase | |
L1640 | NU EP | H 6 | HO, abduction control of hip joints, static, pelvic band or spreader bar, thigh cuffs, custom fabricated | All | N | Purchase | |
L1650 | NU EP | H 6 | HO, abduction control of hip joints, static, adjustable, custom fitted (Ilfled type), prefabricated, includes fitting and adjustment | All | N | Purchase | |
L1660 | NU EP | H 6 | HO, abduction control of hip joints, static, plastic, prefabricated, includes fitting and adjustment | All | N | Purchase | |
L1680 | NU EP | H 6 | HO; abduction control of hip joints, dynamic, pelvic control, adjustable hip motion control, thigh cuffs (Rancho hip action type), custom fabricated | All | Y | Purchase | |
L1685 | NU EP | H 6 | HO, abduction control of hip joint, post operative hip abduction type, custom fabricated | All | Y | Purchase | |
L1686 | NU EP | H 6 | HO, abduction control of hip joint, post operative hip abduction type, prefabricated, includes fitting and adjustments | All | Y | Purchase | |
L1690 | NU | H | Combination, bilateral, lumbo-sacral, hip, femur orthosis providing adduction and internal rotation control, prefabricated, includes fitting and adjustment | 21+ | Y | Purchase | |
L1700 | NU EP | H 6 | Legg Perthes orthosis (Toronto type), custom fabricated | All | Y | Purchase | |
L1710 | NU EP | H 6 | Legg Perthes orthosis (Newington type), custom fabricated | All | Y | Purchase | |
L1720 | NU EP | H 6 | Legg Perthes orthosis, trilateral (Tachdijan type), custom fabricated | All | Y | Purchase | |
L1730 | NU EP | H 6 | Legg Perthes orthosis (Scottish Rite type) custom fabricated | All | Y | Purchase | |
L1750 | NU EP | H 6 | Legg Perthes orthosis, Legg Perthes sling (Sam Brown type), prefabricated, includes fitting and adjustment | All | Y | Purchase | |
L1755 | NU EP | H 6 | Legg Perthes orthosis (Patten bottom type), custom fabricated | All | Y | Purchase | |
L1800 | NU EP | H 6 | KO, elastic with stays, prefabricated, includes fitting and adjustment | All | N | Purchase | |
L1810 | NU EP | H 6 | KO, elastic with joints, prefabricated, includes fitting and adjustment | All | N | Purchase | |
L1815 | NU EP | H 6 | KO, elastic or other elsastic type material with condylar pad(s), prefabricated, includes fitting and adjustment | All | N | Purchase | |
L1820 | NU EP | H 6 | KO, elastic with condyle pads and joints, prefabricated, includes fitting and adjustment | All | N | Purchase | |
L1825 | NU EP | H 6 | KO, elastic knee cap. prefabricated, includes fitting and adjustment | All | N | Purchase | |
L1830 | NU EP | H 6 | KO, immobilizer, canvas longitudinal, prefabricated, includes fitting and adjustment | All | N | Purchase | |
L1832 | NU EP | H 6 | KO, adjustable knee joints, positional orthosis, rigid support, prefabricated, includes fitting and adjustment rigid support | All | N | Purchase | |
L1834 | NU EP | H 6 | KO, without knee joint, rigid, custom fabricated | All | N | Purchase | |
L1840 | NU EP | H 6 | KO, derotation, medial-lateral, anterior cruciate ligament, custom fabricated | All | Y | Purchase | |
L1843 | NU | H | Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint, medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, includes fitting and adjustment | 21+ | Y | Purchase | |
L1844 | NU | H | KO, single upright, thigh and calf, with adjustable flexion and extension joint, medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated | 21+ | Y | Purchase | |
L1845 | NU EP | H 6 | KO, double upright, thigh and calf, with adjustable flexion and extension joint, medial-lateral and rotation control, prefabricated, includes fitting and adjustment | All | Y | Purchase | |
L1846 | NU EP | H 6 | KO, double upright, thigh and calf, with adjustable flexion and extension joint, medial-lateral and rotation control, custom fabricated | All | Y | Purchase | |
L1847 | NU | H | Knee orthosis, double upright with adjustable joint, with inflatable air support chamber(s) prefabricated, includes fitting and adjustment | 21+ | N | Purchase | |
L1850 | NU EP | H 6 | KO, Swedish type, prefabricated, includes fitting and adjustment | All | N | Purchase | |
L1855 | NU EP | H 6 | KO, molded plastic, thigh and calf sections, with double upright knee joints, custom fabricated | All | Y | Purchase | |
L1858 | NU EP | H 6 | KO, molded plastic, polycentric knee joints, pneumatic knee pads (CTI), custom fabricated | All | Y | Purchase | |
L1860 | NU EP | H 6 | KO, modification of supracondylar prosthetic socket, custom fabricated (SK) | All | Y | Purchase | |
L1870 | NU EP | H 6 | KO, double upright, thigh and calf lacers, with knee joints, custom fabricated | All | Y | Purchase | |
L1880 | NU EP | H 6 | KO, double upright, nonmolded thigh and calf cuff/lacers with knee joints, custom fabricated | All | N | Purchase | |
L1900 | NU EP | H 6 | AFO, spring wire, dorsiflexion assist calf band, custom fabricated | All | N | Purchase | |
L1902 | NU EP | H 6 | AFO, ankle gauntlet, prefabricated, includes fitting and adjustment | All | N | Purchase | |
L1904 | NU EP | H 6 | AFO, molded ankle gauntlet, custom fabricated | All | N | Purchase | |
L1906 | NU EP | H 6 | AFO, multigamentus ankle support, prefabricated, includes fitting and adjustment | All | N | Purchase | |
L1907 | NU EP | H 6 | AFO, supramalleolar with straps, with or without interface/pads, custom fabricated | All | N | Purchase | |
L1910 | NU EP | H 6 | AFO, posterior, single bar, clasp attachment to shoe counter prefabricated, includes fitting and adjustment | All | N | Purchase | |
L1920 | NU EP | H 6 | AFO, single upright with static or adjustable stop (Phelps or Perlstein type), custom fabricated | All | N | Purchase | |
L1920 | EP | 6 | ***(Custom night ?A? frame-KAFO, torsion control, bilateral night ?A? frame) AFO, single upright with static or adjustable stop (Phelps or Perlstein type), custom fabricated | U21 | N/A | Purchase | |
L1930 | NU EP | H 6 | AFO, plastic or other material, prefabricated, includes fitting and adjustment | All | N | Purchase | |
L1932 | NU EP | H 6 | AFO, rigid anterior tibial section, total carbon fiber or equal material, prefabricated, includes fitting and adjustment | All | N | Purchase | |
L1940 | NU EP | H 6 | AFO, plastic or other material, custom-fabricated | All | N | Purchase | |
L1945 | NU EP | H 6 | AFO, molded to patient model, plastic, rigid anterior tibial section (floor reaction), custom fabricated | All | Y | Purchase | |
L1950 | NU EP | H 6 | AFO, spiral (Institute of Rehabilitative Medicine type), plastic, custom fabricated | All | N | Purchase | |
L1960 | NU EP | H 6 | AFO, posterior solid ankle, plastic, custom fabricated | All | N | Purchase | |
L1970 | NU EP | H 6 | AFO, plastic, with ankle joint, custom fabricated | All | N | Purchase | |
L1980 | NU EP | H 6 | AFO, single upright free plantar dorsiflexion, solid stirrup, calf band/cuff (single bar ?BK? orthosis), custom fabricated | All | N | Purchase | |
L1990 | NU EP | H 6 | AFO, double upright free plantar dorsiflexion, solid stirrup, calf band/cuff (double bar ?BK? orthosis), custom fabricated | All | N | Purchase | |
L2000 | NU EP | H 6 | KAFO, single upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar ?AK? orthosis), custom fabricated | All | Y | Purchase | |
L2005 | NU EP | H 6 | KAFO, any material, single or double upright, stance control, automatic lock and swing phase release, mechanical activation, includes ankle joint, any type, custom fabricated | All | N | Purchase | |
L2010 | NU EP | H 6 | KAFO, single upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar ?AK? orthosis), without knee joint, custom fabricated | All | Y | Purchase | |
L2020 | NU EP | H 6 | KAFO, double upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (double bar ?AK? orthosis), custom fabricated | All | Y | Purchase | |
L2030 | NU EP | H 6 | KAFO, double upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs, (double bar ?AK? orthosis), without knee joint, custom fabricated | All | Y | Purchase | |
L2035 | NU | H | KAFO, full plastic, static prefabricated (pediatric size) prefabricated, includes fitting and adjustment | 21+ | N | Purchase | |
L2036 | NU EP | H 6 | KAFO, full plastic, double upright, free knee, custom fabricated | All | Y? | Purchase | |
L2037 | NU EP | H 6 | KAFO, full plastic, single upright, free knee, custom fabricated | All | Y | Purchase | |
L2038 | NU EP | H 6 | KAFO, full plastic, without knee joint, multi-axis ankle, (Lively orthosis or equal), custom fabricated | All | Y | Purchase | |
L2039 | NU | H | KAFO, full plastic, single upright, poly-axial hinge, medial lateral rotation control, custom fabricated | 21+ | Y | Purchase | |
L2040 | NU EP | H 6 | HKAFO, torsion control, bilateral rotation straps, pelvic band/belt, custom fabricated | All | N | Purchase | |
L2040 | NU EP | U1 U1 | ***(Night ?A? frame-KAFO, torsion control, bilateral night ?A? frame) HKAFO, torsion control, bilateral rotation straps, pelvic band/belt, custom fabricated | All | N | Manually Priced Purchase | |
L2040 | NU EP | U1 U1 | H 6 | ***(Night ?A? frame-KAFO, torsion control, bilateral night ?A? frame) HKAFO, torsion control, bilateral rotation straps, pelvic band/belt, custom fabricated | All | N | Manually Priced Purchase |
L2050 | NU EP | H 6 | HKAFO, torsion control, bilateral torsion cables, hip joint, pelvic band/belt, custom fabricated | All | N | Purchase | |
L2060 | NU EP | H 6 | HKAFO, torsion control, bilateral torsion cables, ball bearing hip joint, pelvic band/belt, custom fabricated | All | N | Purchase | |
L2070 | NU EP | H 6 | HKAFO, torsion control, unilateral rotation straps, pelvic band/belt, custom fabricated | All | N | Purchase | |
L2080 | NU EP | H 6 | HKAFO, torsion control, unilateral torsion cable, hip joint, pelvic band/belt, custom fabricated | All | N | Purchase | |
L2090 | NU EP | H 6 | HKAFO, torsion control, unilateral torsion cable, ball bearing hip joint, pelvic band/belt, custom fabricated | All | N | Purchase | |
L2106 | NU EP | H 6 | AFO, fracture orthosis, tibial fracture cast orthosis, thermoplastic type casting material, custom fabricated | All | N | Purchase | |
L2108 | NU EP | H 6 | AFO, fracture orthosis, tibial fracture cast orthosis, custom fabricated | All | Y | Purchase | |
L2112 | NU EP | H 6 | AFO, fracture orthosis, tibial fracture orthosis, soft, prefabricated, includes fitting and adjustment | All | N | Purchase | |
L2114 | NU EP | H 6 | AFO, fracture orthosis, tibial fracture orthosis, semi-rigid, prefabricated, includes fitting and adjustment | All | N | Purchase | |
L2116 | NU EP | H 6 | AFO, fracture orthosis, tibial fracture orthosis, rigid, prefabricated, includes fitting and adjustment | All | N | Purchase | |
L2126 | NU EP | H 6 | KAFO, fracture orthosis, femoral fracture cast orthosis, thermoplastic type casting material, molded to patient | All | Y | Purchase | |
L2128 | NU EP | H 6 | KAFO, fracture orthosis, femoral fracture cast orthosis, thermoplastic type casting material, custom fabricated | All | Y | Purchase | |
L2132 | NU EP | H 6 | KAFO, fracture orthosis, femoral fracture cast orthosis, soft, prefabricated, includes fitting and adjustment | All | Y | Purchase | |
L2134 | NU EP | H 6 | KAFO, fracture orthosis, femoral fracture cast orthosis, semi-rigid custom fitted | All | Y | Purchase | |
L2136 | NU EP | H 6 | KAFO, fracture orthosis, femoral fracture cast orthosis, rigid, prefabricated, includes fitting and adjustment | All | Y | Purchase | |
L2180 | NU EP | H 6 | Addition to lower extremity fracture orthosis, plastic shoe insert with ankle joints | All | N | Purchase | |
L2182 | NU EP | H 6 | Addition to lower extremity fracture orthosis, drop lock knee joint | All | N | Purchase | |
L2184 | NU EP | H 6 | Addition to lower extremity fracture orthosis, limited motion knee joint | All | N | Purchase | |
L2186 | NU EP | H 6 | Addition to lower extremity fracture orthosis, adjustable motion knee joint (Lerman type) | All | N | Purchase | |
L2188 | NU EP | H 6 | Addition to lower extremity fracture orthosis, quadrilateral brim | All | N | Purchase | |
L2190 | NU EP | H 6 | Addition to lower extremity fracture orthosis, waist belt | All | N | Purchase | |
L2192 | NU EP | H 6 | Addition to lower extremity fracture orthosis, hip joint, pelvic band, thigh flange, and pelvic belt | All | N | Purchase | |
L2200 | NU EP | H 6 | Additions to lower extremity, dorsiflexion and plantar flexion | All | N | Purchase | |
L2210 | NU EP | H 6 | Addition to lower extremity, dorsiflexion assist (plantar flexion resist), each joint | All | N | Purchase | |
L2220 | NU EP | H 6 | Addition to lower extremity, dorsiflexion and plantar flexion assist/resist, each joint | All | N | Purchase | |
L2230 | NU EP | H 6 | Addition to lower extremity, split flat caliper stirrups and plate attachment | All | N | Purchase | |
L2232 | NU EP | H 6 | Addition to lower extremity orthosis, rocker bottom for total contact ankle foot orthosis, for custom fabricated orthosis only | All | N | Purchase | |
L2240 | NU EP | H 6 | Addition to lower extremity, round caliper and plate attachment | All | N | Purchase | |
L2250 | NU EP | H 6 | Addition to lower extremity, foot plate, molded to patient model, stirrup attachment | All | N | Purchase | |
L2260 | NU EP | H 6 | Addition to lower extremity, reinforced solid stirrup (Scott-Craig type) | All | N | Purchase | |
L2265 | NU EP | H 6 | Addition to lower extremity, long tongue stirrup | All | N | Purchase | |
L2270 | NU EP | H 6 | Addition to lower extremity, varus/valgus correction (?T?) strap, padded/lined or malleolus pad | All | N | Purchase | |
L2275 | NU | H | Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined | 21+ | N | Purchase | |
L2280 | NU EP | H 6 | Addition to lower extremity, molded inner boot | All | N | Purchase | |
L2300 | NU EP | H 6 | Addition to lower extremity, abduction bar (bilateral hip involvement), jointed, adjustable | All | N | Purchase | |
L2310 | NU EP | H 6 | Addition to lower extremity, abduction bar straight | All | N | Purchase | |
L2320 | NU EP | H 6 | Addition to lower extremity, nonmolded lacer | All | N | Purchase | |
L2330 | NU EP | H 6 | Addition to lower extremity, lacer molded to patient model | All | N | Purchase | |
L2335 | NU EP | H 6 | Addition to lower extremity, anterior swing band | All | N | Purchase | |
L2340 | NU EP | H 6 | Addition to lower extremity, pretidial shell, molded to patient model | All | N | Purchase | |
L2350 | NU EP | H 6 | Addition to lower extremity, prosthetic type, (BK) socket, molded to patient model, (used for ?PTB? ?AFO? orthoses) | All | Y | Purchase | |
L2360 | NU EP | H 6 | Addition to lower extremity, extended steel shank | All | N | Purchase | |
L2370 | NU EP | H 6 | Addition to lower extremity, Patten bottom | All | N | Purchase | |
L2375 | NU EP | H 6 | Addition to lower extremity, torsion control, ankle joint and half solid stirrup | All | N | Purchase | |
L2380 | NU EP | H 6 | Addition to lower extremity, torsion control, straight knee joint, each joint | All | N | Purchase | |
L2385 | NU EP | H 6 | Addition to lower extremity, straight knee joint, heavy duty, each joint | All | N | Purchase | |
L2390 | NU EP | H 6 | Addition to lower extremity, offset knee joint, each joint | All | N | Purchase | |
L2395 | NU EP | H 6 | Addition to lower extremity, offset knee joint, heavy duty, each joint | All | N | Purchase | |
L2397 | NU | H | Addition to lower extremity orthosis, suspension sleeve | 21+ | N | Purchase | |
L2405 | NU EP | H 6 | Addition to knee joint, lock; drop, stance or swing phase, each joint | All | N | Purchase | |
L2415 | NU EP | H 6 | Addition to knee lock with integrated release mechanism, (bail, cable or equal, any material, each joint | All | N | Purchase | |
L2425 | NU EP | H 6 | Addition to knee joint, disc or dial lock for adjustable knee flexion, each joint | All | N | Purchase | |
L2430 | NU | H | Addition to knee joint, ratchet lock for active and progressive knee extension, each joint | 21+ | N | Purchase | |
L2492 | NU EP | H 6 | Addition to knee joint, lift loop for drop lock ring | All | N | Purchase | |
L2500 | NU EP | H 6 | Addition to lower extremity, thigh/weight bearing, gulteal/ischial weight bearing, ring | All | N | Purchase | |
L2510 | NU EP | H 6 | Addition to lower extremity, thigh/weight bearing, quadrilateral brim, molded to patient model | All | N | Purchase | |
L2520 | NU EP | H 6 | Addition to lower extremity, thigh/weight bearing, quadrilateral brim, custom fitted | All | N | Purchase | |
L2525 | NU EP | H 6 | Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim molded to patient model | All | N | Purchase | |
L2526 | NU EP | H 6 | Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim, custom fitted | All | N | Purchase | |
L2530 | NU EP | H 6 | Addition to lower extremity, thigh/weight bearing, lacer, non-molded | All | N | Purchase | |
L2540 | NU EP | H 6 | Addition to lower extremity, thigh/weight bearing, lacer, molded to patient model | All | N | Purchase | |
L2550 | NU EP | H 6 | Addition to lower extremity, thigh/weight bearing, high roll cuff | All | N | Purchase | |
L2570 | NU EP | H 6 | Addition to lower extremity, pelvic control, hip joint, clevis type two position joint, each | All | N | Purchase | |
L2580 | NU EP | H 6 | Addition to lower extremity, pelvic control, pelvic sling | All | N | Purchase | |
L2600 | NU EP | H 6 | Addition to lower extremity, pelvic control, hip joint, Clevis type, or thrust bearing free, each | All | N | Purchase | |
L2610 | NU EP | H 6 | Addition to lower extremity, pelvic control, hip joint, Clevis or thrust bearing, lock, each | All | N | Purchase | |
L2620 | NU EP | H 6 | Addition to lower extremity, pelvic control, hip joint, heavy duty, each | All | N | Purchase | |
L2622 | NU EP | H 6 | Addition to lower extremity, pelvic control, hip joint, adjustable flexion, each | All | N | Purchase | |
L2624 | NU EP | H 6 | Addition to lower extremity, pelvic control, hip joint, adjustable flexion, extension, abduction control, each | All | N | Purchase | |
L2627 | NU EP | H 6 | Addition to lower extremity, pelvic control, plastic, molded to patient model, reciprocating hip joint and cables | All | N | Purchase | |
L2628 | NU EP | H 6 | Addition to lower extremity, pelvic control, metal frame, reciprocating hip joint and cables | All | N | Purchase | |
L2630 | NU EP | H 6 | Addition to lower extremity, pelvic control, band and belt unilateral | All | N | Purchase | |
L2640 | NU EP | H 6 | Addition to lower extremity, pelvic control, band and belt bilateral | All | N | Purchase | |
L2650 | NU EP | H 6 | Addition to lower extremity, pelvic and thoracic control, gluteal pad, each | All | N | Purchase | |
L2660 | NU EP | H 6 | Addition to lower extremity, thoracic control, thoracic band | All | N | Purchase | |
L2670 | NU EP | H 6 | Addition to lower extremity, thoracic control, paraspinal uprights | All | N | Purchase | |
L2680 | NU EP | H 6 | Addition to lower extremity, thoracic control, lateral support uprights | All | N | Purchase | |
L2750 | NU EP | H 6 | Addition to lower extremity orthosis, plating chrome or nickel, per bar | All | N | Purchase | |
L2755 | NU | H | Addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepreg composite, per segment | 21+ | N | Purchase | |
L2755 | NU EP | H 6 | ***(Carbon composite ankles; addition to AFO) Addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepreg composite, per segment | All | N | Manually Priced Purchase | |
L2760 | NU EP | H 6 | Addition to lower extremity orthosis, extension, per extension, per bar (for linear adjustment for growth) | All | N | Purchase | |
L2770 | NU EP | H 6 | Addition to lower extremity orthosis, any material, per bar or joint | All | N | Purchase | |
L2780 | NU EP | H 6 | Addition to lower extremity orthosis, non-corrosive finish, per bar | All | N | Purchase | |
L2785 | NU EP | H 6 | Addition to lower extremity orthosis, drop lock retainer, each | All | N | Purchase | |
L2795 | NU EP | H 6 | Addition to lower extremity orthosis, knee control, full kneecap | All | N | Purchase | |
L2800 | NU EP | H 6 | Addition to lower extremity orthosis, knee control, kneecap, medial or lateral pull | All | N | Purchase | |
L2810 | NU EP | H 6 | Addition to lower extremity orthosis, knee control, condylar pad | All | N | Purchase | |
L2810 | EP | 6 | ***(Custom night ?A? frame-KAFO, torsion control, bilateral night ?A? frame) Addition to lower extremity orthosis, knee control, condylar pad | U21 | N/A | Purchase | |
L2820 | NU EP | H 6 | Addition to lower extremity orthosis, soft interface for molded plastic, below knee section | All | N | Purchase | |
L2830 | NU EP | H 6 | Addition to lower extremity orthosis, soft interface for molded plastic, above knee section | All | N | Purchase | |
L2840 | NU EP | H 6 | Addition to lower extremity orthosis, tibial length sock, fracture or equal, each | All | N | Purchase | |
L2850 | NU EP | H 6 | Addition to lower extremity orthosis, femoral length sock, fracture or equal, each | All | N | Purchase | |
L2999 | NU EP | H 6 | Lower extremity orthoses, NOS | All | N | Manually Priced | |
L2999 | NU EP | H 6 | ***(Unlisted prosthetic devices or orthotic appliances; the manufacturer?s invoice must be attached to all claims.) Lower extremity orthoses, NOS | All | Y | Manually Priced | |
L3000 | NU EP | H 6 | Foot insert, removable, molded to patient model, ?UCB? type, Berkeley shell, each | All | N | Purchase | |
L3002 | NU EP | H 6 | Foot insert, removable, molded to patient model, Plastazote or equal, each | All | N | Manually Priced | |
L3010 | NU EP | H 6 | Foot insert, removable, molded to patient model, longitudinal arch support, each | All | N | Purchase | |
L3020 | NU EP | H 6 | Foot insert, removable, molded to patient model, longitudinal/metatarsal support, each | All | N | Purchase | |
L3030 | NU EP | H 6 | Foot insert, removable, formed to patient foot, each | All | N | Purchase | |
L3040 | NU EP | H 6 | Foot, arch support, removable, premolded, longitudinal, each | All | N | Purchase | |
L3050 | NU EP | H 6 | Foot, arch support, removable, premolded, metatarsal, each | All | N | Purchase | |
L3060 | NU EP | H 6 | Foot, arch support, removable, premolded, longitudinal/metatarsal, each | All | N | Purchase | |
L3070 | NU EP | H 6 | Foot, arch support, non-removable, attached to shoe, longitudinal, each | All | N | Purchase | |
L3080 | NU EP | H 6 | Foot, arch support, non-removable, attached to shoe, metatarsal, each | All | N | Purchase | |
L3090 | NU EP | H 6 | Foot, arch support, non-removable, attached to shoe, longitudinal/metatarsal, each | All | N | Purchase | |
L3100 | NU EP | H 6 | Hallus?valgus night dynamic splint | All | N | Purchase | |
L3140 | NU EP | UB | H 6 | ***(Bebox foot orthosis clubfood abduction orthosis) Foot, abduction rotation bar, including shoes | All | N | Manually Priced Purchase |
L3140 | NU | H | ***(Don Joy knee orthosis) Foot, abduction rotation bar, including shoes | 21+ | Y | Manually Priced | |
L3150 | NU EP | H 6 | Foot, abduction rotation bar, without shoes | All | N | Purchase | |
L3150 | EP | 6 | ***(Custom night ?A? frame-KAFO, torsion control, bilateral night ?A? frame) Foot, abduction rotation bar, without shoes | U21 | N/A | Purchase | |
L3170 | NU EP | H 6 | Foot, plastic heel stabilizer | All | N | Purchase | |
L3202 | EP | 6 | Orthopedic shoe, oxford with supinator or pronator, child | U21 | N/A | Purchase | |
L3204 | EP | 6 | Orthopedic shoe, high-top with supinator or pronator, infant | U21 | N/A | Purchase | |
L3204 | NU EP | H 6 | ***(Straight last high-top shoe, each, size 2-8) Orthopedic shoe, high-top with supinator or pronator, infant | All | N | Manually Priced Purchase | |
L3204 | NU EP | U1 | H 6 | ***(Straight last high-top shoe, each, size 81/2-12) Orthopedic shoe, high-top with supinator or pronator, infant | All | N | Manually Priced Purchase |
L3204 | NU EP | U1 | H 6 | ***(Regular last high-top shoe, each, size 3-6) Orthopedic shoe, high-top with supinator or pronator, infant | All | N | Manually Priced Purchase |
L3204 | NU EP | U1 | H 6 | ***(Regular last high-top shoe, each, size 81/2-12) Orthopedic shoe, high-top with supinator or pronator, infant | All | N | Purchase |
L3204 | NU EP | U1 | H 6 | ***(Reverse last closed toe) Orthopedic shoe, high-top with supinator or pronator, infant | All | N | Manually Priced Purchase |
L3204 | NU | H | ***(Orthopedic shoe, high-top, normal last, each, size 3-8) Orthopedic shoe, high-top with supinator or pronator, infant | 21+ | N | Manually Priced | |
L3204 | NU EP | U1 | H 6 | ***(Orthopedic shoe, high-top, normal last, each, size 81/2-12) Orthopedic shoe, high-top with supinator or pronator, infant | All | N | Manually Priced Purchase |
L3206 | NU EP | H 6 | ***(Straight last high-top shoe, each, size 2-8) Orthopedic shoe, high-top with supinator or pronator, child | All | N | Manually Priced Purchase | |
L3206 | NU EP | U1 | H 6 | ***(Straight last high-top shoe, each, size 81/2-12) Orthopedic shoe, high-top with supinator or pronator, child | All | N | Manually Priced Purchase |
L3206 | NU EP | U1 | H 6 | ***(Regular last high-top shoe, each, size 3-6) Orthopedic shoe, high-top with supinator or pronator, child | All | N | Manually Priced Purchase |
L3206 | NU EP | U1 | H 6 | ***(Regular last high-top shoe, each, size 81/2-12) Orthopedic shoe, high-top with supinator or pronator, child | All | N | Purchase |
L3206 | NU EP | U1 | H 6 | ***(Reverse last closed toe) Orthopedic shoe, high-top with supinator or pronator, child | All | N | Manually Priced Purchase |
L3206 | NU | H | ***(Orthopedic shoe, high-top, normal last, each, size 3-8) Orthopedic shoe, high-top with supinator or pronator, child | 21+ | N | Manually Priced | |
L3206 | NU EP | U1 | H 6 | ***(Orthopedic shoe, high-top, normal last, each, size 81/2-12) Orthopedic shoe, high-top with supinator or pronator, child | All | N | Manually Priced Purchase |
L3207 | NU EP | H 6 | ***(Straight last high-top shoe, each, size 2-8) Orthopedic shoe, high-top with supinator or pronator, junior | All | N | Manually Priced Purchase | |
L3207 | NU EP | U1 | H 6 | ***(Straight last high-top shoe, each, size 81/2-12) Orthopedic shoe, high-top with supinator or pronator, junior | All | N | Manually Priced Purchase |
L3207 | NU EP | U1 | H 6 | ***(Regular last high-top shoe, each, size 3-6) Orthopedic shoe, high-top with supinator or pronator, junior | All | N | Manually Priced Purchase |
L3207 | NU EP | U1 | H 6 | ***(Regular last high-top shoe, each, size 81/2-12) Orthopedic shoe, high-top with supinator or pronator, junior | All | N | Purchase |
L3207 | NU EP | U1 | H 6 | ***(Reverse last closed toe) Orthopedic shoe, high-top with supinator or pronator, junior | All | N | Manually Priced Purchase |
L3207 | NU | H | ***(Orthopedic shoe, high-top, normal last, each, size 3-8) Orthopedic shoe, high-top with supinator or pronator, junior | 21+ | N | Manually Priced | |
L3207 | NU EP | U1 | H 6 | ***(Orthopedic shoe, high-top, normal last, each, size 81/2-12) Orthopedic shoe, high-top with supinator or pronator, junior | All | N | Manually Priced Purchase |
L3207 | NU EP | H 6 | ***(Orthopedic shoe, high-top, normal last, each, size 81/2-12) Orthopedic shoe, high-top with supinator or pronator, junior | All | N | Manually Priced Purchase | |
L3208 | EP | 6 | Surgical boot, each, infant | U21 | N/A | Purchase | |
L3209 | EP | 6 | Surgical boot, each, child | U21 | N/A | Purchase | |
L3215 | NU EP | H 6 | Orthopedic footwear, woman?s shoes, oxford | All | Y | Manually Priced | |
L3216 | NU EP | H 6 | Orthopedic footwear, woman?s shoes, depth inlay | All | Y | Purchase | |
L3217 | NU EP | H 6 | ***(Straight last high-top shoe, each, size 2-8) Orthopedic footwear, woman?s shoes, high-top, depth inlay | All | N | Manually Priced Purchase | |
L3217 | NU EP | U1 U1 | H 6 | ***(Straight last high-top shoe, each, size 81/2-12) Orthopedic footwear, woman?s shoes, high-top, depth inlay | All | N | Manually Priced Purchase |
L3217 | NU EP | U1 | H 6 | ***(Regular last high-top shoe, each, size 3-6) Orthopedic footwear, woman?s shoes, high-top, depth inlay | All | N | Manually Priced Purchase |
L3217 | NU EP | U1 | H 6 | ***(Regular last high-top shoe, each, size 81/2-12) Orthopedic footwear, woman?s shoes, high-top, depth inlay | All | N | Purchase |
L3217 | NU EP | U1 | H 6 | ***(Reverse last closed toe) Orthopedic footwear, woman?s shoes, high-top, depth inlay | All | N | Manually Priced Purchase |
L3219 | NU EP | H 6 | Orthopedic footwear, man?s shoes, oxford | All | Y | Manually Priced | |
L3221 | NU EP | H 6 | Orthopedic footwear, man?s shoes, depth inlay | All | Y | Purchase | |
L3222 | NU EP | H 6 | ***(Straight last high-top shoe, each, size 2-8) Orthopedic footwear, man?s shoes, high-top, depth inlay | All | N | Manually Priced Purchase | |
L3222 | NU EP | U1 | H 6 | ***(Straight last high-top shoe, each, size 81/2-12) Orthopedic footwear, man?s shoes, high-top, depth inlay | All | N | Manually Priced Purchase |
L3222 | NU EP | U1 | H 6 | ***(Regular last high-top shoe, each, size 3-6) Orthopedic footwear, man?s shoes, high-top, depth inlay | All | N | Manually Priced Purchase |
L3222 | NU EP | U1 | H 6 | ***(Regular last high-top shoe, each, size 81/2-12) Orthopedic footwear, man?s shoes, high-top, depth inlay | All | N | Purchase |
L3222 | NU EP | U1 | H 6 | ***(Reverse last closed toe) Orthopedic footwear, man?s shoes, high-top, depth inlay | All | N | Manually Priced Purchase |
L3224 | NU | H | Orthopedic footwear, woman?s shoe, Oxford, used as an integral part of a brace (orthosis) | 21+ | N | Purchase | |
L3225 | NU | H | Orthopedic footwear, man?s shoe, oxford, used as an integral part of a brace (orthosis) | 21+ | N | Purchase | |
L3230 | NU EP | H 6 | Orthopedic footwear, custom shoes, depth inlay | All | Y | Purchase | |
L3250 | NU EP | H 6 | Orthopedic footwear, custom molded shoe, removable inner molded, prosthetic shoe, each | All | Y | Manually Priced | |
L3253 | NU EP | H 6 | Foot, molded shoe Plastazate (or similar), custom fitted, each | All | Y | Purchase | |
L3257 | NU EP | H 6 | Orthopedic footwear, additional charge for split size | All | Y | Purchase | |
L3260 | NU EP | H 6 | Surgical boot/shoe, each | All | N | Purchase | |
L3265 | NU EP | H 6 | Plastazote sandal, each | All | N | Purchase | |
L3310 | NU EP | H 6 | Lift, elevation, heel and sole, neoprene, per inch | All | N | Purchase | |
L3332 | NU EP | H 6 | Lift, elevation, inside shoe, tapered, up to one-half inch | All | N | Purchase | |
L3334 | NU EP | H 6 | Lift, elevation, heel, per inch | All | N | Purchase | |
L3350 | NU EP | H 6 | Heel wedge | All | N | Purchase | |
L3360 | NU EP | H 6 | Sole wedge, outside sole | All | N | Purchase | |
L3370 | NU EP | H 6 | Sole wedge, between sole | All | N | Purchase | |
L3400 | NU EP | H 6 | Metatarsal bar wedge, rocker | All | N | Purchase | |
L3420 | NU EP | H 6 | Full sole and heel wedge, between sole | All | N | Purchase | |
L3450 | NU EP | H 6 | Heel, SACH cushion type | All | N | Purchase | |
L3455 | NU EP | H 6 | Heel, new leather, standard | All | N | Purchase | |
L3465 | NU EP | H 6 | Heel, Thomas with wedge | All | N | Purchase | |
L3540 | NU EP | H 6 | Orthopedic shoe addition, sole full | All | N | Purchase | |
L3580 | NU EP | H 6 | Orthopedic shoe addition, convert instep to velcro closure | All | N | Purchase | |
L3590 | NU EP | H 6 | Orthopedic shoe addition, convert firm shoe counter to soft counter | All | N | Purchase | |
L3600 | NU EP | H 6 | Transfer for an orthosis from one shoe to another, caliper plate, existing | All | N | Purchase | |
L3620 | NU EP | H 6 | Transfer of an orthosis from one shoe to another, solid stirrup, existing | All | N | Purchase | |
L3630 | NU EP | H 6 | Transfer of an orthosis from one shoe to another, solid stirrup, new | All | N | Purchase | |
L3649 | EP | 6 | Orthopedic shoe, modification, addition or transfer, NOS | U21 | N/A | Manually Priced | |
L3649 | NU EP | U1 | H 6 | ***(Unlisted prosthetic devices or orthotic appliances; the manufacturer?s invoice must be attached to all claims.) Orthopedic shoe, modification, addition or transfer, NOS | All | Y | Manually Priced Purchase |
L3649 | NU EP | H 6 | ***(Orthopedic footwear, wooden sole shoe, each) Orthopedic shoe, modification, addition or transfer, NOS | All | N | Manually Priced Purchase | |
L3650 | NU EP | H 6 | SO, figure of eight design abduction re-strainer prefabricated, includes fitting and adjustment | All | N | Purchase | |
L3660 | NU EP | H 6 | SO, figure of eight design, abduction restrainer, canvas and webbing, prefabricated, includes fitting and adjustment | All | N | Purchase | |
L3670 | NU EP | H 6 | SO, acromio/clavicular (canvas and webbing type) prefabricated, includes fitting and adjustment | All | N | Purchase | |
L3675 | NU | H | SO, vest type abduction restrainer, canvas webbing type, or equal, prefabricated, includes fitting and adjustment | 21+ | N | Purchase | |
L3700 | NU EP | H 6 | Elbow orthoses (EO), elastic with stays, prefabricated, includes fitting and adjustment | All | N | Purchase | |
L3710 | NU EP | H 6 | EO, elastic with metal joints, prefabricated, includes fitting and adjustment | All | N | Purchase | |
L3720 | NU EP | H 6 | EO, double upright with forearm/arm cuffs, free motion, custom fabricated | All | N | Purchase | |
L3730 | NU EP | H 6 | EO, double upright with forearm/arm cuffs, extension/flexion assist, custom fabricated | All | Y | Purchase | |
L3740 | NU EP | H 6 | EO, double upright with forearm/arm cuffs, adjustable position lock with active control, custom fabricated | All | Y | Purchase | |
L3800 | NU EP | H 6 | WHFO, short opponens, no attachments, custom fabricated | All | N | Purchase | |
L3805 | NU EP | H 6 | WHFO, long opponens, no attachment, custom fabricated | All | N | Purchase | |
L3810 | NU EP | H 6 | WHFO, addition to short and long opponens, thumb abduction (?C?) bar | All | N | Purchase | |
L3815 | NU EP | H 6 | WHFO, addition to short and long opponens, second M.P. abduction assist | All | N | Purchase | |
L3820 | NU EP | H 6 | WHFO, addition to short and long opponens, I.P. extension assist, with M.P. extension stop | All | N | Purchase | |
L3825 | NU EP | H 6 | WHFO, addition to short and long opponens, M.P. extension stop | All | N | Purchase | |
L3830 | NU EP | H 6 | WHFO, addition to short and long opponens, M.P. extension assist | All | N | Purchase | |
L3835 | NU EP | H 6 | WHFO, addition to short and long opponens, M.P. spring extension assist | All | N | Purchase | |
L3840 | NU EP | H 6 | WHFO, addition to short and long opponens, spring swivel thumb | All | N | Purchase | |
L3845 | NU EP | H 6 | WHFO, addition to short and long opponens, thumb I.P. extension assist, with M.P. stop | All | N | Purchase | |
L3850 | NU EP | H 6 | WHO, addition to short and long opponens, action wrist with dorsiflexion assist | All | N | Purchase | |
L3855 | NU EP | H 6 | WHFO, addition to short and long opponens, adjustable M.P. flexion control | All | N | Purchase | |
L3860 | NU EP | H 6 | WHFO, addition to short and long opponens, adjustable M.P. flexion control and I.P. | All | N | Purchase | |
L3900 | NU EP | H 6 | WHFO, dynamic flexor hinge, reciprocal wrist extension/flexion, finger flexion/extension, wrist or finger driven, custom fabricated | All | Y | Purchase | |
L3901 | NU EP | H 6 | WHFO, dynamic flexor hinge, reciprocal wrist extension/flexion, finger flexion/extension, cable driven, custom fabricated | All | Y | Purchase | |
L3902 | NU EP | H 6 | WHFO, external powered, compressed gas, custom fabricated | All | Y | Purchase | |
L3904 | NU EP | H 6 | WHFO, external powered, electric, custom fabricated | All | Y | Purchase | |
L3906** | NU EP | H 6 | WHFO, wrist gauntlet, molded to patient model, custom fabricated | All | N | Purchase | |
L3907** | NU EP | H 6 | WHFO, wrist gauntlet with thumb spica, molded to patient model, custom fabricated | All | N | Purchase | |
L3908 | NU EP | H 6 | WHFO, wrist extension control cock-up, nonmolded, prefabricated, includes fitting and adjustment | All | N | Purchase | |
L3910 | NU EP | H 6 | WHFO, Swanson design, prefabricated, includes fitting and adjustment | All | N | Purchase | |
L3912 | NU EP | H 6 | HFO, flexion glove with elastic finger control, prefabricated, includes fitting and adjustment | All | N | Purchase | |
L3914 | NU EP | H 6 | WHO, wrist extension (cock-up) prefabricated, includes fitting and adjustment | All | N | Purchase | |
L3916 | NU EP | H 6 | WHFO, wrist extension (cock-up), with outrigger, prefabricated, includes fitting and adjustment | All | N | Purchase | |
L3918 | NU EP | H 6 | HFO, knuckle bender prefabricated, includes fitting and adjustment | All | N | Purchase | |
L3920 | NU EP | H 6 | HFO, knuckle bender, with outrigger prefabricated, includes fitting and adjustment | All | N | Purchase | |
L3922 | NU EP | H 6 | HFO, knuckle bender, two segment to flex joints prefabricated, includes fitting and adjustment | All | N | Purchase | |
L3924 | NU EP | H 6 | WHFO, Oppenheimer, prefabricated, includes fitting and adjustment | All | N | Purchase | |
L3926 | NU EP | H 6 | WHFO, Thomas suspension, prefabricated, includes fitting and adjustment | All | N | Purchase | |
L3928 | NU EP | H 6 | HFO, finger extension, with lock spring, prefabricated, includes fitting and adjustment | All | N | Purchase | |
L3930 | NU EP | H 6 | WHFO, finger extension, with wrist support, prefabricated, includes fitting and adjustment | All | N | Purchase | |
L3932 | NU EP | H 6 | FO, safety pin, spring wire, prefabricated, includes fitting and adjustment | All | N | Purchase | |
L3934 | NU EP | H 6 | FO, safety pin, modified, prefabricated, includes fitting and adjustment | All | N | Purchase | |
L3936 | NU EP | H 6 | WHFO, Palmer prefabricated, includes fitting and adjustment | All | N | Purchase | |
L3938 | NU EP | H 6 | WHFO, Dorsal wrist, prefabricated, includes fitting and adjustment | All | N | Purchase | |
L3940 | NU EP | H 6 | WHFO, Dorsal wrist, with outrigger attachment, prefabricated, includes fitting and adjustment | All | N | Purchase | |
L3942 | NU EP | H 6 | HFO, reverse knuckle bender, prefabricated, includes fitting and adjustment | All | N | Purchase | |
L3944 | NU EP | H 6 | HFO, reverse knuckle bender, with outrigger, prefabricated, includes fitting and adjustment | All | N | Purchase | |
L3946 | NU EP | H 6 | HFO, composite elastic, prefabricated, includes fitting and adjustment | All | N | Purchase | |
L3948 | NU EP | H 6 | FO, finger knuckle bender, prefabricated, includes fitting and adjustment | All | N | Purchase | |
L3950 | NU EP | H 6 | WHFO, combination Oppenheimer, with knuckle bender and two attachments, prefabricated, includes fitting and adjustment | All | N | Purchase | |
L3952 | NU EP | H 6 | WHFO, combination Oppenheimer, with reverse knuckle and two attachments, prefabricated, includes fitting and adjustment | All | N | Purchase | |
L3954 | NU EP | H 6 | HFO, spreading hand, prefabricated, includes fitting and adjustment | All | N | Purchase | |
L3956 | NU | H | Addition of joint to upper extremity orthosis, any material; per joint | 21+ | N | Purchase | |
L3960 | NU EP | H 6 | SEWHO, abduction, positioning, airplane design, prefabricated, includes fitting and adjustment | All | Y | Purchase | |
L3962 | NU EP | H 6 | SEWHO, abduction positioning, Erb?s palsy design, prefabricated, includes fitting and adjustment | All | N | Purchase | |
L3963 | NU EP | H 6 | SEWHO, molded shoulder, arm, forearm, and wrist, with articulating elbow joint, custom fabricated | All | Y | Purchase | |
L3964 | NU EP | H 6 | SEO, mobile arm supports attached to wheelchair, balanced, adjustable, prefabricated, includes fitting and adjustment | All | N | Purchase | |
L3965 | NU EP | H 6 | SEO mobile arm support attached to wheelchair, balanced, adjustable Rancho type, prefabricated, includes fitting and adjustment | All | Y | Purchase | |
L3966 | NU EP | H 6 | SEO, mobile arm support attached to wheelchair, balanced, reclining, prefabricated, includes fitting and adjustment | All | Y | Purchase | |
L3968 | NU EP | H 6 | SEO, mobile arm support attached to wheelchair, balanced, friction arm support, (friction dampening to proximal and distal joints), prefabricated, includes fitting and adjustment | All | Y | Purchase | |
L3969 | NU EP | H 6 | SEO, mobile arm support, monosuspension arm and hand support, overhead elbow forearm hand sling support, yoke type arm suspension support, prefabricated, includes fitting and adjustment | All | N | Purchase | |
L3970 | NU EP | H 6 | SEO, addition to mobile arm support elevating proximal arm | All | N | Purchase | |
L3972 | NU EP | H 6 | SEO, addition to mobile arm support, offset or lateral rocker arm with elastic balance control | All | N | Purchase | |
L3974 | NU EP | H 6 | SEO, addition to mobile arm support, supinator | All | N | Purchase | |
L3980 | NU EP | H 6 | Upper extremity fracture orthosis, humeral, prefabricated, includes fitting and adjustment | All | N | Purchase | |
L3982 | NU EP | H 6 | Upper extremity fracture orthosis, radius/ulnar prefabricated, includes fitting and adjustment | All | N | Purchase | |
L3984 | NU EP | H 6 | Upper extremity fracture orthosis, wrist, prefabricated, includes fitting and adjustment | All | N | Purchase | |
L3985 | NU EP | H 6 | Upper extremity fracture orthosis, forearm, hand with wrist hinge, custom fabricated | All | N | Purchase | |
L3986 | NU EP | H 6 | Upper extremity fracture orthosis, combination of humeral, radius/ulnar, wrist (example ? Colles? fracture), custom fabricated | All | N | Purchase | |
L3995 | NU EP | H 6 | Addition to upper extremity orthosis sock, fracture or equal, each | All | N | Purchase | |
L3999 | EP | 6 | Upper limb orthosis, NOS | U21 | N/A | Manually Priced | |
L3999 | NU EP | H 6 | ***(The manufacturer?s invoice must be attached to all claims.) Upper limb orthosis, NOS | All | Y | Manually Priced Manually Priced | |
L4000 | NU EP | H 6 | Replace girdle for spinal orthosis (CTLSO or SO) | All | Y | Purchase | |
L4002 | NU EP | H 6 | Replace strap, any orthosis, includes all components, any length, any type | All | N | Purchase | |
L4010 | NU EP | H 6 | Replace trilateral socket brim | All | N | Purchase | |
L4020 | NU EP | H 6 | Replace quadrilateral socket brim, molded to patient model | All | N | Purchase | |
L4030 | NU EP | H 6 | Replace quadrilateral socket brim, custom fitted | All | N | Purchase | |
L4040 | NU EP | H 6 | Replace molded thigh lacer | All | N | Purchase | |
L4045 | NU EP | H 6 | Replace nonmolded thigh lacer | All | N | Purchase | |
L4050 | NU EP | H 6 | Replace molded calf lacer | All | N | Purchase | |
L4055 | NU EP | H 6 | Replace nonmolded calf lacer | All | N | Purchase | |
L4060 | NU EP | H 6 | Replace high roll cuff | All | N | Purchase | |
L4070 | NU EP | H 6 | Replace proximal and distal upright for KAFO | All | N | Purchase | |
L4080 | NU EP | H 6 | Replace metal bands KAFO, proximal thigh | All | N | Purchase | |
L4090 | EP | 6 | A(Custom night ?A? frame-KAFO, torsion control, bilateral night ?A? frame) Replace metal bands KAFO-AFO, calf or distal thigh | U21 | N/A | Purchase | |
L4090 | NU EP | H 6 | Replace metal bands KAFO-AFO, calf or distal thigh | All | N | Purchase | |
L4100 | NU EP | H 6 | Replace leather cuff KAFO, proximal thigh | All | N | Purchase | |
L4110 | NU EP | H 6 | Replace leather cuff KAFO-AFO, calf or distal thigh | All | N | Purchase | |
L4130 | NU EP | H 6 | Replace pretibial shell | All | N | Purchase | |
L4205 | NU EP | H 6 | Repair of orthotic device, labor component, per 15 minutes | All | Y | Manually Priced Purchase | |
L4210 | NU EP | H 6 | Repair of orthotic device, repair or replace minor parts | All | Y | Manually Priced Purchase | |
L4350 | NU EP | H 6 | Ankle control orthosis, stirrup style, rigid, includes any type interface (e.g., pneumatic, gel), prefabricated, includes fitting and adjustment | All | N | Purchase | |
L4360 | NU EP | H 6 | Walking boot, pneumatic with or without joints, with or without interface material, prefabricated, includes fitting and adjustment | All | N | Purchase | |
L4370 | NU EP | H 6 | Pneumatic full leg splint, prefabricated, includes fitting and adjustment | All | N | Purchase | |
L4380 | NU EP | H 6 | Pneumatic knee splint, prefabricated, includes fitting and adjustment | All | N | Purchase | |
L4392 | Replacement soft interface material, static AFO | All | N | Purchase | |||
L4394 | NU | H | Replace soft interface material, foot drop splint | 21+ | N | Purchase | |
L4396 | NU | H | Static AFO, including soft interface material, adjustable for fit, for positioning, pressure reduction, may be used for minimal ambulation, prefabricated, includes fitting and adjustment | 21+ | N | Purchase | |
L4398 | NU | H | Foot drop splint, recumbent positioning device, prefabricated, includes fitting and adjustment | 21+ | N | Purchase | |
L5999 | NU EP | H 6 | ***(Unlisted Prosthetic Devices or Orthotic Appliances; the manufacturer?s invoice must be attached to all claims.) Lower extremity prosthesis, not otherwise specified | All | Y | Manually Priced Manually Priced | |
L7499 | NU EP | H 6 | ***(Unlisted Prosthetic Devices or Orthotic Appliances; the manufacturer?s invoice must be attached to all claims.) Upper extremity prosthesis, not otherwise specified | All | Y | Manually Priced Manually Priced | |
L7510 | NU EP | UB | H 6 | Repair of prosthetic device, hourly rate | All | Y | Manually Priced Purchase |
L7520 | NU EP | H 6 | Repair prosthetic device, labor component, per 15 minutes | All | Y | Manually Priced Purchase | |
L8499 | NU EP | H 6 | ***(Unlisted Prosthetic Devices or Orthotic Appliances; the manufacturer?s invoice must be attached to all claims.) Unlisted procedure for miscellaneous prosthetic services | All | Y | Manually Priced Purchase |
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 individuals age 21 and over. When a second modifier is listed, that modifier must be used in conjunction with either EP or NU.
Additionally, when billed on paper, procedure codes must be billed with type of service (TOS) code ?6? for individuals under age 21 or TOS code ?H? for beneficiaries age 21 and over.
Modifiers in this section are indicated by the headings M1 and M2. Type of service is indicated by the heading TOS.
Prior authorization requirements are shown under the heading PA. If prior authorization is needed for individuals age 21 and over, 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 individuals under age 21 and ?21+? is shown when the code is payable only for those individuals age 21 and over.
NOTE: Prosthetics providers may continue to use modifier 52 for claims with dates of service through October 31, 2005. Effective for claims with dates of service on and after November 1, 2005, modifier 52 will be replaced with modifier UB.
* Replacement only
***(?) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product.
Procedure Code | M1 | M2 | TOS | Description | All U21 21+ | PA 21+ | Payment Method |
L1499 | NU EP | H 6 | ***(Unlisted Prosthetic Devices or Orthotic Appliances; the manufacturer?s invoice must be attached to all claims.) Spinal orthosis, not otherwise specified | All | Y | Manually Priced Manually Priced | |
L2999 | NU EP | H 6 | ***(Unlisted Prosthetic Devices or Orthotic Appliances; the manufacturer?s invoice must be attached to all claims.) Lower extremity orthoses, NOS | All | Y | Manually Priced Manually Priced | |
L3649 | NU EP | U1 | H 6 | ***(Unlisted Prosthetic Devices or Orthotic Appliances; the manufacturer?s invoice must be attached to all claims.) Orthopedic shoe, modification, addition or transfer, NOS | All | Y | Manually Priced Manually Priced |
L3999 | NU EP | H 6 | ***(Unlisted Prosthetic Devices or Orthotic Appliances; the manufacturer?s invoice must be attached to all claims.) Upper limb orthosis, NOS | All | Y | Manually Priced Manually Priced | |
L4205 | NU EP | H 6 | ***(Orthotics and Prosthetics Repairs) Repair of orthotic device, labor component, per 15 minutes | All | Y | Manually Priced Purchase | |
L4210 | NU EP | H 6 | ***(Orthotics and Prosthetics Repairs) Repair of orthotic device, repair or replace minor parts | All | Y | Manually Priced Purchase | |
L5000 | NU EP | H 6 | Partial foot, shoe insert with longitudinal arch, toe filler | All | N | Purchase | |
L5010 | NU EP | H 6 | Partial foot, molded socket, ankle height, with toe filler | All | Y | Purchase | |
L5020 | NU EP | H 6 | Partial foot, molded socket, tibial tubercle height, with toe filler | All | Y | Purchase | |
L5050 | NU EP | H 6 | Ankle, Symes, molded socket, SACH foot | All | Y | Purchase | |
L5060 | NU EP | H 6 | Ankle, Symes, metal frame, molded leather socket, articulated ankle/foot | All | Y | Purchase | |
L5100 | NU EP | H 6 | Below knee, molded socket, shin, SACH foot | All | Y | Purchase | |
L5105 | NU EP | H 6 | Below knee, plastic socket, joints and thigh lacer, SACH foot | All | Y | Purchase | |
L5150 | NU EP | H 6 | Knee disarticulation (or through knee), molded socket, external knee joints, shin, SACH foot | All | Y | Purchase | |
L5160 | NU EP | H 6 | Knee disarticulation (or through knee), molded socket, bent knee configuration, external knee joints, shin, SACH foot | All | Y | Purchase | |
L5200 | NU EP | H 6 | Above knee, molded socket, single axis constant friction knee, shin, SACH foot | All | Y | Purchase | |
L5210 | NU EP | H 6 | Above knee, short prosthesis, no knee joint (?stubbies?), with foot blocks, no ankle joints, each | All | Y | Purchase | |
L5220 | NU EP | H 6 | Above knee, short prosthesis, no knee joint (stubbies), with articulated ankle/foot, dynamically aligned, each | All | Y | Purchase | |
L5230 | NU EP | H 6 | Above knee, for proximal femoral focal deficiency, constant friction knee, shin, SACH foot | All | Y | Purchase | |
L5250 | NU EP | H 6 | Hip disarticulation, Canadian type, molded socket, hip joint, single axis constant friction knee, shin, SACH foot | All | Y | Purchase | |
L5270 | NU EP | H 6 | Hip disarticulation, tilt table type, molded socket, locking hip joint, single axis constant friction knee, shin, SACH foot | All | Y | Purchase | |
L5280 | NU EP | H 6 | Hemipelvectomy, Canadian type, molded socket, hip joint, single axis constant friction knee, shin, SACH foot | All | Y | Purchase | |
L5301 | NU EP | H 6 | Below knee, molded socket, shin, SACH foot, endoskeletal system | All | Y | Purchase | |
L5311 | NU EP | H 6 | Knee disarticulation (or through knee), molded socket, external knee joints, shin, SACH foot, endoskeletal system | All | Y | Purchase | |
L5321 | NU EP | H 6 | Above knee, molded socket, open end, SACH foot, endoskeletal system, single axis knee | All | Y | Purchase | |
L5331 | NU EP | H 6 | Hip disarticulation, Canadian type, molded socket, endoskeletal system, hip joint, single axis knee, SACH foot | All | Y | Purchase | |
L5341 | NU EP | H 6 | Hemipelvectomy, Canadian type, molded socket, endoskeletal system, hip joint, single axis knee, SACH foot | All | Y | Purchase | |
L5400 | NU EP | H 6 | Immediate post surgical or early fitting, application of initial rigid dressing, including fitting, alignment, suspension, and one cast change, below knee | All | N | Purchase | |
L5410 | NU EP | H 6 | Immediate post surgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension, below knee, each additional cast change and realignment | All | N | Purchase | |
L5420 | NU EP | H 6 | Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension, and one cast change ?AK? or knee disarticulation | All | Y | Purchase | |
L5430 | NU EP | H 6 | Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension, ?AK? or knee disarticulation, each additional cast change and realignment | All | N | Purchase | |
L5450 | NU EP | H 6 | Immediate postsurgical or early fitting, application of nonweight bearing rigid dressing, below knee | All | N | Purchase | |
L5460 | NU EP | H 6 | Immediate post surgical or early fitting, application of nonweight bearing rigid dressing, above knee | All | N | Purchase | |
L5500 | NU EP | H 6 | Initial, below knee (?PTB? type socket, non-alignable system, pylon, no cover, SACH foot, plaster socket, direct formed | All | N | Purchase | |
L5505 | NU EP | H 6 | Initial, above knee-knee disarticulation (ischial level socket, non-alignable system, pylon, no cover, SACH foot plaster socket, direct formed | All | Y | Purchase | |
L5510 | NU EP | H 6 | Preparatory, below knee ?PTB? type socket, non-alignable system, pylon, no cover, SACH foot, plaster socket, molded to model | All | Y | Purchase | |
L5520 | NU EP | H 6 | Preparatory, below knee ?PTB? type socket, non-alignable pylon, no cover, SACH foot, thermoplastic or equal, direct formed | All | Y | Purchase | |
L5530 | NU EP | H 6 | Preparatory, below knee ?PTB? type socket, non-alignable system, pylon, no cover, SACH foot, thermoplastic or equal, molded to model | All | Y | Purchase | |
L5535 | NU EP | H 6 | Preparatory, below knee ?PTB? type socket, non-alignable system, pylon, no cover, SACH foot, prefabricated, adjustable open end socket | All | Y | Purchase | |
L5540 | NU EP | H 6 | Preparatory, below knee ?PTB? type socket, non alignable, pylon, no cover, SACH foot, laminated socket, molded to model | All | Y | Purchase | |
L5560 | NU EP | H 6 | Preparatory, above knee-knee disarticulation ischial level socket, non-alignable system, pylon, no cover, SACH foot, plaster socket, molded to model | All | Y | Purchase | |
L5570 | NU EP | H 6 | Preparatory, above knee-knee disarticulation ischial level socket, non-alignable system, pylon, no cover, SACH foot thermoplastic or equal, direct formed | All | Y | Purchase | |
L5580 | NU EP | H 6 | Preparatory, above knee-knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, SACH foot, thermoplastic or equal, molded to model | All | Y | Purchase | |
L5585 | NU EP | H 6 | Preparatory, above knee-knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, SACH foot, prefabricated adjustable open end socket | All | Y | Purchase | |
L5590 | NU EP | H 6 | Preparatory, above knee-knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, SACH foot, laminated socket, molded to model | All | Y | Purchase | |
L5595 | NU EP | H 6 | Preparatory, hip disarticulation-hemipelvectomy, pylon, no cover, SACH foot, thermoplastic or equal, molded to patient model | All | Y | Purchase | |
L5600 | NU EP | H 6 | Preparatory, hip disarticulation-hemipelvectomy, pylon, no cover, SACH foot, laminated socket, molded to patient model | All | Y | Purchase | |
L5610 | NU EP | H 6 | Addition to lower extremity, endoskeletal system, above knee, hydracadence system | All | Y | Purchase | |
L5611 | NU EP | H 6 | Addition to lower extremity, endoskeletal system, above knee-knee disarticulation, 4-bar linkage, with friction swing phase control | All | N | Purchase | |
L5613 | NU EP | H 6 | Addition to lower extremity, endoskeletal system, above knee-knee disarticulation, 4-bar linkage, with hydraulic swing phase control | All | Y | Purchase | |
L5614 | NU | H | Addition to lower extremity, endoskeletal system, above knee ? knee disarticulation, 4-bar linkage, with pneumatic swing phase control | 21+ | Y | Purchase | |
L5616 | NU EP | H 6 | Addition to lower extremity, endoskeletal system above knee, universal multiplex system, friction swing phase control | All | Y | Purchase | |
L5617 | NU | H | Addition to lower extremity, quick change self-aligning unit, above or below knee, each | 21+ | Y | Purchase | |
L5618 | NU EP | H 6 | Addition to lower extremity, test socket, Symes | All | N | Purchase | |
L5620 | NU EP | H 6 | Addition to lower extremity, test socket, below knee | All | N | Purchase | |
L5622 | NU EP | H 6 | Addition to lower extremity, test socket, knee disarticulation | All | N | Purchase | |
L5624 | NU EP | H 6 | Addition to lower extremity, test socket, above knee | All | N | Purchase | |
L5626 | NU EP | H 6 | Addition to lower extremity, test socket, hip disarticulation | All | N | Purchase | |
L5628 | NU EP | H 6 | Addition to lower extremity, test socket, hemipelvectomy | All | N | Purchase | |
L5629 | NU EP | H 6 | Addition to lower extremity, below knee, acrylic socket | All | N | Purchase | |
L5630 | NU EP | H 6 | Addition to lower extremity, Symes type, expandable wall socket | All | N | Purchase | |
L5631 | NU EP | H 6 | Addition to lower extremity, above knee or knee disarticulation, acrylic socket | All | N | Purchase | |
L5632 | NU EP | H 6 | Addition to lower extremity, Symes type, ?PTB? brim design socket | All | N | Purchase | |
L5634 | NU EP | H 6 | Addition to lower extremity, Symes type posterior opening (Canadian) socket | All | N | Purchase | |
L5636 | NU EP | H 6 | Additions to lower extremity, Symes type, medial opening socket | All | N | Purchase | |
L5637 | NU EP | H 6 | Addition to lower extremity, below knee, total contact | All | N | Purchase | |
L5638 | NU EP | H 6 | Addition to lower extremity, below knee, leather socket | All | N | Purchase | |
L5639 | NU EP | H 6 | Addition to lower extremity, below knee, wood socket | All | N | Purchase | |
L5640 | NU EP | H 6 | Addition to lower extremity, knee disarticulation, leather socket | All | N | Purchase | |
L5642 | NU EP | H 6 | Addition to lower extremity, above knee, leather socket | All | N | Purchase | |
L5643 | NU EP | H 6 | Addition to lower extremity, hip disarticulation, flexible inner socket, external frame | All | Y | Purchase | |
L5644 | NU EP | H 6 | Addition to lower extremity, above knee, wood socket | All | N | Purchase | |
L5645 | NU EP | H 6 | Addition to lower extremity, below knee, flexible inner socket, external frame | All | N | Purchase | |
L5646 | NU EP | H 6 | Addition to lower extremity, below knee, air, fluid, gel or equal, cushion socket | All | N | Purchase | |
L5647 | NU EP | H 6 | Addition to lower extremity, below knee suction socket | All | N | Purchase | |
L5648 | NU EP | H 6 | Addition to lower extremity, above knee, air, fluid, gel or equal, cushion socket | All | N | Purchase | |
L5649 | NU EP | H 6 | Addition to lower extremity, ischial containment/narrow M-L socket | All | Y | Purchase | |
L5650 | NU EP | H 6 | Addition to lower extremity, total contact, above knee or knee disarticulation socket | All | N | Purchase | |
L5651 | NU EP | H 6 | Addition to lower extremity, above knee, flexible inner socket, external frame | All | N | Purchase | |
L5652 | NU EP | H 6 | Addition to lower extremity, suction suspension, above knee or knee disarticulation, socket | All | N | Purchase | |
L5653 | NU EP | H 6 | Addition to lower extremity, knee disarticulation, expandable wall socket | All | N | Purchase | |
L5654 | NU EP | H 6 | Addition to lower extremity, socket insert, Symes, (Kemblo, Pelite, Aliplast, Plastazote or equal) | All | N | Purchase | |
L5655 | NU EP | H 6 | Addition to lower extremity, socket insert, below knee (Kemblo, Pelite, Aliplast, Plastazote or equal) | All | N | Purchase | |
L5656 | NU EP | H 6 | Addition to lower extremity, socket insert, knee disarticulation (Kemblo, Pelite, Aliplast, Plastazote or equal) | All | N | Purchase | |
L5658 | NU EP | H 6 | Addition to lower extremity, socket insert, above knee (Kemblo, Pelite, Aliplast, Plastazote or equal) | All | N | Purchase | |
L5661 | NU EP | H 6 | Addition to lower extremity, socket insert, multi durometer Symes | All | N | Purchase | |
L5665 | EP | 6 | Addition to lower extremity, socket insert, multo-durometer, below knee | U21 | N/A | Purchase | |
L5666 | NU EP | H 6 | Additions to lower extremity, below knee, cuff suspension | All | N | Purchase | |
L5668 | NU EP | H 6 | Addition to lower extremity, below knee, molded distal cushion | All | N | Purchase | |
L5670 | NU EP | H 6 | Addition to lower extremity, below knee, molded supracondyular suspension (?PTS? or similar) | All | N | Purchase | |
L5672 | NU EP | H 6 | Addition to lower extremity, below knee, removable medial brim suspension | All | N | Purchase | |
L5676 | NU EP | H 6 | Addition to lower extremity, below knee, knee joints, single axis, pair | All | N | Purchase | |
L5677 | NU EP | H 6 | Addition to lower extremity, below knee, knee joints, polycentric, pair | All | N | Purchase | |
L5678 | NU EP | H 6 | Addition to lower extremity, below knee, joint covers, pair | All | N | Purchase | |
L5680 | NU EP | H 6 | Addition to lower extremity, below knee, thigh lacer, nonmolded | All | N | Purchase | |
L5682 | NU EP | H 6 | Addition to lower extremity, below knee, thigh lacer, gluteal/ischial, molded | All | N | Purchase | |
L5684 | NU EP | H 6 | Addition to lower extremity, below knee, fork strap | All | N | Purchase | |
L5685 | NU EP | H 6 | Addition to lower extremity prosthesis, below knee, suspension/sealing sleeve, with or without valve, any material, each | All | N | Purchase | |
L5686 | NU EP | H 6 | Addition to lower extremity, below knee, back check (extension control) | All | N | Purchase | |
L5688 | NU EP | H 6 | Addition to lower extremity, below knee, waist belt, webbing | All | N | Purchase | |
L5690 | NU EP | H 6 | Addition to lower extremity, below knee, waist belt, padded and lined | All | N | Purchase | |
L5692 | NU EP | H 6 | Addition to lower extremity, above knee, pelvic control belt, light | All | N | Purchase | |
L5694 | NU EP | H 6 | Addition to lower extremity, above knee, pelvic control belt, padded and lined | All | N | Purchase | |
L5695 | NU EP | H 6 | Addition to lower extremity, above knee, pelvic control, sleeve suspension, neoprene or equal, each | All | N | Purchase | |
L5696 | NU EP | H 6 | Addition to lower extremity, above knee or knee disarticulation, pelvic joint | All | N | Purchase | |
L5697 | NU EP | H 6 | Addition to lower extremity, above knee or knee disarticulation, pelvic band | All | N | Purchase | |
L5698 | NU EP | H 6 | Addition to lower extremity, above knee or knee disarticulation, silesian bandage | All | N | Purchase | |
L5699 | NU EP | H 6 | All lower extremity prosthesis, shoulder harness | All | N | Purchase | |
L5700 | NU | H | Replacement, socket, below knee, molded to patient model | 21+ | Y | Purchase | |
L5701 | NU | H | Replacement, socket, above knee/knee disarticulation, including attachment plate, molded to patient model | 21+ | Y | Purchase | |
L5702 | NU | H | Replacement, socket, hip disarticulation, including hip joint, molded to patient model | 21+ | Y | Purchase | |
L5704 | NU | H | Custom shaped protective cover, below knee | 21+ | N | Purchase | |
L5705 | NU | H | Custom shaped protective cover, above knee | 21+ | N | Purchase | |
L5706 | NU | H | Custom shaped protective cover, knee disarticulation | 21+ | N | Purchase | |
L5707 | NU | H | Custom shaped protective cover, hip disarticulation | 21+ | N | Purchase | |
L5710 | NU EP | H 6 | Addition, exoskeletal knee-shin system, single axis, manual lock | All | N | Purchase | |
L5711 | NU EP | H 6 | Addition exoskeletal knee-shin system, single axis, manual lock, ultra-light material | All | N | Purchase | |
L5712 | NU EP | H 6 | Addition exoskeletal knee-shin system, single axis, friction swing and stance phase control (safety knee) | All | N | Purchase | |
L5714 | NU EP | H 6 | Addition, exoskeletal knee-shin system, single axis, variable friction swing phase control | All | N | Purchase | |
L5716 | NU EP | H 6 | Addition, exoskeletal knee-shin system, polycentric, mechanical stance phase lock | All | N | Purchase | |
L5718 | NU EP | H 6 | Addition, exoskeletal knee-shin system, polycentric, friction swing and stance phase control | All | N | Purchase | |
L5722 | NU EP | H 6 | Addition, exoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase control | All | N | Purchase | |
L5724 | NU EP | H 6 | Addition, exoskeletal knee-shin system, single axis, fluid swing phase control | All | Y | Purchase | |
L5726 | NU EP | H 6 | Addition, exoskeletal knee-shin system, single axis, external joints, fluid swing phase control | All | Y | Purchase | |
L5728 | NU EP | H 6 | Addition, exoskeletal knee-shin system, single axis, fluid swing and stance phase control | All | Y | Purchase | |
L5780 | NU EP | H 6 | Addition, exoskeletal knee-shin system, single axis, pneumatic/hydra pneumatic swing phase control | All | N | Purchase | |
L5785 | NU EP | H 6 | Addition, exoskeletal system, below knee, ultra-light material (titanium, carbon fiber or equal) | All | N | Purchase | |
L5790 | NU EP | H 6 | Addition, exoskeletal system, above knee, ultra-light material (titanium, carbon fiber or equal) | All | N | Purchase | |
L5795 | NU EP | H 6 | Addition, exoskeletal system, hip disarticulation, ultra-light material (titanium, carbon fiber or equal) | All | N | Purchase | |
L5810 | NU EP | H 6 | Addition, endoskeletal knee-shin system, single axis, manual lock | All | N | Purchase | |
L5811 | NU EP | H 6 | Addition, endoskeletal knee-shin system, single axis, manual lock, ultra-light material | All | N | Purchase | |
L5812 | NU EP | H 6 | Addition, endoskeletal knee-shin system, single axis, friction swing and stance phase control (safety knee) | All | N | Purchase | |
L5816 | NU EP | H 6 | Addition, endoskeletal knee-shin system, polycentric, mechanical stance phase lock | All | N | Purchase | |
L5818 | NU EP | H 6 | Addition, endoskeletal knee-shin system, polycentric, friction swing, and stance phase control | All | N | Purchase | |
L5822 | NU EP | H 6 | Addition, endoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase control | All | Y | Purchase | |
L5824 | NU EP | H 6 | Addition, endoskeletal knee-shin system, single axis, fluid swing phase control | All | Y | Purchase | |
L5826 | NU | H | Addition, endoskeletal knee-shin system, single axis, hydraulic swing phase control with miniature high activity frame | 21+ | Y | Purchase | |
L5828 | NU EP | H 6 | Addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control | All | Y | Purchase | |
L5830 | NU EP | H 6 | Addition, endoskeletal knee-shin system, single axis, pneumatic/swing phase control | All | Y | Purchase | |
L5840 | NU | H | Addition, endoskeletal knee-shin system, 4-bar linkage or multiaxial, pneumatic swing phase control | 21+ | N | Purchase | |
L5845 | NU | H | Addition, endoskeletal knee-shin system, stance flexion feature, adjustable | 21+ | Y | Purchase | |
L5850 | NU EP | H 6 | Addition, endoskeletal system, above knee or hip disarticulation, knee extension assist | All | N | Purchase | |
L5855 | NU EP | H 6 | Addition, endoskeletal system, hip disarticulation, mechanical hip extension assist | All | N | Purchase | |
L5910 | NU EP | H 6 | Addition, endoskeletal system, below knee, alignable system | All | N | Purchase | |
L5920 | NU EP | H 6 | Addition, endoskeletal system, above knee or hip disarticulation, alignable system | All | N | Purchase | |
L5925 | NU | H | Addition, endoskeletal system, above knee, knee disarticulation, manual lock | 21+ | N | Purchase | |
L5930 | NU | H | Addition, endoskeletal system, high activity knee control frame | 21+ | Y | Purchase | |
L5940 | NU EP | H 6 | Addition, endoskeletal system, below knee, ultra-light material (titanium, carbon fiber or equal) | All | N | Purchase | |
L5950 | NU EP | H 6 | Addition, endoskeletal system, above knee, ultra-light material (titanium, carbon fiber or equal) | All | N | Purchase | |
L5960 | NU EP | H 6 | Addition, endoskeletal system, hip disarticulation, ultra-light material (titanium, carbon fiber or equal) | All | N | Purchase | |
L5962 | NU | H | Addition, endoskeletal system, below knee, flexible protective outer surface covering system | 21+ | N | Purchase | |
L5964 | NU | H | Addition, endoskeletal system, above knee, flexible protective outer surface covering system | 21+ | N | Purchase | |
L5966 | NU | H | Addition, endoskeletal system, hip disarticulation, flexible protective outer surface covering system | 21+ | N | Purchase | |
L5968 | NU | H | Addition to lower limb prostheses, multiaxial ankle with swing phase active dorsiflexion feature | 21+ | Y | Purchase | |
L5970 | NU EP | H 6 | All lower extremity prostheses, foot, external keel, SACH foot | All | N | Purchase | |
L5972 | NU EP | H 6 | All lower extremity prostheses, flexible keel foot (Safe, Sten, Bock Dynamic or equal) | All | N | Purchase | |
L5974 | NU EP | H 6 | All lower extremity prostheses, foot, single axis ankle/foot | All | N | Purchase | |
L5975 | NU | H | All lower extremity prosthesis, combination single axis ankle and flexible keel foot | 21+ | N | Purchase | |
L5976 | NU EP | H 6 | All lower extremity prostheses, energy storing foot (Seattle Carbon Copy II or equal) | All | N | Purchase | |
L5978 | NU EP | H 6 | All lower extremity prostheses, foot, multiaxial ankle/foot | All | N | Purchase | |
L5979 | NU | H | All lower extremity prostheses, multi-axial ankle, dynamic response foot, one piece system | 21+ | Y | Purchase | |
L5980 | NU EP | H 6 | All lower extremity prostheses, flex-foot system | All | Y | Purchase | |
L5981 | NU | H | All lower extremity prostheses, flex -walk system or equal | 21+ | Y | Purchase | |
L5982 | NU EP | H 6 | All exoskeletal lower extremity prostheses, axial rotation unit | All | N | Purchase | |
L5984 | NU EP | H 6 | All endoskeletal lower extremity prosthesis, axial rotation unit, with or without adjustability | All | N | Purchase | |
L5985 | NU | H | All endoskeletal lower extremity prostheses, dynamic prosthetic pylon | 21+ | N | Purchase | |
L5986 | NU EP | H 6 | All lower extremity prostheses, multi-axial rotation unit (?MCP? or equal) | All | N | Purchase | |
L5987 | NU | H | All lower extremity prostheses, shank foot system with vertical loading pylon | 21+ | Y | Purchase | |
L5988 | NU | H | Addition to lower limb prosthesis, vertical shock reducing pylon feature | 21+ | Y | Purchase | |
L5999 | NU EP | H 6 | ***(Unlisted Prosthetic Devices or Orthotic Appliances; the manufacturer?s invoice must be attached to all claims.) Lower extremity prosthesis, not otherwise specified | All | Y | Manually Priced Manually Priced | |
L6000 | NU EP | H 6 | Partial hand, Robin-Aids, thumb remaining (or equal) | All | N | Purchase | |
L6010 | NU EP | H 6 | Partial hand, Robin-Aids, little and/or ring finger remaining (or equal) | All | N | Purchase | |
L6020 | NU EP | H 6 | Partial hand, Robin-Aids, no finger remaining (or equal) | All | N | Purchase | |
L6050 | NU EP | H 6 | Wrist disarticulation, molded socket, flexible elbow hinges, triceps pad | All | Y | Purchase | |
L6055 | NU EP | H 6 | Wrist disarticulation, molded socket with expandable interface, flexible elbow hinges, triceps pad | All | Y | Purchase | |
L6100 | NU EP | H 6 | Below elbow, molded socket, flexible elbow hinge, triceps pad | All | Y | Purchase | |
L6110 | NU EP | H 6 | Below elbow, molded socket (Muenster or Northwestern suspension types) | All | Y | Purchase | |
L6120 | NU EP | H 6 | Below elbow, molded double wall split socket, step-up hinges, half cuff | All | Y | Purchase | |
L6130 | NU EP | H 6 | Below elbow, molded double wall split socket, stump activated locking hinge, half cuff | All | Y | Purchase | |
L6200 | NU EP | H 6 | Elbow disarticulation, molded socket, outside locking hinge, forearm | All | Y | Purchase | |
L6205 | NU EP | H 6 | Elbow disarticulation, molded socket with expandable interface, outside locking hinges, forearm | All | Y | Purchase | |
L6250 | NU EP | H 6 | Above elbow, molded double wall socket, internal locking elbow, forearm | All | Y | Purchase | |
L6300 | NU EP | H 6 | Shoulder disarticulation, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearm | All | Y | Purchase | |
L6310 | NU EP | H 6 | Shoulder disarticulation, passive restoration (complete prosthesis) | All | Y | Purchase | |
L6320 | NU EP | H 6 | Shoulder disarticulation, passive restoration (shoulder cap only) | All | Y | Purchase | |
L6350 | NU | H | Interscapular thoracic, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearm | 21+ | Y | Purchase | |
L6360 | NU EP | H 6 | Interscapular thoracic, passive restoration (complete prosthesis) | All | Y | Purchase | |
L6370 | NU EP | H 6 | Interscapular thoracic, passive restoration (shoulder cap only) | All | Y | Purchase | |
L6380 | NU EP | H 6 | Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting alignment and suspension of components, and one cast change, wrist disarticulation or below elbow | All | N | Purchase | |
L6382 | NU EP | H 6 | Immediate postsurgical or early fitting, application of initial rigid dressing including fitting alignment and suspension of components, and one cast change, elbow disarticulation or above elbow | All | N | Purchase | |
L6384 | NU EP | H 6 | Immediate postsurgical or early fitting, application of initial rigid dressing including fitting alignment and suspension of components, and one cast change, shoulder disarticulation or interscapular thoracic | All | Y | Purchase | |
L6386 | NU EP | H 6 | Immediate postsurgical or early fitting, each additional cast change and realignment | All | N | Purchase | |
L6388 | NU EP | H 6 | Immediate postsurgical or early fitting, application of rigid dressing only | All | N | Purchase | |
L6400 | NU EP | H 6 | Below elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping | All | Y | Purchase | |
L6450 | NU EP | H 6 | Elbow disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue shaping | All | Y | Purchase | |
L6500 | NU EP | H 6 | Above elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping | All | Y | Purchase | |
L6550 | NU EP | H 6 | Shoulder disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue shaping | All | Y | Purchase | |
L6570 | NU EP | H 6 | Interscapular thoracic, molded socket, endoskeletal system including soft prosthetic tissue shaping | All | Y | Purchase | |
L6580 | NU EP | H 6 | Preparatory, wrist disarticulation or below elbow, single wall plastic socket, friction wrist, flexible elbow hinges, figure of eight harness, humeral cuff, Bowden cable control, ?USMC? or equal pylon, no cover, molded to patient model | All | Y | Purchase | |
L6582 | NU EP | H 6 | Preparatory, wrist disarticulation or below elbow, single wall socket, friction wrist, flexible elbow hinges, figure of eight harness, humeral cuff, Bowden cable control, ?USMC? or equal pylon, no cover, direct formed | All | N | Purchase | |
L6584 | NU EP | H 6 | Preparatory, elbow 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 | All | Y | Purchase | |
L6586 | NU EP | H 6 | Preparatory, elbow disarticulation or above elbow, single wall socket, friction wrist, locking elbow, figure of eight harness, fair lead cable control, ?USMC? or equal pylon, no cover, direct formed | All | Y | Purchase | |
L6588 | NU EP | H 6 | Preparatory, shoulder disarticulation or interscapular thoracic, single wall plastic socket, shoulder joint, locking elbow, friction wrist, chest strap, fair lead cable control, ?USMC? or equal pylon, no cover, molded to patient model | All | Y | Purchase | |
L6590 | NU EP | H 6 | Preparatory, shoulder disarticulation or interscapular thoracic, single wall socket, shoulder joint, locking elbow, friction wrist, chest strap, fair lead cable control, ?USMC? or equal pylon, no cover, direct formed | All | Y | Purchase | |
L6600 | NU EP | H 6 | Upper extremity additions, polycentric hinge, pair | All | N | Purchase | |
L6605 | NU EP | H 6 | Upper extremity additions, single pivot hinge, pair | All | N | Purchase | |
L6610 | NU EP | H 6 | Upper extremity additions, flexible metal hinge, pair | All | N | Purchase | |
L6615 | NU EP | H 6 | Upper extremity addition, disconnect locking wrist unit | All | N | Purchase | |
L6616 | NU EP | H 6 | Upper extremity addition, additional disconnect insert for locking wrist unit, each | All | N | Purchase | |
L6620 | NU EP | H 6 | Upper extremity addition, flexion/extension wrist unit, with or without friction | All | N | Purchase | |
L6623 | NU EP | H 6 | Upper extremity addition, spring assisted rotational wrist unit with latch release | All | N | Purchase | |
L6625 | NU EP | H 6 | Upper extremity addition, rotation wrist unit with cable lock | All | N | Purchase | |
L6628 | NU EP | H 6 | Upper extremity addition, quick disconnect hook adapter, Otto Bock or equal | All | N | Purchase | |
L6629 | NU EP | H 6 | Upper extremity addition, quick disconnect lamination collar with coupling piece, Otto Bock or equal | All | N | Purchase | |
L6630 | NU EP | H 6 | Upper extremity addition, stainless steel, any wrist | All | N | Purchase | |
L6632 | NU EP | H 6 | Upper extremity addition, latex suspension sleeve, each | All | N | Purchase | |
L6635 | NU EP | H 6 | Upper extremity additions, lift assist for elbow | All | N | Purchase | |
L6637 | NU EP | H 6 | Upper extremity addition, nudge control elbow lock | All | N | Purchase | |
L6640 | NU EP | H 6 | Upper extremity additions, shoulder abduction joint, pair | All | N | Purchase | |
L6641 | NU EP | H 6 | Upper extremity addition, excursion amplifier, pulley type | All | N | Purchase | |
L6642 | NU EP | H 6 | Upper extremity addition, excursion amplifier, lever type | All | N | Purchase | |
L6645 | NU EP | H 6 | Upper extremity addition, shoulder flexion-abduction joint, each | All | N | Purchase | |
L6650 | NU EP | H 6 | Upper extremity addition, shoulder universal joint, each | All | N | Purchase | |
L6655 | NU EP | H 6 | Upper extremity addition, standard control cable, extra | All | N | Purchase | |
L6660 | NU EP | H 6 | Upper extremity addition, heavy duty control cable | All | N | Purchase | |
L6665 | NU EP | H 6 | Upper extremity addition, teflon, or equal, cable lining | All | N | Purchase | |
L6670 | NU EP | H 6 | Upper extremity addition, hook to hand cable adapter | All | N | Purchase | |
L6672 | NU EP | H 6 | Upper extremity addition, harness, chest or shoulder, saddle type | All | N | Purchase | |
L6675 | NU EP | H 6 | Upper extremity addition, harness, (e.g., figure of eight type), single cable design | All | N | Purchase | |
L6676 | NU EP | H 6 | Upper extremity additions, harness, (e.g., figure of eight type), dual cable design | All | N | Purchase | |
L6680 | NU EP | H 6 | Upper extremity addition, test socket, wrist disarticulation or below elbow | All | N | Purchase | |
L6682 | NU EP | H 6 | Upper extremity addition, test socket, elbow disarticulation or above elbow | All | N | Purchase | |
L6684 | NU EP | H 6 | Upper extremity addition, test socket, shoulder disarticulation or interscapular thoracic | All | N | Purchase | |
L6686 | NU EP | H 6 | Upper extremity addition, suction socket | All | N | Purchase | |
L6687 | NU EP | H 6 | Upper extremity addition, frame type socket, below elbow or wrist disarticulation | All | N | Purchase | |
L6688 | NU EP | H 6 | Upper extremity addition, frame type socket, above elbow or elbow disarticulation | All | N | Purchase | |
L6689 | NU EP | H 6 | Upper extremity addition, frame type socket, shoulder disarticulation | All | N | Purchase | |
L6690 | NU EP | H 6 | Upper extremity addition, frame type socket, interscapular-thoracic | All | N | Purchase | |
L6691 | NU EP | H 6 | Upper extremity addition, removable insert, each | All | N | Purchase | |
L6692 | NU EP | H 6 | Upper extremity addition, silicone gel insert or equal, each | All | N | Purchase | |
L6693 | NU | H | Upper extremity addition, locking elbow, forearm counterbalance | 21+ | Y | Purchase | |
L6700 | NU EP | H 6 | Terminal device, hook, Dorrance or equal, model # 3 | All | N | Purchase | |
L6705 | NU EP | H 6 | Terminal device, hook, Dorrance or equal, model # 3 | All | N | Purchase | |
L6710 | NU EP | H 6 | Terminal device, hook, Dorrance or equal, model # 5x | All | N | Purchase | |
L6715 | NU EP | H 6 | Terminal device, hook, Dorrance or equal, Model # 5xa | All | N | Purchase | |
L6720 | NU EP | H 6 | Terminal device, hook, Dorrance or equal, model # 6 | All | N | Purchase | |
L6725 | NU EP | H 6 | Terminal device, hook, Dorrance or equal, model # 7 | All | N | Purchase | |
L6730 | NU EP | H 6 | Terminal device, hook, Dorrance or equal, model # 7LO | All | N | Purchase | |
L6735 | NU EP | H 6 | Terminal device, hook, Dorrance or equal, model # 8 | All | N | Purchase | |
L6740 | NU EP | H 6 | Terminal device, hook, Dorrance or equal, model # 8x | All | N | Purchase | |
L6745 | NU EP | H 6 | Terminal device, hook, Dorrance or equal, model # 88x | All | N | Purchase | |
L6750 | NU EP | H 6 | Terminal device, hook, Dorrance or equal, model # 10P | All | N | Purchase | |
L6755 | NU EP | H 6 | Terminal device, hook, Dorrance or equal, model # 10x | All | N | Purchase | |
L6765 | NU EP | H 6 | Terminal device, hook, Dorrance or equal, model # 12P | All | N | Purchase | |
L6770 | NU EP | H 6 | Terminal device, hook, Dorrance or equal, model # 99x | All | N | Purchase | |
L6775 | NU EP | H 6 | Terminal device, hook, Dorrance or equal, model # 555 | All | N | Purchase | |
L6780 | NU EP | H 6 | Terminal device, hook, Dorrance or equal, model # SS555 | All | N | Purchase | |
L6790 | NU EP | H 6 | Terminal device, hook-Accu hook or equal | All | N | Purchase | |
L6795 | NU EP | H 6 | Terminal device, hook 2 load or equal | All | N | Purchase | |
L6800 | NU EP | H 6 | Terminal device, hook-APRL VC or equal | All | N | Purchase | |
L6805 | NU EP | H 6 | Terminal device, modifier wrist flexion unit | All | N | Purchase | |
L6806 | NU EP | H 6 | Terminal device, hook, TRS grip, Grip III, VC, or equal | All | Y | Purchase | |
L6807 | NU EP | H 6 | Terminal device, hook, Grip I, Grip II, VC, or equal | All | N | Purchase | |
L6808 | NU EP | H 6 | Terminal device, hook, TRS Adept, infant or child, VC, or equal | All | N | Purchase | |
L6809 | NU EP | H 6 | Terminal device, hook, TRS Super Sport, passive | All | N | Purchase | |
L6810 | NU EP | H 6 | Terminal device, pincher tool, Otto Bock or equal | All | N | Purchase | |
L6825 | NU EP | H 6 | Terminal device, hand, Dorrance, VO | All | N | Purchase | |
L6830 | NU EP | H 6 | Terminal device, hand, APRL, VC | All | N | Purchase | |
L6835 | NU EP | H 6 | Terminal device, hand, Sierra, VO | All | N | Purchase | |
L6840 | NU EP | H 6 | Terminal device, hand, Becker Imperial | All | N | Purchase | |
L6845 | NU EP | H 6 | Terminal device, hand, Becker Lock Grip | All | N | Purchase | |
L6850 | NU EP | H 6 | Terminal device, hand, Becker Plylite | All | N | Purchase | |
L6855 | NU EP | H 6 | Terminal device, hand, Robin-Aids, VO | All | N | Purchase | |
L6860 | NU EP | H 6 | Terminal device, hand, Robin-Aids, VO soft | All | N | Purchase | |
L6865 | NU EP | H 6 | Terminal device, hand, passive hand | All | N | Purchase | |
L6867 | NU EP | H 6 | Terminal device, hand, Detroit Infant Hand (mechanical) | All | N | Purchase | |
L6868 | NU EP | H 6 | Terminal device, hand, passive infant hand, Steeper, Hosmer or equal | All | N | Purchase | |
L6870 | NU EP | H 6 | Terminal device, hand, child mitt | All | N | Purchase | |
L6872 | NU EP | H 6 | Terminal device, hand, NYU child hand | All | N | Purchase | |
L6873 | NU EP | H 6 | Terminal device, hand, mechanical infant hand, Steeper or equal | All | N | Purchase | |
L6875 | NU EP | H 6 | Terminal device, hand, Bock, VC | All | N | Purchase | |
L6880 | NU EP | H 6 | Terminal device, hand, Bock, VO | All | N | Purchase | |
L6890 | NU EP | H 6 | Terminal device, gloves for above hands, production glove | All | N | Purchase | |
L6895 | NU EP | H 6 | Terminal device, glove for above hands, custom glove | All | N | Purchase | |
L6900 | NU EP | H 6 | Hand restoration (casts, shading and measurements included), partial hand, with glove, thumb or one finger remaining | All | N | Purchase | |
L6905 | NU EP | H 6 | Hand restoration (casts, shading and measurements included), partial hand, with glove, multiple fingers remaining | All | N | Purchase | |
L6910 | NU EP | H 6 | Hand restoration (casts, shading and measurements included), partial hand, with glove, no fingers remaining | All | N | Purchase | |
L6915 | NU EP | H 6 | Hand restoration (shading and measurements included), replacement glove for above | All | N | Purchase | |
L6920* | NU EP | H 6 | Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal, switch, cables, two batteries and one charger, switch control of terminal device | All | Y | Purchase | |
L6925* | NU EP | H 6 | Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device | All | Y | Purchase | |
L6930* | NU EP | H 6 | Below elbow, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal switch, cables, two batteries and one charger, switch control of terminal device | All | Y | Purchase | |
L6935* | NU EP | H 6 | Below elbow, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device | All | Y | Purchase | |
L6940* | NU EP | H 6 | Elbow disarticulation, external 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 | All | Y | Purchase | |
L6945* | NU EP | H 6 | Elbow disarticulation, external 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 | All | Y | Purchase | |
L6950* | NU EP | H 6 | Above elbow, external power, 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 | All | Y | Purchase | |
L6955* | NU EP | H 6 | Above elbow, external power, 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 | All | Y | Purchase | |
L6960* | NU EP | H 6 | Shoulder disarticulation, 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 | All | Y | Purchase | |
L6965* | NU EP | H 6 | Shoulder disarticulation, 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 | All | Y | Purchase | |
L6970* | NU EP | H 6 | Interscapular-thoracic, 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 | All | Y | Purchase | |
L6975* | NU EP | H 6 | Interscapular-thoracic, 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 | All | Y | Purchase | |
L7010* | NU EP | H 6 | Electronic hand, Otto Bock, Steeper or equal, switch controlled | All | Y | Purchase | |
L7015* | NU EP | H 6 | Electronic hand, System Teknik, Variety Village or equal, switch controlled | All | Y | Purchase | |
L7020* | NU EP | H 6 | Electronic greifer, Otto Bock or equal, switch controlled | All | Y | Purchase | |
L7025* | NU EP | H 6 | Electronic hand, Otto Bock or equal, myoelectronically controlled | All | Y | Purchase | |
L7030* | NU EP | H 6 | Electronic hand, System Teknik, Variety Village or equal, myoelectronically controlled | All | Y | Purchase | |
L7035* | NU EP | H 6 | Electronic greifer, Otto Bock or equal, myoelectronically controlled | All | Y | Purchase | |
L7040* | NU EP | H 6 | Prehensile actuator, Hosmer or equal, switch controlled | All | Y | Purchase | |
L7045* | NU EP | H 6 | Electronic hook, child, Michigan or equal, switch controlled | All | Y | Purchase | |
L7170* | NU EP | H 6 | Electronic elbow, Hosmer or equal, switch controlled | All | Y | Purchase | |
L7180* | NU EP | H 6 | Electronic elbow, Utah or equal, myoelectronically controlled | All | Y | Purchase | |
L7185 | EP | 6 | Electronic elbow, adolescent, Variety Village or equal, switch controlled | U21 | N/A | Purchase | |
L7186 | EP | 6 | Electronic elbow, child, Variety Village or equal, switch controlled | U21 | N/A | Purchase | |
L7190 | EP | 6 | Electronic elbow, adolescent, Variety Village or equal, myoelectronically controlled | U21 | N/A | Purchase | |
L7191 | EP | 6 | Electronic elbow, child, Variety Village or equal, myoelectronically controlled | U21 | N/A | Purchase | |
L7260* | NU EP | H 6 | Electronic wrist rotator, Otto Bock or equal | All | Y | Purchase | |
L7261* | NU EP | H 6 | Electronic wrist rotator, for Utah arm | All | Y | Purchase | |
L7266* | NU EP | H 6 | Servo control, Steeper or equal | All | N | Purchase | |
L7272* | NU EP | H 6 | Analogue control, UNB or equal | All | Y | Purchase | |
L7274* | NU EP | H 6 | Proportional control, 6-12 volt, Liberty, Utah or equal | All | Y | Purchase | |
L7360* | NU EP | H 6 | Six volt battery, Otto Bock or equal, each | All | N | Purchase | |
L7362* | NU EP | H 6 | Battery charger, six volt, Otto Bock or equal | All | N | Purchase | |
L7364* | NU EP | H 6 | Twelve volt battery, Utah or equal, each | All | N | Purchase | |
L7366* | NU EP | H 6 | Battery charger, twelve volt, Utah or equal | All | N | Purchase | |
L7499 | NU EP | H 6 | ***(Unlisted Prosthetic Devices or Orthotic Appliances; the manufacturer?s invoice must be attached to all claims.) Upper extremity prosthesis, NOS | All | Y | Manually Priced Manually Priced | |
L7510 | NU EP | UB | H 6 | ***(Orthotics and Prosthetics Repairs) Repair of prosthetic device, repair or replace minor parts | All | Y | Manually Priced Purchase |
L7510 | NU EP | H 6 | ***(Twister cables - repair/replace) Repair of prosthetic device, repair or replace minor parts | All | N | Manually Priced Purchase | |
L7520 | NU EP | H 6 | ***(Orthotics and Prosthetics Repairs) Repair prosthetic device, labor component, per 15 minutes | All | Y | Manually Priced Purchase | |
L8000 | NU EP | H 6 | Breast prosthesis, mastectomy bra | All | N | Purchase | |
L8010 | NU EP | H 6 | Breast prosthesis, mastectomy sleeve | All | N | Purchase | |
L8015 | NU | H | External breast prosthesis garment, with mastectomy form, post-mastectomy | 21+ | N | Purchase | |
L8020 | NU EP | H 6 | Breast prosthesis, mastectomy form | All | N | Purchase | |
L8030 | NU EP | H 6 | Breast prosthesis, silicone or equal | All | N | Purchase | |
L8100 | NU EP | H 6 | Gradient support compression stocking, below knee, 18-30 mmhg, each | All | N | Purchase | |
L8300 | NU EP | H 6 | Truss, single with standard pad | All | N | Purchase | |
L8310 | NU EP | H 6 | Truss, double with standard pads | All | N | Purchase | |
L8320 | NU EP | H 6 | Truss, addition to standard pad, water pad | All | N | Purchase | |
L8330 | NU EP | H 6 | Truss, addition to standard pad, scrotal pad | All | N | Purchase | |
L8400 | NU EP | H 6 | Prosthetic sheath, below knee, each | All | N | Purchase | |
L8410 | NU EP | H 6 | Prosthetic sheath, above knee, each | All | N | Purchase | |
L8415 | NU EP | H 6 | Prosthetic sheath, upper limb, each | All | N | Purchase | |
L8417 | NU | H | Prosthetic sheath/sock, including a gel cushion layer, below knee or above knee, each | 21+ | N | Purchase | |
L8420 | NU EP | H 6 | Prosthetic sock, multiple ply, below knee, each | All | N | Purchase | |
L8430 | NU EP | H 6 | Prosthetic sock, multiple ply, above knee, each | All | N | Purchase | |
L8435 | NU EP | H 6 | Prosthetic sock, multiple ply upper limb, each | All | N | Purchase | |
L8440 | NU EP | H 6 | Prosthetic shrinker, below knee, each | All | N | Purchase | |
L8460 | NU EP | H 6 | Prosthetic shrinker, above knee, each | All | N | Purchase | |
L8465 | NU EP | H 6 | Prosthetic shrinker, upper limb, each | All | N | Purchase | |
L8470 | NU EP | H 6 | Prosthetic sock, single ply, fitting below knee, each | All | N | Purchase | |
L8480 | NU EP | H 6 | Prosthetic sock, single ply fitting, above knee, each | All | N | Purchase | |
L8485 | NU | H | Prosthetic sock, single ply, fitting, upper limb, each | 21+ | N | Purchase | |
L8499 | NU EP | H 6 | ***(Unlisted Prosthetic Devices or Orthotic Appliances; the manufacturer?s invoice must be attached to all claims.) Unlisted procedure for miscellaneous prosthetic services | All | Y | Manually Priced Manually Priced | |
L8500 | NU EP | H 6 | Artificial larynx, any type | All | N | Purchase | |
L8501 | NU EP | H 6 | Tracheostomy speaking valve | All | N | Purchase | |
L8600 | NU EP | H 6 | Implantable breast prosthesis, silicone or equal | All | N | Manually Priced |
for Individuals Age Two Through Adult
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.
Additionally, when billed on paper, procedure codes found in this section must be billed with a type of service (TOS) code ?6? for individuals under age 21 or TOS code ?H? for individuals age 21 and over.
Modifiers in this section are indicated by the headings M1 and M2. Type of service is indicated by the heading TOS. Prior authorization requirements are shown under the heading PA. If prior authorization is needed, that information is indicated with a ?Y? in the column; if not, an ?N? is shown.
Other coding information found in the chart:
NOTE: Prosthetics providers may continue to use modifier 52 for claims with dates of service through October 31, 2005. Effective for claims with dates of service on and after November 1, 2005, modifier 52 will be replaced with modifier UB.
* The purchase of wheelchairs for individuals age 21 and over is limited to one per five-year period.
** Bill only for TOS code ?6.?
# This procedure code is payable for individuals ages 2 through 20, using TOS code ?6.? 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 another 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.
Specialized Wheelchairs and Wheelchair Seating Systems for Individuals Age Two Through Adult (section 242.191)
Procedure Code | M1 | M2 | TOS | Description | PA | Payment Method |
E0700 | NU EP | U2 U2 | H 6 | ***(Travel restraint auto safe harness, E-Z on vest, no known comparable product) Safety equipment, e.g., belt, harness or vest | N**** | Purchase |
E0950 | NU EP | U7 U7 | H 6 | Wheelchair accessory, tray, each | N | Purchase |
E0950 | NU EP | U2 U2 | H 6 | ***(ABS tray, 4-SM 5-LG) W/C accessory, tray, each | N**** | Purchase |
E0950 | NU EP | U5 U5 | H 6 | ***(Clear upper Ex support system) W/C accessory, tray, each | N**** | Purchase |
E0950 | NU EP | U4 U4 | H 6 | ***(Tray, customized) W/C accessory, tray, each | N | Purchase |
E0950 | NU EP | H 6 | ***(Tray for W/C) W/C accessory, tray, each | N | Purchase | |
E0950 | NU EP UE | U7 U7 | H 6 U | ***(Removable Hinged Overlay for Tray) W/C accessory, tray, each | N**** | Purchase |
E0950 | NU EP | U8 U8 | H 6 | ***(Lap Tray for Switch Array) Wheelchair accessory, tray, each | Y | Purchase |
E0950 | NU EP | U6 U6 | H 6 | ***(Lap Tray Switch Array) Wheelchair accessory, tray, each | N**** | Purchase |
E0950 | NU EP | U3 U3 | H 6 | ***(W/C Tray, Custom) W/C accessory, tray, each | N**** | Purchase |
E0951 | NU EP | H 6 | Heel loop/holder, with or without ankle strap, each | N**** | Purchase | |
E0952 | NU EP | H 6 | Toe loop/holder, each | N**** | Purchase | |
E0953 | NU EP | H 6 | ***(8? x 2? for manual W/C, each, replacement) Pneumatic tire, each | N | Purchase | |
E0954 | NU EP | H 6 | Semi-pneumatic caster, each | N**** | Purchase | |
E0955 | NU EP | H 6 | W/C accessory, headrest, cushioned, prefabricated, w/fixed mounting hardware, each | N | Purchase | |
E0956 | NU EP | H 6 | ***(Trunk supports for any W/C, other than travel, with hardware) W/C accessory, lateral trunk or hip support, prefabricated w/fixed mounting hardware, each | N**** | Purchase | |
E0956 | NU EP | U1 U1 | H 6 | ***(Lateral trunk supports, swing away, ea.) W/C accessory, lateral trunk or hip support, prefabricated w/fixed mounting hardware, each | N**** | Purchase |
E0956 | NU EP | U2 U2 | H 6 | ***(Med. Chest Panel Support) W/C accessory, lateral trunk or hip support, prefabricated w/fixed mounting hardware, each | N**** | Purchase |
E0956 | NU EP | U3 U3 | H 6 | ***(Chest/Thoracic Supports) W/C accessory, lateral trunk or hip support, prefabricated w/fixed mounting hardware, each | N**** | Purchase |
E0957 | NU EP | H 6 | W/C accessory, medial thigh support, prefabricated, w/fixed mounting hardware, each | N | Purchase | |
E0958 | NU EP | H 6 | Manual W/C accessory, one-arm drive attachment, each | N**** | Purchase | |
E0959 | NU EP | U1 U1 | H 6 | Manual W/C accessory, adapter for amputee, each | N | Purchase |
E0959 | NU EP | H 6 | ***(Amputee adapters for conventional chair, ea.) Manual W/C accessory, adapter for amputee, each | N**** | Purchase | |
E0959 | NU EP | H 6 | ***(Amputee axle plate for high performance manual W/C, ea.) Manual W/C accessory, adapter for amputee, each | N**** | Purchase | |
E0960 | NU EP | H 6 | W/C accessory, shoulder harness/straps or chest strap including any type mounting hardware | N | Purchase | |
E0961 | NU EP | H 6 | Manual W/C accessory, wheel lock brake extension (handle), each | N**** | Purchase | |
E0966 | NU EP | H 6 | ***(Headrest/Fixture, O.B., 46-LG 45-SM) Manual W/C accessory, headrest extension, each | N**** | Purchase | |
E0967 | NU EP | H 6 | ***(Hand rim, any type) Manual W/C accessory, hand rim w/projections, any type, replacement only, each | N**** | Purchase | |
E0967 | NU EP | U1 U1 | H 6 | ***(Hand rim, any type) Manual W/C accessory, hand rim w/projections, any type, replacement only, each | N**** | Purchase |
E0967 | NU EP | U2 U2 | H 6 | ***(Hand rim, any type) Manual W/C accessory, hand rim w/projections, any type, replacement only, each | N**** | Purchase |
E0967 | NU EP | U3 U3 | H 6 | ***(Hand rim, any type) Manual W/C accessory, hand rim w/projections, any type, replacement only, each | N**** | Purchase |
E0967 | NU EP | U4 U4 | H 6 | ***(Hand rim, any type) Manual W/C accessory, hand rim w/projections, any type, replacement only, each | N**** | Purchase |
E0970 | NU EP | H 6 | No. 2 footplates, except for elevating legrest | N**** | Purchase | |
E0971 | NU EP | H 6 | Anti-tipping device W/C | N**** | Purchase | |
E0972 | NU EP | U1 U1 | H 6 | ***(Wood transfer board) W/C accessory, transfer board or device, each | N | Purchase |
E0972 | NU EP | H 6 | ***(Plastic transfer board) W/C accessory, transfer board or device, each | N | Purchase | |
E0973 | NU EP | H 6 | W/C accessory, adjustable height, detachable armrest, complete assembly, each | N**** | Purchase | |
E0973 | NU EP | U1 U1 | H 6 | ***(Height Adj. Arms, replacement) W/C accessory, adjustable height, detachable armrest, complete assembly, each | N**** | Purchase |
E0974 | NU EP | H 6 | Manual W/C accessory, anti-rollback device, each | N**** | Purchase | |
E0978 | NU EP | U2 | H 6 | W/C accessory, safety belt/pelvic strap, each | N**** | Purchase |
E0978 | NU EP | U1 | H 6 | ***(Belt, safety or chest, w/pad) W/C accessory, safety belt/ pelvic strap, each | N**** N | Purchase |
E0980 | NU EP | H 6 | ***(Chest panel, 21-SM 22-LG) Safety vest, W/C | N**** | Purchase | |
E0980 | NU EP | U1 U1 | H 6 | ***(Shoulder retractors) Safety vest, W/C | N**** | Purchase |
E0981 | NU EP | H 6 | W/C accessory, seat upholstery, replacement only, each | N | Purchase | |
E0982 | NU EP | U1 U1 | H 6 | ***(Standard back upholstery replacement) W/C accessory, back upholstery, replacement only, each | N**** | Purchase |
E0990 | EP | 6 | ***(Elevating foot, leg rest) W/C accessory, elevating leg rest, complete assembly, each | N**** | Purchase | |
E0990 | NU EP | U1 U1 | H 6 | ***(Elevating Leg Rest 90 Degree, 12" -16" Width) W/C accessory, elevating leg rest, complete assembly, each | N**** | Purchase |
E0992 | NU EP | H 6 | Manual w/c accessory, solid seat insert | N**** | Purchase | |
E0992 | NU EP | U3 U3 | H 6 | ***(Foam & Plywood Seat, MPI Like) Manual w/c access, solid seat insert | N**** | Purchase |
E0992 | NU EP | U2 U2 | H 6 | ***(Foam and Plywood Flat Side) Manual w/c access, solid seat insert | N**** | Purchase |
E0992 | NU EP | U4 U4 | H 6 | ***(Adjustable solid standard seat w/hardware) Manual w/c accessory, solid seat insert | N**** | Purchase |
E0992 | NU EP | U1 U1 | H 6 | AManual w/c accessory, solid seat insert (Large adjustable solid seat w/hardware) | N**** | Purchase |
E0994 | NU EP | H 6 | Armrest, each | N**** | Purchase | |
E1001 | NU | H | Wheel, single | N | Manually Priced | |
E1002 | NU EP | H 6 | W/C accessory, power seating system, tilt only | Y | Purchase | |
E1002 | NU EP | H 6 | W/C accessory power seating system, tilt only | Y* | Purchase | |
E1004 | NU EP | H 6 | W/C accessory, power seat system, recline only, w/mechanical shear reduction | Y | Purchase | |
E1004 | NU EP | H 6 | W/C accessory, power seating system, recline only, with mechanical shear reduction | Y* | Purchase | |
E1006 | NU EP | H 6 | W/C accessory, power seating system, combination tilt and recline, w/o shear reduction | Y | Purchase | |
E1006 | NU EP | U1 U1 | H 6 | ***(Power tilt and recline system with zero sheer) W/C accessory, power seating system, combination tilt and recline, without mechanical shear reduction | Y* | Purchase |
E1010 | NU EP | H 6 | W/C accessory, addition to power seating system, power leg elevation system, including leg rest, each | Y | Purchase | |
E1019 | NU EP | H 6 | W/C accessory, power seating, heavy duty feature, patient weight capacity greater than 250 lbs, and less than or equal to 400 lbs | Y | Purchase | |
E1020 | NU EP | H 6 | ***(Adjustable Contour Lateral Thigh Support) Residual limb support system for W/C | N**** | Purchase | |
E1026 | EP | 6 | ***(Adjustable Contour Back, 10" - 12" Frame) Lateral thoracic support, contoured, for pediatric W/C, each (includes hardware) | N**** | Purchase | |
E1026 | EP | U1 | 6 | ***(Adjustable Contour Back, 14" - 16" Frame) Lateral thoracic support, contoured, for pediatric W/C, each (includes hardware) | N**** | Purchase |
E1029 | NU EP | H 6 | ***(Ventilator Tray Wth Battery Tray) Wheelchair accessory, ventilator tray, fixed | Y | Purchase | |
E1030 | NU EP | H 6 | Wheelchair accessory, ventilator tray, gimbaled | Y | Purchase | |
E1050* | NU EP | H 6 | Full reclining W/C, fixed full-length arms, swing-away, detachable elevating legrests | N**** | Purchase | |
E1060* | NU EP | H 6 | Full reclining W/C, detachable arms, desk or full-length, swing-away detachable, elevating legrests | Y* | Purchase | |
E1065* | NU EP | H 6 | Power attachment (to convert any W/C to motorized W/C, e.g., Solo) | Y* | Purchase | |
E1070# | 6 | ***(A maximum use of three months only) Fully reclining W/C, detachable arms, desk or full-length, swing-away, detachable footrests | Y | Rental only | ||
E1084* | NU EP | H 6 | Hemi-W/C; detachable arms, desk or full-length, swing-away, detachable, elevating leg rests | N**** | Purchase | |
E1086* | NU EP | U1 U1 | H 6 | Hemi W/C, detachable arms, desk or full-length, swing-away detachable footrests | Y* | Purchase |
E1086* | NU EP | H 6 | Hemi W/C; detachable arms, desk or full-length, swing-away, detachable footrests | N**** | Purchase | |
E1088* | NU EP | H 6 | High strength lightweight W/C; detachable arms, desk or full-length, swing-away, detachable, elevating legrests | Y* | Purchase | |
E1090 | NU EP | H 6 | High-strength lightweight W/C; detachable arms, desk or full-length, swing-away, detachable footrests | N**** | Purchase | |
E1091** | EP | UB | 6 | Youth stroller | N**** | Purchase |
E1091 | NU EP | H 6 | Youth positioning stroller | N | Purchase | |
E1091 | NU EP | U1 U1 | H 6 | Youth positioning stroller | N | Manually Priced |
E1092* | NU EP | H 6 | Wide, heavy-duty W/C; detachable arms, desk or full-length, swing-away, detachable, elevating legrests | Y* | Purchase | |
E1093* | NU EP | H 6 | Wide, heavy-duty W/C; detachable arms, desk or full-length arms, swing-away, detachable footrests | Y* | Purchase | |
E1110* | NU EP | H 6 | Semi-reclining W/C; detachable arms, desk or full-length, elevating legrest | Y* | Purchase | |
E1161 | NU EP | H 6 | Manual adult size W/C, includes tilt in space | Y* | Purchase | |
E1170* | NU EP | H 6 | Amputee W/C; fixed full-length arms, swing-away, detachable, elevating legrests | N**** | Purchase | |
E1172* | NU EP | H 6 | Amputee W/C; detachable arms, desk or full-length, without footrests or legrests | Y* | Purchase | |
E1180* | NU EP | H 6 | Amputee W/C; detachable arms, desk or full-length, swing-away, detachable footrests | Y* | Purchase | |
E1200* | NU EP | H 6 | Amputee W/C; fixed full-length arms, swing-away, detachable footrests | N**** * | Purchase | |
E1211* | NU EP | H 6 | Motorized W/C; detachable arms, desk or full-length, swing-away, detachable, elevating legrests | Y* | Purchase | |
E1213* | NU EP | H 6 | Motorized W/C; detachable arms, desk or full-length, swing-away, detachable footrests | Y* | Purchase | |
E1220* | NU EP | H 6 | W/C, specially sized or constructed (indicate brand name, model number, if any, and justification) | Y | Manually Priced | |
E1225 | NU EP | H 6 | ***(Folding Backrest, 8 Degree Bend, Low, 15" - 16") Manual W/C accessory, semi-reclining back, (recline greater than 15 degrees, but less than 80 degrees), each | N**** | Purchase | |
E1226* | NU EP | H 6 | Manual w/c accessory, fully reclining back, each | Y | Purchase | |
E1228 | NU EP | U2 U2 | H 6 | ***(Positioning tall back) Special back height for W/C | N**** | Purchase |
E1228 | NU EP | H 6 | ***(Folding Backrest, Tall, 19" - 20") Special back height for W/C | N**** | Purchase | |
E1228 | NU EP | H 6 | ***(Folding Straight Backrest, Low, (15" -16") Special back height for W/C | N**** | Purchase | |
E1228 | NU EP | H 6 | ***(Folding Straight Backrest, Tall, 19" -20") Special back height for W/C | N**** | Purchase | |
E1228 | NU EP | U1 U1 | H 6 | ***(High back contour seat) Special back height for W/C | N**** | Purchase |
E1230* | NU EP | H 6 | Power operated vehicle (three- or four-wheel nonhighway), specify brand name and model number | Y* | Purchase | |
E1232* | EP | 6 | W/C, pediatric size, tilt-in-space, folding, adjustable, with seating system | Y* | Purchase | |
E1233* | EP | 6 | W/C, pediatric size, tilt-in-space, rigid, adjustable, without seating system | Y* | Purchase | |
E1234* | EP | 6 | W/C, pediatric size, tilt-in-space, folding, adjustable, without seating system | Y* | Purchase | |
E1235* | NU EP | H 6 | W/C, pediatric size, rigid, adjustable, with seating system | Y* | Purchase | |
E1235 | NU EP | H 6 | ***(Snug Seat I Mobility System) W/C, pediatric size, rigid, adjustable, with seating system | Y* | Purchase | |
E12351,2 | EP | U1 U1 | 6 | ***(Rigid W/C Frame) W/C, pediatric size, rigid, adjustable with seating system | Y | Purchase |
E1236 | EP | 6 | Wheelchair, pediatric size, folding, adjustable, with seating system | Y | Purchase | |
E1237* | NU EP | H 6 | W/C, pediatric size, rigid, adjustable, without seating system | Y* | Purchase | |
E1238* | NU EP | H 6 | W/C, pediatric size, folding, adjustable, without seating system | Y* | Purchase | |
E1240* | NU EP | H 6 | Lightweight W/C; detachable arms, desk or full-length, swing-away, detachable, elevating legrest | Y* | Purchase | |
E1260* | NU EP | H 6 | Lightweight W/C; detachable arms, desk or full-length, swing-away, detachable footrests | N**** | Purchase | |
E1280* | NU EP | H 6 | Heavy-duty W/C; detachable arms, desk or full-length, elevating legrests | Y* | Purchase | |
E1290* | NU EP | H 6 | Heavy-duty W/C; detachable arms, swing-away, detachable footrests | Y* | Purchase | |
E1340 | NU EP | U1 U1 | H 6 | ***(Labor Only; a maximum of twenty [20] units [20 units = 5 hours of labor] per date of service is allowable.) Repair or nonroutine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes | Y | Manually Priced |
E1340 | NU EP | U3 U3 | H 6 | ***(Unlisted Repairs/Parts Only Wheelchairs; applicable pages from the manufacturer?s catalog must be attached to the claim form.) Repair or nonroutine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes | N**** | Manually Priced |
E2201 | NU EP | U3 U3 | H 6 | Manual w/c accessory, nonstandard seat frame width [GREATER THAN] than or equal to 20 inches and [LESS THAN]24 inches | N**** | Manually Priced |
E2201 | NU EP | U1 U1 | H 6 | ***(Frame Width 14"-15") Manual w/c accessory, nonstandard seat frame width[GREATER THAN]than or equal to 20 inches and [LESS THAN]24 inches | N**** | Manually Priced (21+) Purchase |
E2201 | NU EP | U2 U2 | H 6 | ***(Frame Wdth 19"-20") Manual w/c accessory, nonstandard seat frame width[GREATER THAN]than or equal to 20 inches and [LESS THAN]24 inches | N**** | Manually Priced (21+) Purchase |
E2201 | NU EP | H 6 | ***(Seat Wdth 20") Manual w/c accessory, nonstandard seat frame width [GREATER THAN] than or equal to 20 inches and [LESS THAN] 24 inches | N**** | Manually Priced Purchase | |
E2203 | NU EP | U4 U4 | H 6 | Manual w/c accessory, nonstandard seat frame depth, 20 to less than 22 inches | N | Manually Priced Purchase |
E2203 | NU EP | U2 U2 | H 6 | ***(Frame, Long; 16", 17"3, 18", 19"3, 20" Depth) Manual w/c accessory, nonstandard seat frame depth, 20 to less than 22 inches | N**** | Manually Priced (21+) Purchase |
E2203 | NU EP | U3 U3 | H 6 | ***(Seat Depth 19" - 20") Manual w/c accessory, nonstandard seat frame depth, 20 to less than 22 inches | N**** | Manually Priced Purchase |
E2203 | NU EP | H 6 | ***(Seat Depth 15") Manual w/c accessory, nonstandard seat frame depth, 20 to less than 22 inches | N**** | Manually Priced Purchase | |
E2203 | NU EP | U1 U1 | H 6 | ***(Seat Depth 17" - 18") Manual w/c accessory, nonstandard seat frame depth, 20 to less than 22 inches | N**** | Manually Priced Purchase |
E2206 | NU EP | H 6 | Manual wheelchair accessory, wheel lock assembly, complete, each | N | Purchase | |
E2291 | EP | 6 | Back, planar, for pediatric-size wheelchair, including fixed attaching hardware | N | Purchase | |
E2292 | EP | 6 | Seat, planar, for pediatric-size wheelchair, including fixed attaching hardware | N | Purchase | |
E2293 | NU EP | H 6 | Back, contoured, for pediatric-size wheelchair, including fixed attaching hardware | N | Purchase | |
E2294 | NU EP | H 6 | Seat, contoured, for pediatric-size wheelchair, including fixed attaching hardware | N | Purchase | |
E2310 | NU EP | H 6 | Power w/c accessory, electronic connection between wheelchair controller and one power seating system motor, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware | Y | Purchase | |
E2311 | NU EP | H 6 | Power w/c accessory, electronic 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 | Y | Purchase | |
E2320 | NU EP | H 6 | Power w/c accessory, hand or chin control interface, remote joystick or touchpad, proportional, including all related electronics and fixed mounting hardware | Y | Purchase | |
E2322 | NU EP | H 6 | Power w/c accessory, hand control interface, multiple mechanical switches, nonproportional, including all related electronics, mechanical stop switch, and fixed mounting hardware | Y | Purchase | |
E2323 | NU EP | H 6 | Power w/c accessory, specialty joystick handle for hand control interface, prefabricated | N | Purchase | |
E2324 | NU EP | H 6 | Power w/c accessory, chin cup for chin control interface | N | Purchase | |
E2325 | NU EP | H 6 | Power w/c accessory, sip & puff interface nonproportional, including all related electronics, mechanical stop switch, and manual swingaway mounting hardware | Y | Purchase | |
E2326 | NU EP | H 6 | Power w/c accessory, breath tube kit for sip & puff interface | Y | Purchase | |
E2327 | NU EP | H 6 | Power w/c accessory, head control interface, mechanical, proportional, including all related electronics, mechanical direction change switch, and fixed mounting hardware | Y | Purchase | |
E2360 | NU EP | H 6 | Power w/c accessory, 22 NF non-sealed lead acid battery, each | N | Purchase | |
E2361 | NU EP | H 6 | Power w/c accessory, 22 NF sealed lead acid battery, each, (e.g., gel cell, absorbed glassmat) | N | Purchase | |
E2362 | NU EP | H 6 | Power wheelchair accessory, group 24 non-sealed lead acid battery, each | N | Purchase | |
E2363 | EP | 6 | ***(Group 24 Gel Batteries) Power W/C accessory, group 24 sealed lead acid battery, each, e.g., gel cell, absorbed glassmat | N**** | Purchase | |
E2363 | NU EP | H 6 | Power w/c accessory, group 24 sealed lead acid battery, each (e.g., gel cell, absorbed glassmat) | N | Purchase | |
E2363 | NU EP | U1 U1 | H 6 | Power w/c accessory, group 24 sealed lead acid battery, each (e.g., gel cell, absorbed glassmat) | N | Purchase |
E2364 | NU EP | H 6 | Power wheelchair accessory, U-1 non-sealed lead acid battery, each | N | Purchase | |
E2365 | NU EP | H 6 | ***(U-1 gel cell battery, each) Power wheelchair accessory, U-1 sealed lead acid battery, each, (e.g., gel cell, absorbed glassmat) | N | Purchase | |
E2365 | NU EP | H 6 | Power w/c accessory, U-1 sealed lead acid battery, each, gel cell | N | Purchase | |
E2365 | NU EP | U1 U1 | H 6 | Power w/c accessory, U-1 sealed lead acid battery, each, gel cell | N | Purchase |
E2366 | NU EP | H 6 | ***(24-Volt Battery Charger - Standard, Replacement) Power w/c accessory, battery charger, single mode, for use with only one battery type, sealed or non-sealed, each | N | Purchase | |
E2367 | NU EP | H 6 | ***(24-Volt Battery Charger - Dual Mode, Replacement) Power w/c accessory, battery charger, dual mode, sealed or non-sealed, each | N | Purchase | |
E2368 | NU EP | H 6 | Power wheelchair component, motor, replacement only | N | Purchase | |
E2369 | NU EP | H 6 | Power wheelchair component, gear box, replacement only | N | Purchase | |
E2601 | NU EP UE | H 6 H | General use wheelchair seat cushion, width less than 22 in., any depth | N | Purchase | |
E2602 | NU EP UE | H 6 H | General use wheelchair seat cushion, width 22 in. or greater, any depth | N | Purchase | |
E2611 | NU EP UE | H 6 H | General use wheelchair back cushion, width less than 22 in., any height, including any type mounting hardware | N | Purchase | |
E2612 | NU EP UE | H 6 H | General use wheelchair back cushion, width 22 in. or greater, any height, including any type mounting hardware | N | Purchase | |
E2618 | NU EP | H 6 | Wheelchair accessory, solid seat support base (replaces sling seat), for use with manual wheelchair or lightweight power wheelchair, including any type mounting hardware | N | Manually Priced | |
E2619 | NU EP | H 6 | Replacement cover for wheelchair seat cushion or back cushion, each | N | Purchase | |
E2620 | NU | H | Positioning wheelchair back cushion, planar back with lateral supports, width less than 22 in., any height, including any type mounting hardware | N**** | Purchase | |
E2621 | NU | H | Positioning wheelchair back cushion, planar back with lateral supports, width 22 in. or greater, any height, including any type mounting hardware | N**** | Purchase | |
K0004 | NU EP | H 6 | High-strength lightweight wheelchair | Y**** | Purchase | |
K0005* | NU EP | H 6 | ***(High-performance manual W/C-adult) Ultralightweight W/C | Y* | Purchase | |
K0005* | NU EP | U1 U1 | H 6 | ***(High-performance manual W/C with growth adjustability-child) Ultralightweight W/C | Y* | Purchase |
K0010 | NU EP | H 6 | ***(Motorized, standard frame, DA, swing away footrests) Standard weight frame motorized/power W/C | Y* | Purchase | |
K0010 | NU EP | U1 U1 | H 6 | ***(Motorized, standard frame, DA, swing away ELR) Standard weight frame motorized/power W/C | Y* | Purchase |
K0011 | NU EP | H 6 | ***(Motorized, power base or 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 | Y* | Purchase | |
K0011 | NU EP | U1 U1 | H 6 | ***(Motorized, power base or 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 | Y* | Purchase |
K0012 | NU EP | H 6 | ***(Motorized folding frame, DA, swing away footrests) Lightweight portable motorized/power W/C | Y* | Purchase | |
K0012 | NU EP | U1 U1 | H 6 | ***(Motorized folding frame, DA, swing away ELR) Lightweight portable motorized/power W/C | Y* | Purchase |
K00141,2 | NU EP | U1 U1 | H 6 | ***(Center Drive power base) Other motorized/ power W/C base | Y | Purchase |
K0017 | NU EP | U1 U1 | H 6 | ***(Dual post and adjustable height DA) Detachable, adjustable height armrest, base, each | N**** | Purchase |
K0017 | NU EP | H 6 | ***(Receiver for height adj. arms, replacement) Detachable, adjustable height armrest, base, each | N**** | Purchase | |
K0019 | NU EP | H 6 | Arm pad, each | N | Purchase | |
K0020 | NU EP | H 6 | Fixed, adjustable height armrest, pair | N**** | Purchase | |
K0038 | NU EP | H 6 | ***(Single leg strap, each) Leg strap, each | N**** | Purchase | |
K0038 | NU EP | U2 U2 | H 6 | ***(Foot straps, pair) Leg strap, each | N**** | Purchase |
K0038** | EP | U1 | 6 | ***(Knee strap) Leg strap, each | N | Purchase |
K0039 | NU EP | H 6 | Leg strap, H style, each | N**** | Purchase | |
K0040 | NU EP | H 6 | Adjustable angle footplate, each | N**** | Purchase | |
K0043 | NU EP | H 6 | ***(SWFR, replacement) Footrest, lower extension tube, each | N | Purchase | |
K0044 | NU EP | H 6 | ***(SWFR Hanger bracket, replacement) Footrest, upper hanger bracket, each | N**** | Purchase | |
K0045 | NU EP | H 6 | ***(Padded custom foot box) Footrest, complete assembly | N**** | Purchase | |
K0047 | NU EP | H 6 | Elevating legrest, upper hanger bracket, each | N**** | Purchase | |
K0056 | NU EP | H 6 | Seat height less than 17 inches or equal to or greater than 21 inches for a high-strength, lightweight, or ultralightweight W/C | N**** | Manually Priced | |
K0056 | NU EP | U1 U1 | H 6 | ***(Seat height 19.5"5) Seat height less than 17 inches or equal to or greater than 21 inches for a high strength, lightweight or ultralightweight W/C | N**** | Purchase |
K0064 | NU EP | H 6 | ***(Zero pressure tube or wheel insert, each, rear wheels) Zero pressure tube (flat free insert), any size, each | N**** | Purchase | |
K0064 | NU EP | U1 U1 | H 6 | ***(12? or 14? flat free insert for power base, ea.) Zero pressure tube (flat free insert), any size, each | N**** | Purchase |
K0065 | NU EP | H 6 | Spoke protectors, each | N**** | Purchase | |
K0066 | NU EP | H 6 | ***(20-26? Tires for manual W/C, ea., replacement) Solid tire, any size, each | N | Purchase | |
K0067 | NU EP | H 6 | ***(Pneumatic Caster 8 X 2 with Airless Insert) Pneumatic tire, any size | N**** | Purchase | |
K0068 | NU EP | H 6 | ***(20-26? for manual W/C, ea., replacement) Pneumatic tire tube, each | N | Purchase | |
K0070 | NU EP | H 6 | ***(Wheel assembly, complete with pneumatic tires, 20?/22?/24?/26?/ea. replacement) Rear wheel assembly, complete with pneumatic tire, spokes or molded, each | N**** | Purchase | |
K0071 | NU EP | U1 U1 | H 6 | ***(Wheel assembly with pneumatic tires, 22?, pair, rear wheels) Front caster assembly, complete, with pneumatic tire, each | N**** | Purchase |
K0071 | NU EP | H 6 | ***(Polyeurethane casters, 5?, pair, front casters) Front caster assembly, complete, with pneumatic tire, each | N**** | Purchase | |
K0072 | NU EP | H 6 | ***(Polyeurethane casters, 5?, pair, front casters) Front caster assembly, complete, with semipneumatic tire, each | N**** | Purchase | |
K0073 | NU EP | H 6 | Caster pin lock, each | N**** | Purchase | |
K0074 | NU EP | H 6 | ***(Pneumatic casters 8 x 1 1/4?, each, front casters) Pneumatic caster tire, any size each | N**** | Purchase | |
K0074 | NU EP | H 6 | ***(Pneumatic casters 8 x 1 1/4?, each, front casters) Pneumatic caster tire, any size each | N**** | Purchase | |
K0074 | NU EP | U2 U2 | H 6 | ***(9 x 2 3/4? pneumatic caster for power base W/C) Pneumatic caster tire, any size each | N**** | Purchase |
K0074 | NU EP | U1 U1 | H 6 | ***(6?-8? tires for manual W/C, ea., replacement) Pneumatic caster tire, any size, each | N | Purchase |
K0074 | NU EP | U3 U3 | H 6 | ***(Pneumatic Caster 8 X 2) Pneumatic caster tire, any size, each | N**** | Purchase |
K0075 | NU EP | H 6 | Semipneumatic caster tire, any size, each | N | Purchase | |
K0076 | NU EP | U1 U1 | H 6 | ***(10? x 3? Rear Wheel for Power W/C, ea., replacement) Solid caster tire, any size, each | N | Purchase |
K0076 | NU EP | H 6 | ***(9? x 3? Caster Tire for Power W/C, ea., replacement) Solid caster tire, any size, each | N | Purchase | |
K0076 | NU EP | U2 U2 | H 6 | ***(Polyurethane 5?, replacement) Solid caster tire, any size, each | N**** | Purchase |
K0077 | NU EP | H 6 | Front caster assembly, complete, with solid tire, each | N | Purchase | |
K0078 | NU EP | H 6 | ***(6?-8? for manual W/C, each, replacement) Pneumatic caster tire tube, each | N | Purchase | |
K0078 | NU EP | U1 U1 | H 6 | APneumatic caster tire tube, each | N | Purchase |
K0078 | NU EP | U2 U2 | H 6 | ***(9? x 3? for Power W/C, ea., replacement) Pneumatic caster tire tube, each | N | Purchase |
K0091 | NU EP | U1 U1 | H 6 | ***(20? x 2 1/8? tubes for power W/C, ea., replacement) Rear wheel tire tube other than zero pressure for power W/C, any size, each | N | Purchase |
K0091 | NU EP | H 6 | ***(10? x 3? Rear Wheel Caster Tube for Power W/C, ea., replacement) Rear wheel tire tube other than zero pressure for power W/C, any size, each | N | Purchase | |
K0092 | NU EP | H 6 | Rear wheel assembly for power wheelchair, complete, each | N | Purchase | |
K0093 | NU EP | H 6 | ***(Zero pressure insert for rear wheel for power w/c, ea.) Rear wheel zero pressure tire tube (flat free insert) for power W/C any size, each | N**** | Purchase | |
K0093 | NU EP | U1 U1 | H 6 | ***(Mag. Airless Insert, Drive Wheel) Rear wheel zero pressure tire tube (flat free insert) for power W/C, any size, each | N**** | Purchase |
K0094 | NU EP | H 6 | ***(20? x 2 1/8? replacement) Wheel tire for power base, any size, each | N | Purchase | |
K0097 | NU EP | H 6 | Wheel, zero pressure tire tube (flat free insert) for power base, any size, each | N**** | Purchase | |
K0099 | NU EP | H 6 | ***(9 x 2 3/4? foam filled caster for power base W/C) Front caster for power W/C | N**** | Purchase | |
K0102 | NU EP | H 6 | Crutch and cane holder, each | N**** | Purchase | |
K0104 | NU EP | H 6 | Cylinder tank carrier, each | N | Purchase | |
K0106 | NU EP | H 6 | Arm trough, each | N**** | Purchase | |
K0108 | NU EP | H 6 | ***(W/C miscellaneous equipment; applicable pages from the manufacturer?s catalog must be attached to the claim form.) Other accessories | N**** | Manually Priced | |
K0195 | NU EP | H 6 | Elevating legrest, pair (for use with capped rental wheelchair base) | N | Rental Only | |
K0452 | NU EP | U1 U1 | H 6 | ***(Rear Wheel Stem, replacement) W/C bearings, any type | N | Purchase |
K0452 | NU EP | H 6 | ***(Caster Bearing, replacement) W/C bearings, any type | N | Purchase | |
K0452 | NU EP | U2 U2 | H 6 | ***(Power Base Wheel Bearing, replacement) W/C bearings, any type | N**** | Purchase |
S1002 | NU EP | H 6 | ***(Wheelchair, custom molded seating system only) Customized item, list in addition to code for basic item | N**** | Manually Priced | |
S1002 | NU EP | U1 U1 | H 6 | ***(Foam-in-place seat, Pindot quick foam contour system) Customized item, list in addition to code for basic item | N**** | Manually Priced |
The following procedure codes may only be billed on paper.
Specialized Wheelchairs and Wheelchair Seating Systems for Individuals Age Two Through Adult (section 242.191)
No National Code | M1 | M2 | TOS | Local Code | Description | PA | Payment Method |
Bill on paper | H 6 | Z1613 | One-piece footboard (each) | N**** | Purchase | ||
Bill on paper | H 6 | Z1663 | Group 27 deep cycle battery (each) | N | Purchase | ||
Bill on paper | H 6 | Z1785 | W/C Mounting Kit, O.B. | N**** | Purchase | ||
Bill on paper | H 6 | Z1789 | Custom Headrest | N**** | Purchase | ||
Bill on paper | H 6 | Z1793 | Custom foot platform | N**** | Purchase | ||
Bill on paper | 6 | Z1824** | PC Car Seat/Snug Seat | Y | Purchase | ||
Bill on paper | H 6 | Z2137 | Adjustable Rem. Abductor w/hardware (ea) | N**** | Purchase | ||
Bill on paper | H 6 | Z2138 | Adjustable Flip Down Abductor w/hardware (ea) | N**** | Purchase | ||
Bill on paper | H 6 | Z2139 | Lateral Hip/Thigh support w/hardware (ea) | N**** | Purchase | ||
Bill on paper | H 6 | Z2140 | Adductor - no hardware | N**** | Purchase | ||
Bill on paper | H 6 | Z2141 | Abductor - no hardware | N**** | Purchase | ||
Bill on paper | H 6 | Z2142 | Hip guides - no hardware | N | Purchase | ||
Bill on paper | H 6 | Z2143 | Fluid supplement | N | Purchase | ||
Bill on paper | H 6 | Z2145 | Laterals - no hardware | N**** | Purchase | ||
Bill on paper | H 6 | Z2159 | Fluid Flo-lite pad (Replacement) | N | Purchase | ||
Bill on paper | H 6 | Z2175 | Power W/C Sleeve Top or Bottom Stem Bearing (Replacement) | N**** | Purchase | ||
Bill on paper | H 6 | Z2178 | SWFR Pivot Saddle (Replacement) | N | Purchase | ||
Bill on paper | H 6 | Z2180 | SWFR Latch Block (Replacement) | N | Purchase | ||
Bill on paper | H 6 | Z2181 | SWFR Composite Foot Plate (Replacement) | N**** | Purchase | ||
Bill on paper | H 6 | Z2183 | Shoe Holders S/M/L/XL | N**** | Purchase | ||
Bill on paper | H 6 | Z2184 | X-Tube Assembly Folding W/C (Replacement) | N**** | Purchase | ||
Bill on paper | H 6 | Z2185 | Rigid Wheelchair Growth Kit | N | Purchase | ||
Bill on paper | H 6 | Z2186 | Rigid Side Guard | N**** | Purchase | ||
Bill on paper | H 6 | Z2187 | Fabric Side Guard | N**** | Purchase | ||
Bill on paper | H 6 | Z2188 | Sub Occipital Three Piece Head Set W/REM Hardware | N**** | Purchase | ||
Bill on paper | H 6 | Z2189 | Forehead Strap System | N**** | Purchase | ||
Bill on paper | H 6 | Z2190 | Regular Links | N**** | Purchase | ||
Bill on paper | H 6 | Z2192 | Pneumatic or Semi Casters (Replacement) 8 x 1 1/4 (ea) or 8 x 1 3/4 (ea) | N**** | Purchase | ||
Bill on paper | H 6 | Z2196 | Swing Away Adj. Stroller Handles | N**** | Purchase | ||
Bill on paper | H 6 | Z2200 | Support Fixture for Head Rest | N**** | Purchase | ||
Bill on paper | H 6 | Z2202 | Lg. Chest Panel Support | N**** | Purchase | ||
Bill on paper | H 6 | Z2203 | Elbow Block w/Bracket | N**** | Purchase | ||
Bill on paper | H 6 | Z2554 | Swing Away Retractable Joystick Mount | N**** | Purchase | ||
Bill on paper | H 6 | Z2571 | Power Elevating Leg Rest With Calf Pads | N**** | Purchase | ||
Bill on paper | H 6 | Z2582 | Quick Release Axle | N**** | Purchase | ||
Bill on paper | H 6 | Z2585 | Growing Seat Pan | N**** | Purchase | ||
Bill on paper | H | Z2586 | Growing Back Upholstery | N**** | Purchase | ||
Bill on paper | H 6 | Z2588 | Deep Contour Back 20" Width | N**** | Purchase | ||
Bill on paper | H 6 | Z2589 | Adjustable Contour Lateral Pelvic Support | N**** | Purchase | ||
Bill on paper | H 6 | Z25911 | Heavy Duty Motor Pack 350 Pounds | N | Purchase | ||
Bill on paper | H 6 | Z2592 | Remote Joystick Module | N**** | Purchase | ||
Bill on paper | H | Z2596 | Adjustable Contour Seat Attaching Hardware | N**** | Purchase | ||
Bill on paper | H 6 | Z2599 | Transit Option | N**** | Purchase | ||
Bill on paper | H 6 | Z2604 | Adjustable Back Upholstery | N**** | Purchase | ||
Bill on paper | H 6 | Z2607 | Lateral/Posterior Pelvic Support | N**** | Purchase | ||
Bill on paper | H 6 | Z2608 | Shoulder Harness Guide Kit | N**** | Purchase | ||
Bill on paper | H 6 | Z2609 | Universal Head Rest Kit | N**** | Purchase | ||
Bill on paper | H 6 | Z2615 | Remote Joystick With 1/8" Jacks | N**** | Purchase | ||
Bill on paper | H 6 | Z2616 | Swing Away Mount (Joystick) | N**** | Purchase |
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.
Additionally, when billed on paper, procedure codes must be billed with a type of service (TOS) code ?6? for individuals under 21 years of age or TOS code ?H? for individuals age 21 or over.
Modifiers in this section are indicated by the headings M1 and M2. Type of service is indicated by the heading TOS. Prior authorization requirements are shown under the heading PA. If prior authorization is needed, that information is indicated with a ?Y? in the column; if not, an ?N? is shown.
NOTE: Prosthetics providers may continue to use modifier 52 for claims with dates of service through October 31, 2005. Effective for claims with dates of service on and after November 1, 2005, modifier 52 will be replaced with modifier UB.
** Indicates that providers may bill only for individuals under age 21.
* Prior authorization is not required when another 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.
Specialized Rehabilitative Equipment, All Ages (section 242.192)
Procedure Code | M1 | M2 | TOS | Description | PA | Payment Method |
E0149 | NU EP | H 6 | ***(4 Wheel Reverse Walker) Walker, heavy duty, wheeled, rigid or folding, any type | N | Purchase | |
E0163 | EP | 6 | ***(Potty Chair - Sm) Commode chair, stationary, with fixed arms | Y | Purchase | |
E0166 | EP | U1 | 6 | ***(Potty Chair - Lg) Commode chair, mobile, with detachable arms | Y | Purchase |
E0168 | NU | U1 | H | ***(Rehab Shower/Commode Chair) Commode chair, extra wide and/or heavy duty, stationary or mobile, with or without arms, any type, each | Y* | Purchase |
E0168 | EP | 6 | ***(Rehab Shower/Commode Chair) Commode chair, extra wide and/or heavy duty, stationary or mobile, with or without arms, any type, each | Y* | Purchase | |
E0168 | NU | H | ***(Adaptive Commode Chair) Commode chair, extra wide and/or heavy duty, stationary or mobile, with or without arms, any type, each | N | Purchase | |
E0168 | EP | UB | 6 | ***(Adaptive Commode Chair) Commode chair, extra wide and/or heavy duty, stationary or mobile, with or without arms, any type, each | N | Purchase |
E0241 | NU EP | H 6 | ***(Bolt-on Sm. Grab Bar) Bathroom wall rail, each | N | Purchase | |
E0241 | NU EP | U1 U1 | H 6 | ***(Bolt-on Lg. Grab Bar) Bathroom wall rail, each | N | Purchase |
E0241 | NU EP | U2 U2 | H 6 | ***(Bolt-on Med. Grab Bar) Bathroom wall rail, each | N | Purchase |
E0245 | NU EP | U3 U3 | H 6 | ***(30? Bath Chair) Tub stool or bench | N | Purchase |
E0245 | NU EP | U4 U4 | H 6 | ***(38? Bath Chair) Tub stool or bench | N | Purchase |
E0245 | NU EP | U5 U5 | H 6 | ***(47? Bath Chair) Tub stool or bench | N | Purchase |
E0245 | NU EP | U6 U6 | H 6 | ***(56? Bath Chair) Tub stool or bench | N | Purchase |
E0245 | NU EP | U2 U2 | H 6 | ***(Padded Tub Transfer Bench) Tub stool or bench | N | Purchase |
E0245 | NU EP | UB UB | H 6 | ***(Non-padded tub transfer bench) Tub stool or bench | N | Purchase |
E0245 | NU EP | H 6 | ***(Adj. Bath Chair w/Back) Tub stool or bench | N | Purchase | |
E0246 | NU EP | H 6 | ***(Clamp-on Tub Grab Bar) Transfer tub rail attachment | N | Purchase | |
E0638 | NU EP | H 6 | Standing frame system, any size, with or without wheels | Y | Purchase | |
E0638 | EP EP | U1 U2 | 6 6 | Standing frame system, any size, with or without wheels | Y | Purchase |
E0700 | NU EP | H 6 | ***(Chin Guard for Safety Helmet, sm) Safety equipment, e.g., belt, harness or vest | N | Purchase | |
E0701 | NU EP | H 6 | ***(Soft Shell Helmets) Helmet with face guard and soft interface material, prefabricated | N | Purchase | |
E0701 | NU EP | U1 | H 6 | ***(Hard Shell Helmets) Helmet with face guard and soft interface material, prefabricated | N | Purchase |
E0701 | NU EP | U2 U2 | H 6 | ***(Face guard for safety helmet) Helmet with face guard and soft interface material, prefabricated | N | Purchase |
E0950 | NU EP | U1 U1 | H 6 | ***(Tray for gait trainer) Wheelchair accessory, tray, each | N | Purchase |
E1031** | EP | U5 | 6 | ***(Low Back Activity Chair) Rollabout chair, any and all types with casters five inches or greater | N | Purchase |
E1031** | EP | 6 | ***(Transition Toddler Chair - Sm.) Rollabout chair, any and all types with casters five inches or greater | N | Purchase | |
E1031** | EP | 6 | ***(Transition Toddler Chair - Lg.) Rollabout chair, any and all types with casters five inches or greater | Y | Purchase | |
E1031** | EP | U1 | 6 | ***(Corner Chair w/Tray & Casters - Sm.) Rollabout chair, any and all types with casters five inches or greater | N | Purchase |
E1031** | EP | U3 | 6 | ***(Corner Chair w/Tray & Casters - Lg.) Rollabout chair, any and all types with casters five inches or greater | N | Purchase |
E1031** | EP | U4 | 6 | ***(Bolster Chair w/Tray, Chest Support & Casters - Sm.) Rollabout chair, any and all types with casters five inches or greater | N | Purchase |
E1035** | EP | 6 | A(Carrie Seat - Pre School) Multi-positional patient transfer system, with integrated seat, operated by care giver | Y | Purchase | |
E1035** | EP | U1 | 6 | ***(Carrie Seat - Elementary) Multi-positional patient transfer system, with integrated seat, operated by care giver | Y | Purchase |
E1035** | EP | U2 | 6 | ***(Carrie Seat - Jr.) Multi-positional patient transfer system, with integrated seat, operated by care giver | Y | Purchase |
E1035 | NU EP | U3 U3 | H 6 | ***(Carrie Seat - Sm. Adult) Multi-positional patient transfer system, with integrated seat, operated by care giver | Y* | Purchase |
E8000 | EP | 6 | ***(14?) Gait trainer, pediatric size, posterior support, includes all accessories and components | Y | Purchase | |
E8000 | EP | U1 | 6 | ***(19?) Gait trainer, pediatric size, posterior support, includes all accessories and components | Y | Purchase |
E8000 | EP | U2 | 6 | ***(Intermediate) Gait trainer, pediatric size, posterior support, includes all accessories and components | Y | Purchase |
E8001 | EP | 6 | ***(14?) Gait trainer, pediatric size, upright support, includes all accessories and components | Y | Purchase | |
E8001 | EP | U1 | 6 | ***(19?) Gait trainer, pediatric size, upright support, includes all accessories and components | Y | Purchase |
E8001 | EP | U2 | 6 | ***(Intermediate) Gait trainer, pediatric size, upright support, includes all accessories and components | Y | Purchase |
E8002 | EP | 6 | ***(14?) Gait trainer, pediatric size, anterior support, includes all accessories and components | Y | Purchase | |
E8002 | EP | U1 | 6 | ***(19?) Gait trainer, pediatric size, anterior support, includes all accessories and components | Y | Purchase |
E8002 | EP | U2 | 6 | ***(Intermediate) Gait trainer, pediatric size, anterior support, includes all accessories and components | Y | Purchase |
The following list of codes may only be billed on paper.
Specialized Rehabilitative Equipment, All Ages (section 242.192)
No National Code | M1 | M2 | TOS | Local Code | Description | PA | Payment Method |
Bill on paper | H 6 | Z1996 | Sm. 51? Supine Stander | Y* | Purchase | ||
Bill on paper | H 6 | Z1997 | Lg. 71? Supine Stander | Y* | Purchase | ||
Bill on paper | 6 | Z1998** | 27? Prone Stander | Y | Purchase | ||
Bill on paper | 6 | Z2000** | 42? Prone Stander | Y* | Purchase | ||
Bill on paper | H 6 | Z2001 | 50? Prone Stander | Y* | Purchase | ||
Bill on paper | H 6 | Z2002 | Adj. Abduction Wedge w/hip stabilizer | N | Purchase | ||
Bill on paper | H 6 | Z2003 | Tray for Stander-Prone | N | Purchase | ||
Bill on paper | H 6 | Z2004 | Tray for Stander-Supine | N | Purchase | ||
Bill on paper | H 6 | Z2005 | Foot Sandals for Standers | N | Purchase | ||
Bill on paper | 6 | Z2006** | Up Rite Stander - Sm. | Y | Purchase | ||
Bill on paper | 6 | Z2007** | Up Rite Stander - Med. | Y | Purchase | ||
Bill on paper | H 6 | Z2008 | Up Rite Stander - Lg. | Y | Purchase | ||
Bill on paper | H 6 | Z2009 | Caster Base for Up Rite Stander -Sm. | N | Purchase | ||
Bill on paper | H 6 | Z2010 | Caster Base for Up Rite Stander -Med. | N | Purchase | ||
Bill on paper | H 6 | Z2011 | Caster Base for Up Rite Stander -Lg. | N | Purchase | ||
Bill on paper | 6 | Z2012** | Tumble Form Tri Stander w/Tray -Sm. | Y* | Purchase | ||
Bill on paper | 6 | Z2013** | Tumble Form Tri Stander w/Tray -Lg. | Y* | Purchase | ||
Bill on paper | 6 | Z2015** | 48? Side Lyer | N | Purchase | ||
Bill on paper | 6 | Z2016** | 72? Side Lyer | N | Purchase | ||
Bill on paper | 6 | Z2017** | Tumble Form Feeder Seat - Sm. | N | Purchase | ||
Bill on paper | H 6 | Z2018** | Tumble Form Feeder Seat - Med. | N | Purchase | ||
Bill on paper | 6 | Z2019** | Tumble Form Feeder Seat - Lg. | N | Purchase | ||
Bill on paper | 6 | Z2020** | Floor Sitter Wedge | N | Purchase | ||
Bill on paper | 6 | Z2021** | Mobile Floor Sitter Med/Lg. | N | Purchase | ||
Bill on paper | 6 | Z2022** | Tumble Form Therapy Wedge 4? -Sm. | N | Purchase | ||
Bill on paper | 6 | Z2023** | Tumble Form Therapy Wedge 6? -Sm. | N | Purchase | ||
Bill on paper | 6 | Z2026** | Tumble Form Therapy Wedge 8? -Med. | N | Purchase | ||
Bill on paper | 6 | Z2029** | Tumble Form Therapy Wedge 10? - Lg. | N | Purchase | ||
Bill on paper | 6 | Z2030** | Tumble Form Therapy Rolls 4? | N | Purchase | ||
Bill on paper | 6 | Z2031** | Tumble Form Therapy Rolls 6? | N | Purchase | ||
Bill on paper | 6 | Z2032** | Tumble Form Therapy Rolls 8? | N | Purchase | ||
Bill on paper | 6 | Z2034** | Tumble Form Therapy Rolls 12? | N | Purchase | ||
Bill on paper | 6 | Z2035** | Tumble Form Therapy Rolls 14? | N | Purchase | ||
Bill on paper | 6 | Z2036** | Tumble Form Therapy Rolls 16? | N | Purchase | ||
Bill on paper | 6 | Z2038** | Therapy Ball - Sm. | N | Purchase | ||
Bill on paper | 6 | Z2039** | Therapy Ball - Med. | N | Purchase | ||
Bill on paper | 6 | Z2040** | Therapy Ball - Lg. | N | Purchase | ||
Bill on paper | 6 | Z2043** | Seat & Back Pad for Toddler Chairs | Y | Purchase | ||
Bill on paper | 6 | Z2044** | Tray for Toddler Chair | Y | Purchase | ||
Bill on paper | 6 | Z2045** | 14? T&S High Back w/Support Activity Chair | Y | Purchase | ||
Bill on paper | 6 | Z2046** | 16? T&S High Back w/Support Activity Chair | Y | Purchase | ||
Bill on paper | H 6 | Z2047 | Orthopedic Car Seat | Y | Purchase | ||
Bill on paper | H 6 | Z2048 | 4? Deluxe Wedge w/Strap | N | Purchase | ||
Bill on paper | H 6 | Z2072 | Lg. Wrap Around Bath Support | N | Purchase | ||
Bill on paper | H 6 | Z2073 | Sm. Wrap Around Back Support | N | Purchase | ||
Bill on paper | H 6 | Z2074 | Lg. Toilet Support w/Hi Back | N | Purchase | ||
Bill on paper | H 6 | Z2075 | Sm. Toilet Support w/Hi Back | N | Purchase | ||
Bill on paper | H 6 | Z2077 | Flexible Shower Hose | N | Purchase | ||
Bill on paper | H 6 | Z2089 | Toilet Seat Reducer Ring (Padded) | N | Purchase | ||
Bill on paper | 6 | Z2090** | 14? Gait Trainer | Y | Purchase | ||
Bill on paper | 6 | Z2091** | 19? Gait Trainer | Y* | Purchase | ||
Bill on paper | 6 | Z2092** | Intermediate Gait Trainer | Y* | Purchase | ||
Bill on paper | H 6 | Z2093 | Adult Gait Trainer | Y* | Purchase | ||
Bill on paper | 6 | Z2094** | Tyke Strider Walker w/2 Wheels | N | Purchase | ||
Bill on paper | 6 | Z2095** | Tweener Strider Walker w/2 Wheels | N | Purchase | ||
Bill on paper | 6 | Z2096** | Middle Strider Walker w/2 Wheels | N | Purchase | ||
Bill on paper | H 6 | Z2097 | Adult Strider Walker w/2 Wheels | N | Purchase | ||
Bill on paper | H 6 | Z2099 | 4 Wheel Reverse Walker | N | Purchase | ||
Bill on paper | H 6 | Z2100 | 4 Wheel Reverse Walker | N | Purchase | ||
Bill on paper | H 6 | Z2101 | 4 Wheel Reverse Walker | N | Purchase | ||
Bill on paper | H 6 | Z2102 | 4 Wheel Reverse Walker | N | Purchase | ||
Bill on paper | H 6 | Z2104 | 4 Wheel Front Swivel Reverse Walker | N | Purchase | ||
Bill on paper | H 6 | Z2105 | 4 Wheel Front Swivel Reverse Walker | N | Purchase | ||
Bill on paper | H 6 | Z2106 | 4 Wheel Front Swivel Reverse Walker | N | Purchase | ||
Bill on paper | H | Z2107 | 4 Wheel Front Swivel Reverse Walker | N | Purchase | ||
Bill on paper | H 6 | Z2239 | Bath Chair Headrest | N | Purchase | ||
Bill on paper | H 6 | Z2605 | Diverter Valve for Handheld Shower | N | Purchase |
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.
Additionally, when billed on paper, procedure codes must be billed with a type of service (TOS) "6" for individuals under age 21 or TOS "H" for individuals age 21 and over.
Modifiers in this section are indicated by the headings M1 and M2. Type of service is indicated by the heading TOS. Prior authorization requirements are shown under the heading PA. If prior authorization is needed, that information is indicated with a ?Y? in the column; if not, an ?N? is shown.
NOTE: Attach a manufacturer?s invoice to the claim and indicate the item or parts billed on the invoice. A description and the amount billed for each item must be attached to the claim. If more than one item is billed under a procedure code, the description and billed amount of each item must be listed separately under each procedure code and attached to the claim. The total billed for each procedure code should be reflected in field 24F.
* Prior authorization is not required when another insurance pays at least 50% of the Medicaid maximum allowable reimbursement amount.
***(?) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product.
Augmentative Communication Device, All Ages (section 242.193)
Procedure Code | M1 | M2 | TOS | PA | Description | Payment Method |
E2500 | NU EP | H 6 | Y* | ***(Light Technology Communication Aids -communication aids that do not have the memory component to store the information. They are often used in conjunction with higher tech devices as part of a multi-modal communication system.) Speech-generating device, digitized speech, using pre-recorded messages less than or equal to 8 minutes recording time | Purchase | |
E2502 | NU EP | H 6 | Y* | ***(Simple Voice Output Device - simple devices with limited storage capacity and voice output only.) Speech-generating device, digitized speech, using pre-recorded messages, greater than 8 minutes but less than or equal to 20 minutes recording time | Purchase | |
E2504 | NU EP | H 6 | Y* | ***(Simple Voice Output Device - simple devices with limited storage capacity and voice output only) Speech-generating device, digitized speech, using pre-recorded messages, greater than 20 minutes but less than or equal to 40 minutes recording time | Purchase | |
E2506 | NU EP | H 6 | Y* | ***(Simple Voice Output Device - simple devices with limited storage capacity and voice output only) Speech-generating device, digitized speech, using pre-recorded messages, greater than 40 minutes recording time. | Purchase | |
E2508 | NU EP | H 6 | Y* | ***(More Advanced Voice Output Communication Aids - offer more storage capacity and often have other output methods in addition to voice output; e.g., LED display) Speech-generating device, synthesized speech, requiring message formulation by spelling and access by physical contact with the device | Purchase | |
E2510 | NU EP | 6 | Y* | ***(Higher Technology Voice Output Communication Aids - offer greater memory capabilities, various types of output, computer interface options, etc.) Speech-generating device synthesized speech, permitting multiple methods of message formulation and multiple methods of device access | Purchase | |
E2510 | NU EP | H 6 | Y* | ***(State-of-the-Art Voice Output Communication Aids - represents state-of-the-art communication aid technology. Have extensive memory capabilities, various output methods, computer interface options; offer a variety of input methods in a single device and advanced functions such as auditory scanning, icon and word prediction, etc.) Speech-generating device synthesized speech, permitting multiple methods of message formulation and multiple methods of device access | Purchase | |
E2511 | NU EP | H 6 | Y* | ***(Software - often recommended for augmentative communication device. Software may change as the child matures.) Speech-generating software program, for personal computer or personal digital assistant | Purchase | |
E2512 | NU EP | H 6 | Y | Accessory for speech generating device, mounting system | Manually Priced | |
E2599 | NU EP | H 6 | Y* | ***(Switches - used with training aids and augmentative communication devices as a means of access) Accessory for speech generating device, not otherwise classified | Manually Priced | |
V5336 | NU EP | H 6 | Y | ***(Augmentative Communication Device Repair - parts only) Repair/modification of augmentative communicative system or device (excludes adaptive hearing aid) | Purchase | |
V5336 | NU EP | H 6 | Y | ***(Augmentative Communication Device Repair - labor only) Repair/modification of augmentative communicative system or device (excludes adaptive hearing aid) | Purchase |
016.06.05 Ark. Code R. 041