016-06-07 Ark. Code R. § 19

Current through Register Vol. 49, No. 6, June, 2024

Rule 016.06.07-019 - Prosthetics Update Transmittal #96, Physician/Independent Lab/CRNA/Radiation Therapy Center Update Transmittal #129, and ARKids First-B Update #58

SECTION IIARKIDS FIRST - B

262.000ARKids First-B Billing Procedures

262.100CPT and/or HCPCS Procedure Codes

National codes must be used for both electronic and paper claims. Where only a local code is available, it can be used indefinitely, but it can be billed only on a paper claim.

262.110Medical Supplies Procedure Codes

The following medical supplies procedure codes may be billed by Medicaid-enrolled Home Health and Prosthetics providers for ARKids First-B participants.

A4206	A4221	A4222	A4253 U1	A4256
A4259 U2	A4265	A4310	A4311	A4312
A4313	A4314	A4315	A4316	A4320
A4322	A4326	A4327	A4328	A4330
A4338	A4340	A4344	A4346	A4348
A4351	A4352	A4354	A4355	A4356
A4357	A4358	A4359	A4361	A4362
A4364	A4367	A4369	A4371	A4397
A4398	A4399	A4400	A4402	A4404
A4405	A4406	A4450	A4452	A4455
A4558	A4561	A4562	A4623	A4624
A4625	A4626	A4628	A4629	A4772
A4927	A5051	A5052	A5053	A5054
A5055	A5061	A5062	A5063	A5071
A5072	A5073	A5081	A5082	A5093
A5102	A5105	A5112	A5113	A5114
A5120	A5121	A5122	A5126	A5131
A6154	A6234	A6241	A6242	A6248
A7520	B4086	E0776

Procedure Code	Required Modifier(s)	Description
A6257	-	Transparent film, each (16 square inches or less)
A6258	-	Transparent film, each (more than 16, but less than 48 square inches)
A6259	-	Transparent film, each (more than 48 square inches)
A6216 A6219 A6228	Gauze pads medicated or non-medicated, each (16 square inches or less)

A6217 A6220 A6229 A6403	Gauze pads medicated or non-medicated, each (more than 16, but less than 48 square inches)
A6204 A6218 A6221 A6230	Gauze pads medicated or non-medicated, each (more than 48 square inches)
A6441 A6446	-	Gauze, non-elastic, per roll (1 linear yard)
A6242 A6245	-	Hydrogel dressing, each (16 square inches or less)
A6243 A6246	-	Hydrogel dressing, each (more than 16, but less than 48 square inches)
A6244 A6247	-	Hydrogel dressing, each (more than 48 square inches)
A6248	-	Hydrogel dressing, each (1 ounce)
A6234 A6237	-	Hydrocolloid dressing, each (16 square inches or less)
A6235 A6238	-	Hydrocolloid dressing, each (more than 16, but less than 48 square inches)
A6238	U1	Hydrocolloid dressing, each (more than 48 square inches)
A6196	-	Alginate dressing, each (16 square inches or less)
A6197	-	Alginate dressing, each (more than 16, but less than 48 square inches)
A6198	-	Alginate dressing, each (more than 48 square inches)
A6197	-	Alginate dressing, each (1 linear yard)
A6209 A6212	-	Foam dressing, each (16 square inches or less)
A6210 A6213	-	Foam dressing, each (more than 16, but less than 48 square inches)
A6211	-	Foam dressing, each (more than 48 square inches)
A6200 A6203	-	Composite dressing, each (16 square inches or less)
A6201 A6204	-	Composite dressing, each (more than 16, but less than 48 square inches)
A6202 A6205	-	Composite dressing, each (more than 48 square inches)
A4253	-	Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips
A4353	-	Urinary intermittent catheter with insertion supplies
A4394	-	Ostomy deodorant, all types, per ounce

A4365	-	Adhesive remover wipes, any type, per 50
A4368	-	Ostomy filters, any type, each
A6449 A6452	-	Gauze elastic, all types, per roll (linear yard)
A4483	-	Moisture exchange/agreer, disposable, for use with invasive mech
B4100	-	Food thickener, administered orally, per oz.
A6549*	-	Stocking (Jobst)

*NOTE: A4221, A4222 and A6549 must be prior authorized. Form AFMC-103 must be used for the request for prior authorization. View or print form AFMC-103 and instructions for completion.

The costs of B4100 and A6549 are not subject to the $125 medical supplies monthly benefit limit.

The following procedure code must be utilized when billing for Pedia-Pop. Reimbursement for this product is provider's cost plus ten percent. Pedia-Pop is only for oral consumption, and only in frozen form.

Z2487

Pedia-Pop

1 unit = 1 box

Maximum = 2 units per date of service

NOTE: Pedia-Pop must be billed on paper.

262.120 Durable Medical Equipment (DME) Procedure Codes

The following DME HCPCS procedure codes may be billed by Medicaid-enrolled prosthetics providers for ARKids First-B participants.

HCPCS code	Capped rental, purchase or rental only
A4635	Purchase only
A4636	Purchase only
A4637	Purchase only
E0100	Purchase only
E0105	Purchase only
E0110	Purchase only
E0111	Purchase only
E0112	Purchase only
E0113	Purchase only
E0114	Purchase only
E0116	Purchase only
E0130	Purchase only
E0135	Purchase only
E0140	Purchase only

E0143	Purchase only
E0147	Purchase only
E0153	Purchase only
E0154	Purchase only
E0155	Purchase only
E0157	Purchase only
E0158	Purchase only
E0161	Purchase only
E0163	Purchase only
E0164	Purchase only
E0166	Purchase only
E0167	Purchase only
E0175	Purchase only
E0180	Purchase only
E0181	Capped rental
E0182	Purchase only
E0184	Purchase only
E0185	Purchase only
E0189	Purchase only
E0190	Purchase only
E0191	Purchase only
E2601 E2602	Capped rental
E0196	Purchase only
E0197	Purchase only
E0200	Capped rental
E0202	Rental only
E0205	Capped rental
E0217	Capped rental
E0225	Capped rental
E0235	Purchase only
E0236	Capped rental
E0238	Purchase only
E0239	Capped rental
E0249	Purchase only
E0250	Capped rental
E0255	Capped rental

E0260	Capped rental
E0271	Capped rental
E0272	Capped rental
E0273	Purchase only
E0275	Purchase only
E0276	Purchase only
E0280	Purchase only
E0325	Purchase only
E0326	Purchase only
E0424	Rental only
E0430	Rental only
E0435	Rental only
E0439	Rental only
E0443	Purchase only
E0444	Purchase only
E0480	Capped rental
E0560	Purchase only
E0565	Capped rental
E0570	Purchase only
E0575	Capped rental
E0585	Capped rental
E0600	Rental only
E0605	Purchase only
E0606	Capped rental
E0607 U1	Purchase only
E0630	Capped rental
E0650	Capped rental
E0667	Capped rental
E0668	Capped rental
E0691	Rental only
E0692	Rental only
E0693	Rental only
E0694	Rental only
E0720	Capped rental
E0730	Capped rental
E0740	Purchase only

E0745	Capped rental
E0747	Rental only
E0840	Purchase only
E0850	Purchase only
E0860	Purchase only
E0870	Purchase only
E0880	Purchase only
E0890	Purchase only
E0900	Purchase only
E0910	Capped rental
E0920	Capped rental
E0930	Capped rental
E0935	Capped rental
E0940	Capped rental
E0941	Capped rental
E0942	Purchase only
E0944	Purchase only
E0945	Purchase only
E0946	Purchase only
E0947	Purchase only
E0948	Purchase only
E1130	Capped rental
E1140	Capped rental
E1150	Capped rental
E1160	Capped rental
E1224	Capped rental
E1390	Rental only
E1391	Rental only
E2611	Purchase only
E2612	Purchase only

Procedure Code	Required Modifier	Description	Capped rental, purchase or rental only
E1340	NU	Durable medical equipment 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.)	Manually priced
Z0428 Bill on paper	NU	Unlisted durable medical equipment, $500.00 and over. (The manufacturer's invoice must be attached to the claim form.)	Manually priced
Z1825 Bill on paper	NU	Unlisted durable medical equipment, under $500.00. The manufacturer's invoice must be attached to the claim form.)
E0779 E0779	RR	Ambulatory infusion device, payable only when services are provided to patients receiving chemotherapy, pain management or antibiotic treatment in the home	Rental only
A7034 A7034	RR	CPAP (continuous positive airway pressure) device, nasal (includes necessary accessory items) Note: Complete medical data pertinent to the request must be submitted with a prior authorization request.	Rental only
E0445	-	Pulse oximeter (including 4 disposable probes)	Rental only
E1340	EP, U3	Unlisted repairs/wheelchairs	Manually priced
E0483	UB	High-frequency chest-wall oscillation	Rental only
E0483	RR	air-pulse generator system, incl
E0483	"	Pulmonary vest (The manufacturer's invoice must be attached to the claim form.)	Purchase only
E1340	U4	Maintenance for capped rental items	N/A
E1340	NU, U1	Labor only (a maximum of twenty (20) units per date of service is allowed) (20 units = 5 hours of labor)	Manually priced
E1340	"	Labor only (a maximum of twenty (20) units per date of service is allowed) (20 units = 5 hours of labor)	Manually priced
A4670	-	Electronic blood pressure monitor and cuff	Rental only
A4230	-	Infusion set for external insulin pump, non-needle cannula type	Purchase only

A4213	-	Syringes, sterile, 20 cc or greater, each	Purchase only
Bill on paper	-	Power kit/batteries	Purchase only
A6021 A6022 A6023 A6024	Polyskin dressing	Purchase only
A4627	UB	Spacer bag or reservoir, with or without mask, for use with metered dose inhaler	Purchase only
A4627	-	Spacer bag or reservoir, with mask, for use with metered inhaler	Purchase only

262.140Speech-Language Pathology Procedure Codes

Procedure Code	Required Modifier	Description
92506	Evaluation for Speech Therapy
92507	-	Individual Speech Session
92507	UB	Individual Speech Therapy by Speech Language Pathology Assistant
92508	-	Group Speech Session
92508	UB	Group Speech Therapy by Speech Language Pathology Assistant

262.200National Place of Service Codes

Refer to the appropriate Arkansas Medicaid Provider Manual for instructions.

262.400 Billing Procedures for Preventive Health Screens

ARKids First-B reimburses providers for preventive health screenings performed at the intervals recommended by the American Academy of Pediatrics.

References in this section indicate that ARKids First-B preventive health screenings are similar to Arkansas Medicaid Child Health Services (EPSDT) screens. However, please note these important distinctions:

A. File claims for ARKids First-B preventive health screenings in the CMS-1500 claim format. Do not use the DMS-694 claim format.

NOTE: Certified nurse-midwives are restricted to performing the preventive health screen, Newborn 99431, 99432 or 99435. They may not bill procedure codes 99381-99385 or 99391-99395.

262.430Vaccines for Children Program

The Vaccines for Children (VFC) Program was established to generate awareness and access for childhood immunizations. These vaccines are available for ARKids First-B participants who are under the age of 19. To enroll in the VFC Program, contact the Division of Health. Providers may also obtain the vaccines to administer from the Division of Health. View or print the Division of Health contact information.

Vaccines available through the VFC program are covered for ARKids First-B participants. The administration fee only is reimbursed. When filing claims for administering VFC vaccines, providers must use the CPT procedure code for the vaccine administered. Electronic and paper claims require the modifier TJ.

For information about vaccines covered through the VFC program, contact the Division of Health (see contact link above).

SECTION II- PHYSICIAN/INDEPENDENT LAB/CRNA/RADIATION THERAPY CENTER

229.110Completion of Request Form DMS-671, "Request For Extension of

Benefits for Clinical, Outpatient, Laboratory and X-Ray Services"

Requests for extension of benefits for Clinical Services (Physician's Visits), Outpatient Services (Hospital Outpatient visits), Laboratory Services (Lab Tests) and X-ray services (X-ray, Ultrasound, Electronic Monitoring - e.e.g.; e.k.g.; etc-), must be submitted to AFMC for consideration. Consideration of requests for extension of benefits requires correct completion of all fields on the Request for Extension of Benefits for Clinical, Outpatient, Laboratory and X-Ray (form DMS-671). View or print form DMS-671.

Complete instructions for accurate completion of form DMS- 671 (including indication of required attachments) accompany the form. All forms are listed and accessible in Section V of each Provider Manual.

242.000 Dermatology

The Arkansas Medicaid Program covers CPT procedure code 96900- Actinotherapy (ultraviolet light). The physician must submit documentation with claim to establish medical necessity.

262.000Procedures That Require Prior Authorization

The following procedure codes require prior authorization:

Procedure Codes
J7320	J7340	L8614	L8615	L8616	L8617	L8618	L8619
S0512	S2213	V5014	00170	01966	11960	11970	11971
15400	15831	19318	19324	19325	19328	19330	19340
19342	19350	19355	19357	19361	19364	19366	19367
19368	19369	19370	19371	19380	20974	20975	21076
21077	21079	21080	21081	21082	21083	21084	21085
21086	21087	21088	21089	21120	21121	21122	21123
21125	21127	21137	21138	21139	21141	21142	21143
21145	21146	21147	21150	21151	21154	21155	21159
21160	21172	21175	21179	21180	21181	21182	21183
21184	21188	21193	21194	21195	21196	21198	21199
21208	21209	21244	21245	21246	21247	21248	21249
21255	21256	27412	27415	29866	29867	29868	30220
30400	30410	30420	30430	30435	30450	30460	30462
32851	32852	32853	32854	33140	33282	33284	33945
36470	36471	37785	37788	38240	38241	38242	42820
42821	42825	42826	42842	42844	42845	42860	42870
43257	43644	43645	43842	43845	43846	43847	43848
43850	43855	43860	43865	47135	48155	48160	48554
48556	50320	50340	50360	50365	50370	50380	51925

54360	54400	54415	54416	54417	55400	57335	58150
58152	58180	58260	58262	58263	58267	58270	58280
58290	58291	58292	58293	58294	58345	58550	58552
58553	58554	58672	58673	58750	58752	59135	59840
59841	59850	59851	59852	59855	59856	59857	59866
60512	61850	61860	61862	61870	61875	61880	61885
61886	61888	63650	63655	63660	63685	63688	64555
64573	64585	64809	64818	65710	65730	65750	65755
67900	69300	69310	69320	69714	69715	69717	69718
69930	87901	87903	87904	92081	92100	92326	92393
93980	93981

Procedure Code	Modifier	Description
E0779	RR	Ambulatory infusion device
D0140	EP	EPSDT interperiodic dental screen
J7330	Autologous cultured chondrocytes, implant
L8619	EP	External sound processor
S0512	Daily wear specialty contact lens, per lens
V2501	UA	Supplying and fitting Keratoconus lens (hard or gas permeable) -1 lens
V2501	U1	Supplying and fitting of monocular lens (soft lens) -1 lens
Z1930	80,81,82	Non-emergency hysterectomy following c-section
92002	UB	Low vision services - evaluation

290.000BILLING PROCEDURES

291.000 Introduction to Billing

Physician/Independent Lab/CRNA/Radiation Therapy Center 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.

292.200 Physician National Place of Service

292.210 National Place of Service Codes

Electronic and paper claims now require the same National Place of Service code

Place of Service	POS Codes
Inpatient Hospital	21
Outpatient Hospital	22
Doctor's Office	11
Patient's Home	12
Ambulatory Surgical Center	24
Day Care Facility or DDTCS Facility	99
Nursing Facility	32
Skilled Nursing Facility	31
Other Locations	99
Independent Laboratory	81
End Stage Renal Disease Treatment Facility	65
Emergency Room	23
Inpatient Psychiatric Facility	51

292.300Billing Instructions-Paper Only

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

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

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

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

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

292.310Completion of the CMS-1500 Claim Form

Field Name and Number	Instructions for Completion
1. (type of coverage)	Not required.
1a. INSURED'S I.D. NUMBER (For Program in Item 1)	Beneficiary's or participant's 10-digit Medicaid or ARKids First-A or ARKids First-B identification number.
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)	Beneficiary's or participant's last name and first name.

3. PATIENT'S BIRTH DATE	Beneficiary's or participant's date of birth as given on the individual's Medicaid or ARKids First-A or ARKids First-B identification card. Format: MM/DD/YY.
SEX	Check M for male or F for female.
4. INSURED'S NAME (Last Name, First Name, Middle Initial)	Required if insurance affects this claim. Insured's last name, first name, and middle initial.
5. PATIENT'S ADDRESS (No., Street)	Optional. Beneficiary's or participant's complete mailing address (street address or post office box).
CITY	Name of the city in which the beneficiary or participant resides.
STATE	Two-letter postal code for the state in which the beneficiary or participant resides.
ZIP CODE	Five-digit zip code; nine digits for post office box.
TELEPHONE (Include Area Code)	The beneficiary's or participant's telephone number or the number of a reliable message/contact/ emergency telephone.
6. PATIENT RELATIONSHIP TO INSURED	If insurance affects this claim, check the box indicating the patient's relationship to the insured.
7. INSURED'S ADDRESS (No., Street)	Required if insured's address is different from the patient's address.
CITY
STATE
ZIP CODE
TELEPHONE (Include Area Code)
8. PATIENT STATUS	Not required.
9. OTHER INSURED'S NAME (Last name, First Name, Middle Initial)	If patient has other insurance coverage as indicated in Field 11 d, the other insured's last name, first name, and middle initial.
a. OTHER INSURED'S POLICY OR GROUP NUMBER	Policy and/or group number of the insured individual.
b. OTHER INSURED'S DATE OF BIRTH	Not required.
SEX	Not required.
c. EMPLOYER'S NAME OR SCHOOL NAME	Required when items 9 a-d are required. Name of the insured individual's employer and/or school.
d. INSURANCE PLAN NAME OR PROGRAM NAME	Name of the insurance company.
10. IS PATIENT'S CONDITION RELATED TO:

a. EMPLOYMENT? (Current or Previous)	Check YES or NO.
b. AUTO ACCIDENT?	Required when an auto accident is related to the services. Check YES or NO.
PLACE (State)	If 10b is YES, the two-letter postal abbreviation for the state in which the automobile accident took place.
c. OTHER ACCIDENT?	Required when an accident other than automobile is related to the services. Check YES or NO.
10d. RESERVED FOR LOCAL USE	Not used.
11. INSURED'S POLICY GROUP OR FECA NUMBER	Not required when Medicaid is the only payer.
a. INSURED'S DATE OF BIRTH	Not required.
SEX	Not required.
b. EMPLOYER'S NAME OR SCHOOL NAME	Not required.
c. INSURANCE PLAN NAME OR PROGRAM NAME	Not required.
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?	When private or other insurance may or will cover any of the services, check YES and complete items 9a through 9d.
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE	Not required.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE	Not required.
14. DATE OF CURRENT: ILLNESS (First symptom) OR INJURY (Accident) OR PREGNANCY (LMP)	Required when services furnished are related to an accident, whether the accident is recent or in the past. Date of the accident.
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS, GIVE FIRST DATE	Not required.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION	Not required.
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE	Primary Care Physician (PCP) referral is required for most Physician/Independent Lab/CRNA/Radiation Therapy Center services provided by non-PCPs. Enter the referring physician's name and title.
17a. (blank)	The 9-digit Arkansas Medicaid provider ID number of the referring physician.
17b. NPI	Not required.

18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES	When the serving/billing provider's services charged on this claim are related to a beneficiary's or participant's inpatient hospitalization, enter the individual's admission and discharge dates. Format: MM/DD/YY.
19. RESERVED FOR LOCAL USE	Not used.
20. OUTSIDE LAB?	Not required.
$ CHARGES	Not required.
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY	Diagnosis code for the primary medical condition for which services are being billed. Up to three additional diagnosis codes can be listed in this field for information or documentation purposes. Use the U.S. Department of Health and Human Services diagnosis coding, current as of the claim date (not the service date), from ICD-9-CM.
22. MEDICAID RESUBMISSION CODE	Reserved for future use.
ORIGINAL REF. NO.	Reserved for future use.
23. PRIOR AUTHORIZATION NUMBER	The prior authorization or benefit extension control number if applicable.
24A. DATE(S) OF SERVICE	The "from" and "to" dates of service for each billed service. Format: MM/DD/YY.
1. On a single claim detail (one charge on one line), bill only for services provided within a single calendar month.
2. Providers may bill on the same claim detail for two or more sequential dates of service within the same calendar month when the provider furnished equal amounts of the service on each day of the date sequence.
B. PLACE OF SERVICE	Two-digit national standard place of service code. See Section 292.200 for codes.
C. EMG	Not required.
D. PROCEDURES, SERVICES, OR SUPPLIES
CPT/HCPCS	One CPT or HCPCS procedure code for each detail.
MODIFIER	Modifier(s) if applicable.
For anesthesia, when billed with modifier(s) P1, P2, P3, P4, or P5, hours and minutes must be entered in the shaded portion of that detail in field 24D.

E. DIAGNOSIS POINTER	Enter in each detail the single number-1, 2, 3, or 4-that corresponds to a diagnosis code in Item 21 (numbered 1,2,3, or 4) and that supports most definitively the medical necessity of the service(s) identified and charged in that detail. Enter only one number in E of each detail. Each DIAGNOSIS POINTER number must be only a 1, 2, 3, or 4, and it must be the only character in that field.
F. $ CHARGES	The full charge for the service(s) totaled in the detail. This charge must be the usual charge to any client, patient, or other beneficiary of the provider's services.
G. DAYS OR UNITS	The units (in whole numbers) of service(s) provided during the period indicated in Field 24A of the detail.
H. EPSDT/Family Plan	Enter E if the services resulted from a Child Health Services (EPSDT) screening/referral.
1. IDQUAL	Not required.
J. RENDERING PROVIDER ID#	The 9-digit Arkansas Medicaid provider ID number of the individual who furnished the services billed for in the detail.
NPI	Not required.
25. FEDERAL TAX I.D. NUMBER	Not required. This information is carried in the provider's Medicaid file. If it changes, please contact Provider Enrollment.
26. PATIENT'S ACCOUNT N 0.	Optional entry that may be used for accounting purposes; use up to 16 numeric or alphabetic characters. This number appears on the Remittance Advice as "MRN."
27. ACCEPT ASSIGNMENT?	Not required. Assignment is automatically accepted by the provider when billing Medicaid.
28. TOTAL CHARGE	Total of Column 24F-the sum all charges on the claim.
29. AMOUNT PAID	Enter the total of payments previously received on this claim. Do not include amounts previously paid by Medicaid. * Do not include in this total the automatically deducted Medicaid or ARKids First-B co-payments.
30. BALANCE DUE	From the total charge, subtract amounts received from other sources and enter the result.
31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS	The provider or designated authorized individual must sign and date the claim certifying that the services were personally rendered by the provider or under the provider's direction. "Provider's signature" is defined as the provider's actual signature, a rubber stamp of the provider's signature, an automated signature, a typewritten signature, or the signature of an individual authorized by the provider rendering the service. The name of a clinic or group is not acceptable.

32. SERVICE FACILITY LOCATION INFORMATION	If other than home or office, enter the name and street, city, state, and zip code of the facility where services were performed.
a. (blank)	Not required.
b. (blank)	Not required.
33. BILLING PROVIDER INFO & PH#	Billing provider's name and complete address. Telephone number is requested but not required.
a. (blank)	Not required.
b. (blank)	Enter the 9-digit Arkansas Medicaid provider ID number of the billing provider.

292.400Special Billing Procedures

292.410Abortion Procedure Codes

Abortion procedures performed when the life of the mother would be endangered if the fetus were carried to term require prior authorization from the Arkansas Foundation of Medical Care, Inc. (AFMC).

Abortion for pregnancy resulting from rape or incest must be prior authorized by the Division of Medical Services, Administrator, and Utilization Review.

The physician must request prior authorization for the abortion procedures and for anesthesia. Refer to section 260.000 of this manual for prior authorization procedures. The physician is responsible for providing the required documentation to other providers (hospitals, anesthetist, etc.) for billing purposes.

All claims must be made on paper with attached documentation. A completed Certification Statement for Abortion (form DMS-2698 Rev. 8/04), patient history and physical exam are required for processing of claims.

Use the following procedure codes when billing for abortions.

01966* 59855

59840 59856

59841 59857

59850

59851

59852

*Effective for dates of service on and after March 1, 2006, CPT anesthesia procedure code 01964is non-payable and has been replaced with procedure code 01966.

Refer to section 251.220 of this manual for policies and procedures regarding coverage of abortions and section 261.000, 261.100, 261.200, 261.260 for prior authorization instructions.

292.420Allergy and Clinical Immunology

Allergy testing is available for all eligible Medicaid beneficiaries regardless of age, but allergy immunotherapy is payable only for eligible children under the Child Health Services (EPSDT) Program.

When charges for children under the Child Health Services (EPSDT) Program are billed to the Medicaid Program for the above services, the health care provider should check "Yes" in the child screening referral section of the claim, Field 24H, on the CMS-1500 claim form only if the service is a direct referral resulting from a Child Health Services (EPSDT) screen (examination). View a CMS-1500 sample form.

Appropriate CPT procedure codes should be used when billing for procedures listed in the allergy and clinical immunology section of the CPT book.

Reimbursement of allergy testing will be paid on a "per test" basis. Enter the exact number of tests performed in the "Units" field. Procedure codes 95070and 95071must be billed.

Procedure code 95078is not a payable code.

All laboratory tests done in conjunction with allergy testing or immunotherapy must also be billed by the provider who actually performs the test. Refer to Section 292.600 of this manual for information on specimen collection.

292.430 Ambulatory Infusion Device

Procedure code E0779,modifier RR, Ambulatory Infusion Device,is payable only when services are provided to patients receiving chemotherapy, pain management or antibiotic treatment in the home. One unit of service equals one day. A reimbursement rate has been established and represents a daily rental amount. Refer to section 241.000 of this manual for coverage information and section 261.220 for prior authorization procedures.

292.440 Anesthesia Services

Anesthesia procedure codes (00100through 01999)must be billed in anesthesia time. Anesthesia modifiers P1 through P5 listed under Anesthesia Guidelines in the CPT must be used. When appropriate anesthesia procedure codes have a base of 4 or less, they are eligible to be billed with a second modifier, "22," referencing surgical field avoidance.

Any surgical procedure with local/topical anesthesia is computed to include the administration of the local anesthetic agent, as it is already computed into the reimbursement amount and is billed by the primary surgeon. No modifiers or time may be billed with these procedures.

A. Electronic Claims

PES or electronic claims submission may be used unless paper attachments are required.

B. Paper Claims

If paper billing is required, enter the procedure code, time and units as shown in section 292.447. Enter again the number of units (each 15 minutes of anesthesia equals 1 time unit) in Field 24G. (See cutaway section of a completed claim in Section 292.447.)

National Code

Local Code

Description

Documentation Required

01966*

Anesthesia for induced abortion procedures

Use for billing anesthesia service for all elective, induced abortions, including abortions performed for rape or incest

Certification Statement for Abortion (DMS-2698) (See sections 251.220, 261.000, 261.100, 261.200 and 261.260 of this manual.) View or print form DMS-2698 and instructions for completion.

Z9940

Anesthesia for Abdominal Hysterectomy

Acknowledgement of Hysterectomy (DHS-2606) View or print form DMS-2606 and instructions for completion.

C.The following CPT procedure codes must be billed on CMS-1500 paper claims because they require attachments or documentation:

Procedure Code	Documentation Required
00846	Acknowledgement of Hysterectomy Information (DMS-2606) View or print form DMS-2606 and instructions for completion.
00848	Operative Report
01962 01963	Acknowledgement of Hysterectomy Information (DMS-2606) View or print form DMS-2606 and instructions for completion.
00922	Operative Report
00944	Acknowledgement of Hysterectomy Information (DMS-2606)) View or print form DMS-2606 and instructions for completion.
01999	Procedure Report
00800	On females only, required to name each procedure done by surgeon in "Procedures, Services or Supplies" column. Example - 1. colon resection 2. lysis of adhesions 3. appendectomy
00840	On females only, required to name each procedure done by surgeon in "Procedures, Services or Supplies" column.
00940	Required to name each procedure done by surgeon in "Procedures, Services or Supplies" column.

Anesthesiologist/anesthetists may bill procedure code 00170 for any inpatient or outpatient dental surgery using place of service code "24," "21," 22"or "11," as appropriate. This code does not require prior approval for anesthesia claims.

A maximum of 17 units of anesthesia is allowed for a vaginal delivery or C-Section. Refer to Anesthesia Guidelines of the CPT book for procedure codes related to vaginal or C-section deliveries.

292.442Epidural Therapy

Procedure code 62319should be billed with one (1) unit of service at the time of insertion only. Providers are to bill for daily pain management utilizing procedure code 01996,with one time unit of 15 minutes, with no additional payment to the anesthetist for hospital visits. In cases where the method of anesthesia for surgery is an epidural anesthetic, providers are not allowed to re-bill for the insertion of a catheter for pain management unless there is documentation attached to verify two separate insertions were done. CPT procedure codes describing catheter and/or reservoir/pump implantation are to be used for long-term therapy.

Procedure code 93503must be billed when performed by an anesthesiologist/CRNA.

292.446Time Units

Time units will be added to the Base Value and the Anesthesia Modifier for all cases at the rate of 1.0 Unit for each 15 minutes or any fraction thereof. Anesthesia time begins when the anesthesiologist begins to prepare the patient for the induction of anesthesia in the operating room or in an equivalent area and ends when the anesthesiologist is no longer in personal attendance, that is, when the patient may be safely placed under post-operative supervision. Enter the time units in Field 24G.

Anesthesia stand-by should be billed as detention time using procedure code 99360.One unit equals 30 minutes. A maximum of one unit per date of service may be billed.

292.447Example of Proper Completion of Claim

The following is a cutaway section of the CMS-1500 claim form demonstrating the proper method of entering the following information:

Line No. 1 - Anesthesia for Procedure Line No. 2 - Qualifying Circumstance

Click here to view image

292.450 Assistant Surgery

Assistant surgeon's fees require prior authorization and use of modifier 80 billed with the same procedure code billed by the primary physician.

292.451 Co-SurgeryCo-surgeon billing is indicated with modifier 62. Modifier 62 must be used in accordance with CPT guidelines. Operative reports from all physicians performing surgery during the same operative session must be attached to the claim that includes modifier 62.

292.480Cataract Surgery Post-cataract lens implantmust be billed using procedure code V2630.This procedure code may be billed electronically or on paper. The lens implant code is billed in conjunction with the cataract surgery and is covered for eligible Medicaid beneficiaries of all ages in the outpatient setting.

292.510 Dialysis

A. Hemodialysis

The following procedure codes must be used by the nephrologist when billing for acute hemodialysis on hospitalized patients. Class I and Class II must have a secondary diagnosis listed to justify the level of care billed.

Procedure Code	Required Modifier	Description
90937	Class I - Acute renal failure complicated by illness or failure of other organ systems
90935	Class II - Acute renal failure without failure of other organ systems but with other dysfunction in other areas requiring attention
99221 99231	U1 U1	Class III - Acute renal failure with minor or no other complicating medical problems

These are global codes. Hospital visits are included and must not be billed separately.

B. Peritoneal Dialysis

The following procedure codes must be used when billing for physician inpatient management of peritoneal dialysis. Class I and Class II must have a secondary diagnosis code listed to justify the level of care billed

Procedure Code	Required Modifier(s)	Description
90947	Class I - Acute renal failure complicated by illness or failure of other organ systems (peritoneal dialysis)
90945	Class II -Acute renal failure, without failure of other organ systems but with dysfunction in other areas receiving attention (peritoneal dialysis)
99221 99231	UB UB	Class III - Acute renal failure with minor or no other complicating medical problems

These are global codes. Hospital visits are included and must not be billed separately.

C. Outpatient Management of Dialysis

The Arkansas Medicaid Program will reimburse for outpatient management of dialysis under procedure codes 90922, 90923, 90924and 90925.

One day of dialysis management equals one unit of service. A provider may bill one day of outpatient management for each day of the month unless the beneficiary is hospitalized. When billing for an entire month of management, be sure to include the dates of management in the "Date of Service" column. Only one month of management must be reflected per claim line with a maximum of 31 units per month. If a patient is hospitalized, these days must not be included in the monthly charge. These days must be split billed. An example is:

Date of Service

Procedures, Services, or Supplies CPT/HCPCS

Days

Units

6-1-05 through 6-14-05

90922

6-21-05 through 6-30-05

90922

Arkansas Medicaid also covers Iron Dextran for beneficiaries of all ages who receive dialysis due to acute renal failure. Use procedure code J1750when administering in a physician's office. Units billed are equal to the milliliters administered (1 unit = 50 mg).

Procedure code J0636(Injection, Calcitrol, 1 meg, ampule) is payable for eligible Medicaid beneficiaries of all ages who receive dialysis due to acute renal failure (diagnosis codes 584 - 586).

292.520 Evaluations and Management

292.521Consultations

When billing for office consultations when the place of service is the provider's office (POS: 11)or inpatient hospital (POS: 21), use the appropriate CPT procedure codes according to the description of each level of service.

The consultation procedure codes listed below must be used when the place of service is outpatient hospital or emergency room-hospital (POS: 22or 23,respectively) or ambulatory surgical center (POS 24).

Procedure Code	Required Modifier(s)	Description
99241	UA, UB	Other Outpatient Consultation for a new or established patient, which requires these three key components: A problem-focused history, A problem-focused examination and Straightforward medical decision-making.
99242	UA, UB	Other Outpatient Consultation for a new or established patient, which requires these three key components: An expanded problem-focused history, An expanded problem-focused examination and Straightforward medical decision-making.
99243	UA, UB	Other Outpatient Consultation for a new or established patient, which requires these three key components: A detailed history; A detailed examination and Medical decision making of low complexity.
99244	U1, UA	Other Outpatient Consultation for a new or established patient, which requires these three key components: A comprehensive history, A comprehensive examination and Medical decision making of moderate complexity.
99245	U1, UA	Other Outpatient Consultation for a new or established patient, which requires these three key components: A comprehensive history, An expanded problem-focused examination and Medical decision making of high complexity.

Medicaid does not cover follow-up consultations. A consulting physician assuming care of a patient is providing a primary evaluation and management service and bills Medicaid accordingly within CPT standards.

For information on benefit limits for all consultation (inpatient and outpatient) refer to section 226.100 of this manual.

292.525Hospital Discharge Day Management

Procedure code 99238,hospital discharge day management, may not be billed by providers in conjunction with an initial or subsequent hospital care code, procedures 99221through 99233. Initial hospital care codes and subsequent hospital care codes may not be billed on the day of discharge.

292.540Factor VIM, Factor IX and Cryoprecipitate

Anti-hemophiliac Factor VIII is covered by the Arkansas Medicaid Program when administered in the outpatient hospital, physician's office or in the patient's home. The following procedure codes must be used:

J7190Factor VIM [antihemophilic factor (human)], perlU

J7191Factor VIM [antihemophilic factor (porcine)], perlU

J7192Factor VIM [antihemophilic factor (recombinant)], perlU

The provider must bill his/her cost per unit and the number of units administered.

HCPCS procedure code J7194must be used when billing for Factor IX Complex (human). Factor IX Complex (Human) is covered by Medicaid when administered in the physician's office or the patient's home (residence). The provider must bill his/her cost per unit and the number of units administered.

The Arkansas Medicaid Program covers procedure code P9012 - Cryoprecipitate. This procedure is covered when provided to eligible Medicaid beneficiaries of all ages in the physician's office, outpatient hospital setting or patient's home.

Providers must attach a copy of the manufacturer's invoice to the claim form when billing for Cryoprecipitate.

For the purposes of Factor VIM, Factor IX and Cryoprecipitate coverage, the patient's home is defined as where the patient resides. Institutions, such as a hospital or nursing facility, are not considered a patient's residence.

292.550 Family Planning Services

292.551Family Planning Services For Beneficiaries in Full Coverage Aid Categories

Family planning services are covered for beneficiaries in full coverage aid categories. Family planning procedures payable to physicians require a modifier "FP". All procedure codes in this table require a family planning or sterilization diagnosis code in each claim detail.

A. The following tables include procedure codes that are covered as family planning services for beneficiaries in full coverage aid categories

Procedure Codes
11975	11976	11977	55250	55450	58300	58301	58340**
58345**	58565	58600	58605	58611	58615	58661*	58670
58671	58700*	72190**	74740**	74742**	99144**	99145**

*CPT codes 58661and 58700represent procedures to treat medical conditions as well as for elective sterilizations

**These procedures require special billing instructions. Refer to part C of this section.

Procedure Code	Modifier(s)	Description
J1055	FP	Medroxyprogesterone acetate for contraceptive use

J7300	FP	Intrauterine copper contraceptive
J7302	FP	Levonorgestrel-releasing intrauterine contraceptive system
J7303	FP	Contraceptive supply, hormone containing vaginal ring
J7306	FP	Levonorgestrel (contraceptive) implant system, including implants and supplies
36415	FP	Routine venipuncture for blood collection
99401	FP, UA, UB	Periodic family planning visit
99401	FP, UA, U1	Arkansas Division of Health periodic/follow-up visit
99402	FP, UA	Arkansas Division of Health basic visit
99402	FP, UA, UB	Basic family planning visit

When filing family planning claims for physician services in an outpatient clinic, use modifier U6 for the basic family planning visit and the periodic family planning visit

B. Effective for dates of service on and after June 28, 2006, procedure code S0612is not covered as a family planning procedure. It is covered for regular Medicaid beneficiaries for annual gynecological examinations.

C. Additional procedures have been added as family planning services when related to procedure 58565- hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants (Essure).

1. Effective for dates of service on and after March 1, 2006, conscious sedation procedure codes 99144 and 99145 may be covered as family planning service only when administered in conjunction with the Essure procedure (58565).

To file claims for these professional services, use modifier FP. Whether billing on paper or electronically, the primary detail diagnosis code for each procedure must be a family planning diagnosis.

Claims filed for these professional services when provided in an outpatient hospital clinic do not require modifiers if filed. All claims billed require that the primary detail diagnosis code for each procedure must be a family planning diagnosis.

2. Effective for dates of service on and after February 1, 2006, procedure codes 58340, 58345, 72190, 74740 and 74742are only payable as family planning services within the 6 months after the Essure procedure's date of service.

a. Professional claims for procedure codes 58340 and 58345must be filed with modifier FP. All claims billed require that the primary detail diagnosis for each procedure must be a family planning diagnosis code.

b. Professional claims for procedure codes 72190, 74740 and 74742must be filed with modifier FP All claims billed require that the primary detail diagnosis for each procedure must be a family planning diagnosis code.

c. Procedure codes J1055,11976 and 58301 are covered family planning services. Effective for dates of service on and after February 1, 2006, these procedures are also covered up to six months as necessary for follow-up services to the Essure procedure. When provided as post-Essure follow-up care, billing protocol is unchanged for J1055,11976 and 58301for all providers.

All visits related to post-Essure services during the 6 months following the Essure procedure are included in the fee allowed for 58565.

292.552Family Planning Services for Beneficiaries in

Limited Aid Category 69

Arkansas covers many family planning services for women of child-bearing age who are Medicaid-eligible in aid category 69 and who participate in the Arkansas Women's Health Waiver.

Covered family planning procedures furnished to beneficiaries in aid category 69 are payable to physicians and must be billed with a modifier "FP".

A. The following services are covered for this limited service category.

Procedure Codes
11975	11976	11977	58300	58301	58340*	58345*	58565
58600	58615	58670	58671	72190*	74740*	74742*	99144*
99145*

*Asterisked codes require special billing procedures. Refer to part C of this section.

Procedure Code	Modifier(s)	Description
J1055	FP	Medroxyprogesterone acetate for contraceptive use
J7300	FP	Intrauterine copper contraceptive
J7302	FP	Levonorgestrel-releasing intrauterine contraceptive system
J7303	FP	Contraceptive supply, hormone containing vaginal ring
J7306	FP	Levonorgestrel (contraceptive) implant system, including implants and supplies
36415	FP	Routine venipuncture for blood collection
99401	FP, UA, UB	Periodic family planning visit
99401	FP, UA, U1	Arkansas Division of Health periodic/follow-up visit
99402	FP, UA	Arkansas Division of Health basic visit
99402	FP, UA, UB	Basic family planning visit

When filing family planning claims for physician services in an outpatient clinic, use modifier U6 for the basic family planning visit and the periodic family planning visit.

B. Effective for dates of service on and after June 28, 2006, the following procedure codes are not covered for aid category 69 beneficiaries.

58605

58611

58661

58700

S0612

1. Effective for dates of service on and after March 1, 2006, conscious sedation procedure codes 99144and 99145may be covered as family planning service only when administered in conjunction with the Essure procedure (58565).

To file claims for these professional services, use modifier FP.All claims billed require that the primary detail diagnosis code for each procedure must be a family planning diagnosis.

Claims filed for these professional services when provided in an outpatient hospital clinic do not require modifiers. All claims billed require that the primary detail diagnosis code for each procedure must be a family planning diagnosis.

2. Effective for dates of service on and after February 1, 2006, procedure codes 58340, 58345, 72190, 74740and 74742are only payable as family planning services within the 6 months after the Essure procedure's date of service.

a. Professional claims for procedure codes 58340and 58345must be filed with modifier FP.All claims billed require that the primary detail diagnosis for each procedure must be a family planning diagnosis code.

b. Professional claims for procedure codes 72190, 74740and 74742must be filed with modifier FP.All claims billed require that the primary detail diagnosis for each procedure must be a family planning diagnosis code.

3. Procedure codes J1055, 11976 and 58301are covered family planning services. Effective for dates of service on and after February 1, 2006, these procedures are also covered up to six months as necessary for follow-up services to the Essure procedure. When provided as post-Essure follow-up care, billing protocol is unchanged for J1055, 11976and 58301for all providers.

All visits related to post-Essure services during the 6 months following the Essure procedure are included in the fee allowed for 58565.

292.553Family Planning Laboratory Procedure Codes

This table contains laboratory procedure codes payable as family planning services for regular Medicaid beneficiaries and for beneficiaries in limited aid category 69. They are also payable when used for purposes other than family planning. Claims require modifier FPwhen the service diagnosis indicates family planning.

Independent Lab CPT Codes
Q0111	81000	81001	81002	81003	81025	83020	83520
83896	84703	85014	85018	85660	86592	86593	86687
86701	87075	87081	87087	87210	87390	87470	87490
87491***	87536	87590	87591***	87621**	88142*	88143*	88150**
88152	88153	88154	88155**	88164	88165	88166	88167
88174	88175	89300	89310	89320

*Procedure codes 88142 and 88143 are limited to one unit per beneficiary per state fiscal year.

**Payable only to pathologists and independent labs.

***Procedure codes 87491 and 87591 are payable as family planning services effective for dates of service on and after February 1, 2006.

Procedure Code	Required Modifiers	Description
88302	FP	Surgical Pathology, Complete Procedure, Elective Sterilization
88302	FP, U2	Surgical Pathology, Professional Component, Elective Sterilization
88302	FP, U3	Surgical Pathology, Technical Component, Elective Sterilization

292.560Genetic Services

The Arkansas Medicaid Program covers the following procedure codes regarding genetic services.

National Code	Local Code	Local Code Description
Bill on paper	Z1729	Prenatal Diagnosis Counseling
84702	Prenatal screening for fetal anomalies using maternal serum HCG and AFP

NOTE: Where both a national code and a local code ("Z code") are available, the local code can be used only for dates of service through October 15, 2003; the national code must be used for both electronic and paper claims for dates of service after October 15, 2003. Where only a local code is available, it can be used indefinitely, but it can be billed only on a paper claim. Where only a national code is available, it can be used indefinitely for both electronic and paper claims.

A. Documentation

In addition to the medical records physicians are required to keep as detailed in Section 202.200 of this manual, the beneficiary's medical record must verify the physician providing genetic services is a board-certified maternal fetal medicine physician as required by Arkansas Medicaid genetic policy.

B. Prenatal Diagnosis Counseling

Prenatal Diagnosis Counseling must be performed by a maternal fetal medicine physician or a staff member under his or her direct supervision. This service includes, but is not limited to:

1. Family, medical, pregnancy history

2. Psychosocial assessment and counseling of couple regarding genetic testing and disorder

3. Diagnosis, prognosis, available options, pregnancy management are explained to the couple.

C. Services Not Performed by a Physician

When procedure codes Z1729 (must be billed on paper) and 84702are provided and the services are not performed by a physician, the provider must have written policies with a physician who assumes the responsibility for the provision of the services rendered and agrees:

1. To be immediately available for consultation to the staff performing the services,

2. To ensure that the clinic staff has appropriate training and adequate skills for performing the procedures for which they are responsible and

3. To periodically review the staffs level of performance in administering these procedures.

The physician must be physically present (under the same roof) at all times during the service delivery.

292.561Genetic Testing

Medicaid will reimburse physician services for the following genetic testing procedures.

S3840	S3842	S3843	S3844	S3846	S3847	S3848	S3849
S3850	S3851	S3853

292.580Hysterectomy for Cancer or Severe Dysplasia

Physicians/Primary Surgeon may use procedure code Z0663 with an AA modifierwhen billing for a total hysterectomy procedure when the diagnosis is malignant neoplasm or severe dysplasia. Physician/Assistant Surgeons may use procedure code Z0663 with an AA modifier and an additional modifier of 80, 81, or 82, as indicated. Assistant Surgeons must be prior authorized (see section 292.450).Procedure code Z0663does not require prior authorization and must be billed on paper.

292.590Injections

Providers billing the Arkansas Medicaid Program for covered injections should bill the appropriate CPT or HCPCS procedure code for the specific injection administered. The procedure codes and their descriptions may be found in the CPT coding book, in the HCPCS coding book and in this section of this manual.

Unless otherwise indicated, the procedure code for the injection includes the cost of the drug and the administration of the injection for intramuscular or subcutaneous routes.

Most of the covered drugs can be billed electronically. However, any drug marked with an asterisk (*) must be billed on paper with the name of the drug and dosage listed in the "Procedures, Services, or Supplies" column, Field 24D, of the CMS-1500 claim form. View a CMS-1500 sample form.Reimbursement is based on the "Red Book" drug price. If preferred, a copy of the invoice verifying the provider's cost of the drug may be attached to the Medicaid claim form.

292.592Other Covered Injections and Immunizations with Special

Instructions

Physicians may bill for immunization procedures on either the Child Health Services (EPSDT) DMS-694 claim form or the CMS-1500 claim form. View a DMS-694 sample form. View a CMS-1500 sample form.

When a patient is scheduled for immunization only, reimbursement is limited to the immunization. The provider may bill for the immunization only. Unless otherwise noted in this section of the manual, covered vaccines are payable only for beneficiaries underage 21.The following is a list of injections with special instructions for coverage and billing.

Procedure Code	Modifier(s)	Special Instructions
J0150	Procedure is covered for all ages with no diagnosis restriction.
J0152	Payable for all ages. When administered in the office, the provider must have nursing staff available to monitor the patient's vital signs during infusion. The provider must be able to treat cardiac shock and to provide advanced cardiac life support in the treatment area where the drug is infused.
J0170	Payable if the service is performed on an emergency basis and is provided in a physician's office.
J0180*	This procedure is covered for treatment of Fabry's disease, ICD-9-CM diagnosis code 272.7. Procedure requires prior approval from DMS Medical Director. See section 244.001 for additional coverage information and instructions for requesting prior approval.
J0585	Payable for individuals of all ages when medically necessary. Botox A is reviewed for medical necessity based on diagnosis.
J0636	Payable for individuals of all ages receiving dialysis due to renal failure (diagnosis codes 584-586).
J0637*	Caspofungin acetate injection is covered when administered to patients with refractory aspergillosis who also have a diagnosis of malignant neoplasm or HIV disease. Complete history and physical exam, documentation of failure with other conventional therapy and dosage must be submitted with invoice. After 30 days of use, an updated medical exam and history must be submitted.
J0702	Covered for beneficiaries of all ages. However, when provided to beneficiaries aged 21 and older, there must be a diagnosis of AIDS, cancer or complications during pregnancy (diagnosis code range 640 - 648.93).
J0881 J0885	Payable for dates of service on and after March 1, 2006, for non-ESRD use. Covered by Medicaid only when provided to patients with anemia associated with rheumatoid arthritis, sideroblastic anemia, anemia associated with multiple myeloma, anemia associated with B-cell malignancies, myelodysplastic anemia and chemotherapy induced anemia.
J0882 J0886	Payable for dates of service on and after March 1, 2006. Covered when administered to patients diagnosed with ESRD (diagnosis range 584 - 586).
J1100	Covered for beneficiaries of all ages. However, when provided to beneficiaries aged 21 and older, there must be a diagnosis of HIV/AIDS, cancer or complications during pregnancy (diagnosis code range 640 - 648.93).

J1440 J1441 J1460 J1470 J1480 J1490 J1500 J1510 J1520 J1530 J1540 J1550 J1560	Covered for individuals of all ages with no diagnosis restrictions.
J1566 J1567	Electronic and paper claims are reviewed for medical necessity, based on the diagnosis code.
J1600	Payable for patients with a detail diagnosis of rheumatoid arthritis (diagnosis code range 714.0 - 714.9).
J1640	Payable when administered to beneficiaries with ICD-9-CM detail diagnosis 277.1).
J1745*	For beneficiaries under age 18 years, an approval letter is required, regardless of the diagnosis. For beneficiaries age 18 years and older, procedure code J1745 is payable when one of the following conditions exist: 1) ICD-9-CM code 555.9 as the primary detail diagnosis AND a secondary diagnosis of 565.1 or 569.81 OR 2) ICD-9-CM code range 556.0 - 556.9 OR 3) ICD-9-CM code 696.0 OR 4) ICD-9-CM code 714.0 NOTE:ICD-9 diagnosis code 714.0 requires a prior approval letter from the Medical Director. The request for approval must include documentation showing failed trial of Enbrel or Humira. Claims must be submitted to EDS with any applicable attachments. Claims will be manually reviewed by Medicaid medical staff prior to payment. OR 5) ICD-9-CM 724.9. NOTE:ICD-9 diagnosis code 724.9 requires a prior approval letter from the Medical Director. The request for approval must include documentation showing failed trial of Enbrel or Humira. Claims must be submitted to EDS with any applicable

attachments. Claims will be manually reviewed by Medicaid medical staff prior to payment.
J1751 J1752	Effective for dates of service on and after March 1, 2006, procedure codes J1750 became non-payable and was replaced with procedure codes J1751 and J1752. These services are payable for individuals with a diagnosis of ICD-9-CM code 280.9.
J1785*	This procedure is covered for the treatment of Type I Gaucher disease with complications, with a detail diagnosis of ICD-9 code 272.7. Prior approval from the DMS Medical Director is required. See section 244.001 for additional coverage information and instructions for requesting prior approval. A copy of the prior approval letter must be attached to each claim.
J1931*	This procedure is covered for treatment of mucopolysaccharidosis (MPS I), ICD-9-CM diagnosis code 277.5. Prior approval from DMS Medical Director is required. See section 244.001 for additional coverage information and instructions for requesting prior approval. A copy of the prior approval letter must be attached to each claim.
J2260	Payable for Medicaid beneficiaries of all ages with congestive heart failure (ICD-9 diagnosis codes 428-428.9)
J2353* J2354*	Payable for Medicaid beneficiaries of all ages. For ages 21 and older, J2353 and J2354 are covered for diagnosis of aids and cancer (ICD-9-CM diagnosis codes 140.0 - 208.91, 230.0 - 238.9 or 042). For other diagnoses, a prior approval letter is required and must be attached to each claim. See section 244.100 for information of requesting a prior approval letter. Paper billing is required for all diagnoses for all beneficiaries.
J2503	Payable for beneficiaries diagnosed with macular degeneration (ICD-9-CM diagnosis code 362.50 - 362.52).
J2504	Payable for beneficiaries of all ages with a primary detail diagnosis of 279.2.
J2505*	Covered for beneficiaries of all ages with a detail diagnosis from diagnosis code ranges 162.0 - 165.9, or 174.0 - 175.9 or 201.00 - 201.98 or 202.80 - 202.88.
J2513	Covered when administered to beneficiaries of all ages with no diagnosis restrictions.
J2788	Limited to one injection per pregnancy.
J2790 J2792	Payable with a primary diagnosis of 999.7; reviewed for medical necessity prior to payment.
J2910	Payable for patients with a primary detail diagnosis of rheumatoid arthritis (ICD-9 diagnosis codes 714.0 - 714.9).

J2916	Payable for beneficiaries aged 21 and older when there is a diagnosis of cancer, aids, or acute renal failure with a diagnosis on the claim that also includes 964.0. indicating that the beneficiary is allergic to iron dextran. May be billed electronically or on paper.
J2997	Payable for beneficiaries of all ages with no diagnosis restrictions. Limited to 2 units per day in the office place of service.
J3396	Covered for all ages if one of the following: diagnoses exist: ICD-9 diagnosis code 362.50 or 362.52; or ICD-9 diagnosis code 360.21; or ICD-9 diagnosis code 115.02 or 115.12 or 115.92. Claims may be filed electronically or on paper. See section 244.003 for additional coverage information.
J3420	Payable for patients with a primary detail diagnosis of pernicious anemia, 281.0. Coverage includes the B-12, administration and supplies. It must not be billed in multiple units.
J3465*	Covered for non-pregnant beneficiaries aged 18 and older with a diagnosis of AIDS or cancer and one of the following diagnoses: 112.2, 112.3, 112.5, 112.84, 112.85, 112.9 or 117.3. Claims must be filed on paper.
J3487	Payable to physicians when provided in the office if one of the following diagnoses exist: AIDS or cancer along with diagnosis code 275.42 or diagnosis code 198.5; or diagnosis code 203.0. Claim will be manually reviewed prior to payment.
J7198	Payable for all ages with no diagnosis restrictions.
J7199	Must be billed on a paper claim form with the name of the drug, dosage and the route of administration.
J7320	Requires prior authorization. Limited to 3 injections per knee, per beneficiary, per lifetime. (This includes Synvisc.) See section 261.240.
J7330	Requires prior authorization from AFMC for all providers. See sections 260.000, 261.000, 261.100 and 261.110.
J7341	Payable for beneficiaries of all ages with no diagnosis restrictions.
J9025	Coverage of this procedure code requires an ICD-9-CM diagnosis within the code range of 205.00 - 205.91 with applicable 4^th and 5^th digits per ICD-9-CM, or a diagnosis of 238.7.
J9035*	Coverage of this procedure code requires an ICD-9-CM diagnosis within the code range of 140.0 - 208.91, 230.0 -238.9, 042, 362.50 or 362.52. A prior approval letter is required and must be attached to each claim. See section 244.100 for information on requesting prior approval.

J9219	This procedure code is covered for males of all ages with ICD-9-CM diagnosis code 185, 198.82 or V10.46. Benefit limit is one procedure every 12 months.
J9225	Payable for beneficiaries with a diagnosis of malignant neoplasm of prostate (ICD-9-CM code 185).
J9250	Payable for beneficiaries of all ages without restriction.
J9350	Covered for beneficiaries of all ages with a primary detail diagnosis of 162.9 or 183.0. Billable on electronic and paper claims.
J9395*	Payable for beneficiaries of all ages, with a diagnosis of 174.0 - 174.9 after treatment failure with antiestrogen drugs. A prior approval letter is required. Requests for prior approval must include the history, physical exam and plan of treatment stating that request for this drug is due to a treatment failure. See section 244.001 for additional coverage information and instructions for requesting prior approval. A copy of the prior approval letter must be attached to each claim.
Q3025 Q3026	These procedure codes are covered for all ages based on medical necessity.
Q4079*	Procedure requires a prior approval letter. See section 244.100. The history and physical showing a relapse of multiple sclerosis must be submitted with the request for the prior approval letter. This procedure must be billed on a paper claim. The approval letter must be attached to each claim. Requires review before payment.
S0145 S0146	Procedures are payable when there is a primary detail diagnosis ICD-9-CM 070.54
90371	One unit equals 1/2 cc, with a maximum of 10 units payable per day. Payable for Medicaid beneficiaries of all ages in the physician's office.
90375* 90376*	Covered for all ages. Billing requires paper claims with procedure code and dosage entered infield 24.D of claim form CMS-1500 for each date of service. If date spans are used, I units of service must be identical for each date within the span. The manufacturer's invoice must be attached. Reimbursement rate includes administration fee.
90385	Limited to one injection per pregnancy.
90581*	Payable for ages 18 years and older. Indicate dose and attach manufacturer's invoice.
90585	Payable for all ages.
90586	Payable for ages 18 years and older.
90632	Payable when administered to beneficiaries ages 19 years and older.
90633 90634	EP, TJ	Payable when administered to beneficiaries ages 12 months - 18 years. See section 292.593.

90636	EP, TJ	Payable when administered to beneficiaries age 18 years and older. Modifiers are required only when administered to beneficiaries aged 18 years. See section 292.593.
90645 90646 90647	EP, TJ	Payable when administered to beneficiaries of all ages. See section 292.593 for billing instructions when administered to beneficiaries aged 18 years and younger.
90648	EP, TJ	Payable when administered to beneficiaries aged 18 years and younger. Refer to section 292.593 for more information.
90655 90657	EP, TJ	Influenza vaccines payable through the VFC program for beneficiaries 6-35 months of age. See section 292.593 for billing instructions.
90656 90658	EP, TJ	Influenza vaccines payable for beneficiaries aged 3 years and older. Modifiers required only when administered to children under age 19. Refer to sections 292.593 and 292.594 for influenza vaccine policy.
90660	EP, TJ	Covered for healthy individuals aged 5-49 and not pregnant. Modifiers required only when administered to beneficiaries under age 19. See sections 292.593 and 292.594 of this manual.
90665	Payable when administered to beneficiaries ages 19 years and older.
90669	EP, TJ	Administration of vaccine is covered for children under age 5 years. See section 292.593 for billing instructions.
90675* 90676*	Covered for all ages without diagnosis restrictions. Billing requires paper claims with procedure code and dosage entered in field 24.D of claim form CMS-1500 for each date of service. If date spans are used, units of service must be identical for each date within the span. The manufacturer's invoice must be attached. Reimbursement rate includes administration fee.
90680	EP, TJ	VFC vaccine payable when administered to beneficiaries ages 6 weeks - 32 weeks. See section 292.593 for more information.
90690	Payable for beneficiaries ages 6 years and older.
90691	Payable for beneficiaries aged 3 years and older.
90698	Payable for beneficiaries aged 0-7 years.
90700	EP, TJ	VFC vaccine payable when administered to beneficiaries under age 7 years. Modifiers are required. See section 292.593 for more information.
90703	Payable for ages 18 years and older.
90704	Payable for beneficiaries aged 1 year and older.
90705	Payable for ages 9 months and older.

90706 90707	U1	Payable for ages 1 year and older. Payable when provided to women of childbearing age, ages 21 through 44, who may be at risk of exposure to these diseases. Coverage is limited to two (2) injections per lifetime. U1 modifier is required for this age group. Payable when administered to beneficiaries aged 19 and 20 years.
90707	EP, TJ	Payable when administered to beneficiaries under age 19 years. Modifiers are required when administered to beneficiaries underage 19 years. See section 292.593.
90708	Payable for beneficiaries 9 months of age and older.
90710	EP, TJ	Payable for beneficiaries under age 21 years. Modifiers are required only when administered to children underage 19. See section 292.593 for additional information.
90713	EP, TJ	Payable for beneficiaries of all ages. However, modifiers are required only when administered to beneficiaries under age 19 years. See section 292.593.
90714	EP, TJ	Payable for beneficiaries ages 7 years and older. Modifiers are required when administered to beneficiaries under age 19 years. See section 292.593.
90715	EP, TJ	This vaccine is covered for individuals aged 7 years and older. Modifiers are required only when administered to beneficiaries underage 19 years. See section 292.593.
90716	EP, TJ	This vaccine is covered for beneficiaries under age 21. Modifiers are required only when administered to beneficiaries underage 19. See section 292.593.
90717	Payable for all ages. Submit invoice with claim.
90718	EP, TJ	This vaccine is covered for individuals aged 7 years and older. Modifiers are required only when administered to beneficiaries underage 19.years. See section 292.593.
90719	This vaccine is covered for individuals of all ages.
90721	EP, TJ	Covered for beneficiaries under age 21 years. Modifiers are required only when administered to beneficiaries under age 19 years. See section 292.593.
90723	EP, TJ	Covered for beneficiaries under age 19 years. See section 292.593.
90725*	Payable for all ages; submit manufacturer's invoice.
90727*	{Payable for all ages; submit manufacturer's invoice.
90732	This code is payable for individuals aged 2 years and older. Patients age 21 years and older who receive the injection must be considered by the provider as high risk. All beneficiaries over age 65 may be considered high risk.

90733	Covered for beneficiaries of all ages.
90734	EP, TJ	Covered for beneficiaries of all ages. Modifiers are required only when administered to beneficiaries underage 19 years. See section 292.593.
90735	Payable for individuals under age 21 years.
90740	Three dose schedule. Payable for individuals of all ages.
90743	EP, TJ	Two dose schedule. Payable only when administered to children aged 0-18 years. See section 292.593.
90744	EP, TJ	Three dose schedule. Payable forages 0-18 years. See section 292.593.
90746	Payable for ages 19 years and older.
90747	EP, TJ	Covered for beneficiaries of all ages. Modifiers are required onlywhen administered to beneficiaries underage 19 years. See section 292.593.
90748	EP, TJ	Covered for beneficiaries of all ages. Modifiers are required onlywhen administered to beneficiaries underage 19 years. See section 292.593.

* Procedure code requires paper billing with applicable attachments.

292.593 Vaccines for Children Program

The Vaccines for Children (VFC) Program was established to generate awareness and access for childhood immunizations. Arkansas Medicaid established new procedure codes for billing the administration of VFC immunizations for children under the age of 19. To enroll in the VFC Program, contact the Arkansas Division of Health. Providers may also obtain the vaccines to administer from the Arkansas Division of Health. View or print Arkansas Division of Health contact information.

Medicaid policy regarding immunizations for adults remains unchanged by the VFC Program.

Vaccines available through the VFC program are covered for Medicaid-eligible children. Administration fee only is reimbursed. When filing claims for administering VFC vaccines, providers must use the CPT procedure code for the vaccine administered. Electronic and paper claims require modifiers EP and TJ When vaccines are administered to beneficiaries of ARKids First-B services, only modifier TJ must be used for billing.

The following is a list of covered vaccines for children underage 19.

90633*	90634*	90636	90645	90646	90647	90648	90655
90656	90657	90658	90660	90669	90680**	90700	90707
90710*	90713	90714	90715*	90716	90718	90721	90723
90734*	90743	90744	90747	90748

*Effective for dates of service on and after March 1, 2006, these vaccines are available through the VFC program.

"Effective for dates of service on and after July 10, 2006, procedure code 90680 is available through the VFC program.

292.594Influenza Virus Vaccine

A. Procedure code 90655,influenza virus vaccine, split virus, preservative free, for children 6 to 35 months, is currently covered through the VFC program. Claims for Medicaid beneficiaries must be filed using modifiers EP and TJ

ForARKids First-B beneficiaries, use modifier TJ

B. Effective for dates of service on and after October 1, 2005, Medicaid will cover procedure code 90656, influenza virus vaccine, split virus, preservative free, for ages 3 years and older.

1. For individuals under 19 years of age, claims must be filed using modifiers EP and TJ.

2. ForARKids First-B beneficiaries, use modifier TJ

3. For individuals ages 19 and older, no modifier is necessary.

C. Effective for dates of service on and after October 1, 2005, procedure code 90660,influenza virus vaccine, live, for intranasal use, is covered. Coverage is limited to healthy individuals ages 5 through 49 who are not pregnant.

1. When filing claims for children 5 through18 years of age, use modifiers EP and TJ.

2. ForARKids First-B beneficiaries, the procedure code must be billed using modifier TJ.

3. No modifier is required for filing claims for beneficiaries ages 19 through 49.

D. Procedure code 90657,influenza virus vaccine, split virus, for children ages 6 through 35 months, is covered. Modifiers EP and TJ are required.

ForARKids First-B beneficiaries, use modifier TJ

E. Procedure code 90658, influenza virus vaccine, split virus, for use in individuals ages 3 years and older, will continue to be covered.

1. When filing claims for individuals under age 19, use modifiers EP and TJ.

2. ForARKids First-B beneficiaries, use modifier TJ

3. No modifier is required for filing claims for beneficiaries aged 19 and older.

292.596Zoledronic Acid Injection

A. Zoledronic acid injection, procedure code J3487,is payable to the physician when provided in the office for patients of all ages. However, beneficiaries aged 21 and older must have one of the following:

1. A diagnosis of AIDS or cancer along with diagnosis code 272.42; or

2. A diagnosis of 198.5; or

3. A diagnosis of 203.0

B. Procedure code J3487must be billed on paper. ICD-9-CM diagnosis criteria is used in point A above, no medical records are required.

C. Utilization Review's medical staff must manually review claims for zoledronic acid injections before payment is approved.

292.597Vaccines for Children Program

The Vaccines for Children (VFC) Program was established to generate awareness and access for childhood immunizations. Arkansas Medicaid established new procedure codes for billing the administration of VFC immunizations for children under the age of 19. To enroll in the VFC Program, contact the Arkansas Department of Health. Providers may also obtain the vaccines to administer from the Arkansas Department of Health. View or print Arkansas Department of Health contact information.

Medicaid policy regarding immunizations for adults remains unchanged by the VFC Program.

The following is a list of covered vaccines for children underage 19.

90645	90646	90647	90655	90657	90658	90669	90700
90702	90707	90712	90713	90716	90718	90720	90721
90723	90743	90744	90748

292.598Influenza Virus Vaccine

ForARKids First-B beneficiaries, use modifier TJ.

B. Effective for dates of service on and after October 1, 2005, Medicaid will cover procedure code 90656, influenza virus vaccine, split virus, preservative free, for ages 3 years and older.

1. For individuals under 19 years of age, claims must be filed using modifiers EP and TJ.

2. ForARKids First-B beneficiaries, use modifier TJ.

3. For individuals ages 19 and older, no modifier is necessary.

1. When filing claims for children 5 through18 years of age, use modifiers EP and TJ.

2. ForARKids First-B beneficiaries, the procedure code must be billed using modifier TJ.

3. No modifier is required for filing claims for beneficiaries ages 19 through 49.

D. Procedure code 90657,influenza virus vaccine, split virus, for children ages 6 through 35 months, is covered. Modifiers EP and TJ are required.

ForARKids First-B beneficiaries, use modifier TJ.

E. Procedure code 90658, influenza virus vaccine, split virus, for use in individuals ages 3 years and older, will continue to be covered.

1. When filing paper claims for individuals under age 19, use modifiers EP and TJ.

2. ForARKids First-B beneficiaries, use modifier TJ..

3. No modifier is required for filing claims for beneficiaries aged 19 and older.

292.620Office Medical Supplies - Beneficiaries Under Age 21

For beneficiaries under age 21, procedure code 99070 is payable to physicians for supplies and materials (except eyeglasses), provided by the physician over and above those usually included with the office visit or other services rendered. Procedure code 99070must not be billed for the provision of drug supply samples and may not be billed on the same date of service as a surgery code. When filing claims, physicians must bill procedure code 99070.Claims require National Place of Service code "11". Procedure code 99070is limited to beneficiaries underage 21.

292.672Method 2 - "Itemized Billing"

Use this method only when either of the following conditions exists:

A. Less than two months of antepartum care was provided or

B. The patient was NOT Medicaid eligible for at least the last two months of the pregnancy.

Bill Medicaid for the antepartum care in accordance with the special billing procedures set forth in section 292.675. The visits for antepartum care will not be counted against the patient's annual physician benefit limit. Keep in mind that date-of-service spans may not include any dates for which the patient was not eligible for Medicaid.

Bill Medicaid for the delivery and postpartum care with the applicable procedure code from the following table:

National Codes
59410	59515	59525	59622

National Code	Local Code	Local Code Description
Z1930	80,81,82	Non-Emergency Hysterectomy after C-Section [Requires prior authorization from the Arkansas Foundation for Medical Care (AFMC)]. Bill on paper.

If Method 2 is used to bill for OB services, care should be taken to ensure that the services are billed within the 12-month filing deadline.

If only the delivery is performed and neither antepartum nor postpartum services are rendered, procedure codes 59409or 59612should be billed for vaginal delivery and procedure codes 59514or 59620should be billed for cesarean section. Procedure codes 59400, 59410, 59510and 59515may not be billed in addition to procedure codes 59409, 59612, 59514or 59620.These procedures will be reviewed on a post-payment basis to ensure that these procedures are not billed in addition to antepartum or postpartum care.

Operative standby for a C-section must be billed using procedure code 99360.

Laboratory and X-ray services may be billed separately using the appropriate CPT codes, if this is the physician's standard office practice for billing OB patients. If lab tests and/or X-rays are pregnancy related, the referring physician must be sure to code appropriately when these services are sent to the lab or X-ray facility. The diagnostic facilities are completely dependent on the referring physician for diagnosis information necessary for Medicaid reimbursement.

The obstetrical laboratory profile procedure code 80055 consists of four components: Complete blood count, VDRL, Rubella and blood typing and RH. If the ASO titer (procedure code 86060)is performed, the test should be billed separately using the individual code.

For laboratory procedures, if a blood specimen is sent to an outside laboratory, only a collection fee may be billed. No additional fees are to be billed for other types of specimens that are sent for testing to an outside laboratory. The laboratory could then bill Medicaid for the laboratory procedure. Refer to Section 292.600 of this manual.

NOTE: Payment will not be made for emergency room physician charges on an OB

patient admitted directly from the emergency room into the hospital for delivery.

292.674External Fetal Monitoring

Procedure code 59050must be used exclusively for external fetal monitoring when performed in a physician's office or clinic with National Place of Service code "11. Physicians may bill for one unit per day of external fetal monitoring. Physicians may bill for external fetal monitoring in addition to a global obstetric fee. When itemizing obstetric visits, physicians may bill for medically necessary fetal monitoring in addition to obstetric office visits.

292.675 Obstetrical Care Without Delivery

A. Obstetrical care without delivery may be billed using procedure code 59425, modifier UA, when 1 - 3 visits are provided and 59425with no modifiers when 4 - 6 six visits are provided. Procedure code 59426 with no modifiers is payable for 7 or more visits.

B. These procedure codes enable physicians rendering care to the patient during the pregnancy, but not delivering the baby, to receive reimbursement for these services. Units of service billed with these procedure codes are not counted against the patient's annual physician visit benefit limit. Reimbursement for each visit includes routine sugar and protein analysis. Other lab tests may be billed separately within 12 months of the date of service.

C. Providers must enter the dates of service in the CMS-1500 claim format and the number of units being billed. One visit equals one unit of service. Providers must submit the claim within 12 months of the first date of service.

View a CMS-1500 sample form.

For example:An OB patient is seen by Dr. Smith on 1-10-05, 2-10-05, 3-10-05, 4-10-05, 5-10-05 and 6-10-05. The patient then moves and begins seeing another physician prior to the delivery. Dr. Smith may submit a claim with dates of service shown as 1-10-05 through 6-10-05 and 6 units of service entered in the appropriate field. EDS must receive the claim within the 12 months from the first date of service. Dr. Smith must have on file the patient's medical record that reflects each date of service being billed. Dr. Smith must bill the appropriate code: 59425with modifier UA when 1 - 3 visits are provided, 59425with no modifiers when 4-6 visits are provided and procedure code 59426when 7 or more visits are provided.

292.682Non-Emergency Services

Procedure code T1015,modifier U1, should be billed for a non-emergency physician visit in the emergency department. Procedure code T1015,modifier U1, requires PCP referral. This procedure code is subject to the non-emergency outpatient hospital benefit limit of 12 visits per state fiscal year (SFY).

Physicians must use procedure code T1015,modifier U2, Physician Outpatient Clinic

Servicesfor outpatient hospital visits. This service requires a PCP referral. Procedure codes T1015,modifier U1,and T1015,modifier U2, are subject to the benefit limit of 12 visits perSFY for non-emergency professional visits to an outpatient hospital for patients age 21 and over.

To reimburse emergency department physicians for determining emergent or non-emergent patient status, Medicaid established a physician assessment fee. Procedure code T1015, Physician Assessment in Outpatient Hospitalis payable for beneficiaries enrolled with a PCP. The procedure code does not require PCP referral. The procedure code does not count against the beneficiary's benefit limits, but the beneficiary must be enrolled with a PCP. It is for use when the beneficiary is not admitted for inpatient or outpatient treatment.

292.730 Professional and Technical Components

Covered laboratory and radiology procedure codes in code range 70010through 89399as well as covered services listed in the Medicine section of CPT and HCPCS procedure codes manuals that require the use of a machine may be billed electronically or on paper.

Applicable modifiers are required in Field 24D in addition to the procedure code. Modifier TCmust be used for the technical component and modifier 26must be used for the professional component.

292.741Individual Medical Psychotherapy

The appropriate CPT procedure codes must be used when billing for individual medical psychotherapy. The appropriate National Place of Service code must be entered in Field 24B in the CMS-1500 claim format.

292.750Radiation Therapy

Refer to the Radiology section of the CPT coding book for appropriate CPT procedure codes.

292.760Rural Health Clinic (RHC) Non-Core Services

Physician groups whose individual practitioners are contracting with a rural health clinic are limited to billing Medicaid for Rural Health Clinic (RHC) non-core services. These providers may bill the following procedure codes:

RHC NON-CORE	SERV ICES
Outpatient Hospi	ital Visits	Inpatient Hospital Visits
Non-emergency: Emergency:	T1015 modifier U1 99281 through 99285	99217 through 99223 99231 through 99238 99251 through 99255 99291,99295,99296,99297

Electrocardiograms and Echocardiography Technical component- only Modifier TC

Radiology

Technical component only Modifier

93005,93012,93041,93225,93226,93231, 93232,93236,93270,93271,93307, 93308, 93312,93320,93321, 93325, 93350

70010 through 76946 76950 through 76977 76999 through 78813 78990 through 79999

Surgery, Outpatient and Inpatient

All payable CPT procedure codes within range 10040 through 69990

NOTE: Inpatient and outpatient hospital services are RHC non-core services only if the physician's contract with the RHC does not state that the physician will be compensated by the RHC for those services. Interpretation of X-rays and diagnostic machine tests in the inpatient or outpatient hospital is a non-core service when the visit itself is a non-core service. Home visits, nursing facility visits or other off-site visits are RHC encounters if the physician's agreement with the RHC requires that he or she provide the services and seek compensation from the RHC. Any of these off-site services is payable separately (through the Physician Program) from the RHC encounter fee if it is not a part of the physician's contract with the RHC.

See Sections 201.120 and 246.000 of this manual for additional information.

292.770 Sexual Abuse Examination for Beneficiaries Under Age 21

The procedure code for Sexual Abuse Examination listed in the table below is payable to physicians when provided in the physician's office or in a hospital outpatient department, emergency or non-emergency, with National Place of Service: code "11", "23" or "22".This procedure is exempt from the PCP referral requirement and is covered for beneficiaries under the age of 21 only.

Procedure Code	Modifier	Description	Diagnosis Code
99205	U2	Sexual Abuse Examination	995.53

292.780Substitute Physicians

To comply with Section 4708 of the Omnibus Budget Reconciliation Act of 1990 (OBRA 90), the Arkansas Medicaid Program implemented the following requirements regarding substitute physician billing identification:

A. Under a reciprocal billing arrangement (not to exceed 14 continuous days), the regular physician must identify the services as substitute physician services by entering in Field 24D in the CMS-1500 claim format a "Q5" modifier after the procedure code.

B. Under a locum tenens billing arrangement (90 continuous days or longer), the regular physician must identify the services as substitute physician services by entering in Field 24D in the CMS-1500 claim format a "Q6" modifier after the procedure code.

Under both the above billing arrangements, the billing (regular) physician (or medical group) must keep on file a record of each service provided by the substitute physician, associated with the substitute physician's name and make this record available upon request. A record of the service would include the date and place of the service, the procedure code, the charge and the beneficiary involved.

These billing requirements apply to all substitute physician services including Primary Care Physician Managed Care Program services.

292.790Surgical Procedures with Certain Diagnosis Ranges

The following procedure codes are payable by the Arkansas Medicaid Program only if the diagnosis is in the range listed below:

Procedure Code	Procedure Description	Diagnosis Range
44950	Appendectomy	5400 - 5439
44960	Appendectomy with abscess	5400 - 5439
49520	Hernia	55000 - 55093

292.801Cochlear Implant and External Sound Processor

Procedure code 69930- Cochlear device implantation, with or without mastoidectomy - may be billed only by the physician performing the surgical procedure up to 50 daily units. When the cochlear device is provided by the physician, the physician may bill procedure code L8614for the cochlear device using EPmodifier. Procedure code 69930 and L8614require prior authorization. The physician must attach a copy of the invoice to the CMS-1500 claim form. If the cochlear device is provided by the hospital, the physician may not bill for the device. Refer to Section 251.230 of this manual for coverage information.

External sound processors, procedure code L8619,are covered for eligible Medicaid beneficiaries underage 21 in the EPSDT Program. Additional procedure codes L8615, L8616, L8617, L8618, L8621and L8622are also payable to the physician. These procedure codes require prior authorization and the physician must attach a copy of the invoice to the CMS-1500 claim form. Refer to Section 251.230 of this manual for coverage information.

Procedures are covered for beneficiaries under age 21 and must be billed with modifier EP.

View a CMS-1500 sample form.

292.810Telemedicine (Interactive Electronic Medical Transactions)

292.811Telemedicine Physician Services

A. Physicians providing covered telemedicine services must comply with the definitions and coding requirements of Sections 292.811 through 292.813 when billing Medicaid.

B. Telemedicine transactions involve interaction between individuals who are each physically located at one of two sites.

TelemedicineSite Definitions
Local Site:	The local site is the patient's location.
Remote Site:	The remote site is the location of the physician performing a telemedicine service for the patient at the local site.

C. The National Place of Service (POS) code is determined by the patient's location (the local site) or, if the patient is an inpatient of an acute care or rehabilitative hospital, by the patient's inpatient status.

Telemedicine National Place of Service (POS) Codes

Electronic and paper claims now require the same National Place of Service code.

POS Codes

Descriptions

Inpatient hospital

The place of service for a hospital inpatient is always 21, regardless of the patient's physical location at the time of a particular service.

22	Non-emergency outpatient hospital
11	Physician office or clinic (includes rural health clinics)
24	Ambulatory surgical center
56	Federally qualified health center
23	Emergency department for emergency services.

The remote site is never the place of service.

292.812Telemedicine Evaluation and Management Procedure Codes

Arkansas Medicaid reimburses as telemedicine services, the evaluation and management services listed in this section when the services are billed by their correct procedure codes and place of service codes as listed and defined in Sections 292.811 through 292.813.

HCPCS Code	Modifier	Description
T1015	U1	Non-emergency Outpatient Hospital Visit

Procedure Code
99201	99202	99203	99204	99205	99211	99212	99213
99214	99215	99221	99222	99223	99231	99232	99233
99241	99242	99243	99244	99245	99251	99252	99253
99254	99255	99281	99282	99283	99284	99285

*NOTE: Arkansas Medicaid covers telemedicine evaluation and management services of an attending physician at the local site only when the physician is physically attending the patient and is presenting the case to a consulting physician at the remote site by means of telemedicine media.

292.813 Telemedicine Echography and Echocardiography Procedure Codes

Arkansas Medicaid reimburses as telemedicine services, the radiology procedures listed in this subsection when the services are billed by their correct procedure codes and National Place of Service codes as listed and defined in Sections 292.811 through 292.813.

A. The local site may bill only the technical component (Modifier TC) of the ultrasound procedures listed below.

B. Please note that, when billing for remote site services, the National Place of Service code is determined by the patient's location or by the patient's inpatient status, as explained at Section 292.811, subpart C.

Procedure Code
76805	76810	76815	76816	76818	76825	76826	76827
76828	76830	76856	76857

292.821Billing for Corneal Transplants

The following CPT procedure codes are payable for corneal transplants with prior approval: 65710,65730, 65750and 65755.

Medicaid will reimburse the physician for the acquisition and preservation of the cornea. Medicaid will not reimburse for the transportation of the cornea. HCPCS procedure code V2785must be used when billing for the acquisition and preservation of the cornea. This code must be billed in conjunction with the transplant surgery. An itemized statement for the acquisition and preservation of the cornea must accompany the CMS-1500 claim form. View a CMS-1500 sample form.

292.850Blood or Blood Components for Transfusions

The Arkansas Medicaid Program will reimburse for blood or blood components used for transfusions in the physician's office. CPT procedure code 36430should be used for the administration fee. This includes all supplies used to perform the transfusion. The blood or blood components supplied by the physician may be billed using CPT procedure code 86999.A copy of the invoice must be attached to the claim form with the amount that was charged for the blood product circled. The number of units provided to the Medicaid eligible patient must be indicated on the invoice. Any laboratory procedures performed may be billed using the appropriate CPT procedure codes.

292.860 Hyperbaric Oxygen Therapy Procedures

Physicians may be reimbursed for attendance and supervision of hyperbaric oxygen therapy. Physicians billing for the physician component of "Physician attendance and supervision of hyperbaric oxygen therapy" may bill for only one unit of service per day.The physician's charge for each service date must include all his or her hyperbaric oxygen therapy charges, regardless of how many treatment sessions per day are administered.

A. Physicians may bill for surgery and professional components of anatomical lab procedures, X-rays and machine tests in addition to 99183.

B. Physicians must file paper claims for 99183because the claims are reviewed for medical necessity.

1. Indicate which treatment session is being billed (for example, "Treatment session # 4") and attach pertinent progress and treatment notes.

2. Refer to section 258.000 of this manual for coverage policy, diagnosis requirements and treatment schedules.

292.870Bilaminate Graft or Skin Substitute Procedures

Arkansas Medicaid will reimburse physicians who furnish the manufactured viable bilaminate graft or skin substitute with prior authorization. The product is manually priced and requires paper claims using procedure code J7340.The manufacturer's invoice and the operative report must be attached.

Application procedures for bilaminate skin substitute do not require prior authorization. The procedures are payable to the physician and must be listed separately on claims.

Surgical preparation procedures, CPT codes 15000and 15001,may be reimbursed when performed at the same surgical setting. These codes are to be listed separately in addition to the primary procedure and do not require PA.

292.880Enterra Therapy for Gastroparesis

When filing claims for Enterra therapy for treatment of gastroparesis use procedure code S2213for implantation of gastric electrical stimulation and 64555for implantation of peripheral neurostimulator electrodes. A prior authorization number is required on the claim.

Procedure code 64595must be used when filing claims for revision or removal of the peripheral neurostimulator. This procedure does not require prior authorization but the claim must be filed on paper with operative report attached.

292.890Gastrointestinal Tract Imaging with Endoscopy Capsule

For gastrointestinal tract imaging with endoscopy capsule, claims must be filed on paper with the patient's medical history and physical exam attached. Claims will be manually reviewed prior to reimbursement.

Procedure code 91110must be used when performed in the physician's office. Modifier 26 must additionally be used for professional component when performed as inpatient, outpatient hospital or ambulatory surgical center.

SECTION II- PROSTHETICS

242.110 Respiratory and Diabetic Equipment, All Ages

When billed either electronically or on paper, procedure codes found in this section must be billed with modifier EPfor 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 EPor NU.

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

* Prior authorization is not required when other insurance pays at least 50% of the

Medicaid maximum allowable reimbursement amount.

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

Respiratory and Diabetic Equipment, All Ages (section 242.110)

Procedure Code	M1	M2	Description	PA	Payment Method
A4230	NU	Infusion set for external insulin pump, nonneedle cannula type (each)	Y*	Purchase
A4231	NU	Infusion set for external insulin pump, needle type (each)	Y*	Purchase
A4232	NU	Syringe with needle for external insulin pump, sterile, 3 cc (each)	Y*	Purchase
A4627	NU	UB	***(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	***(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	Replacement battery for external infusion pump, any type, each	Y*	Purchase
A6021	NU	Collagen dressing, pad size 16 sq. in. or less, each	Y*	Purchase
A6022	NU	Collagen dressing, pad size more than 16 sq. in. but less than or equal to 48 sq. in., each	Y*	Purchase
A6023	NU	Collagen dressing, pad size more than 48 sq. in., each	Y*	Purchase
A6024	NU	Collagen dressing wound filler, per 6 in.	Y*	Purchase

A7034	NU	RR	*(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	*(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	*(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	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	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	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	***(Bronchial Drainage System) High-frequency chest wall oscillation air-pulse generator system (includes hoses and vest), each	Y*	Rental Only
E0483	NU	UB	*(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	Humidifier, non-heated, used w/positive airway pressure device	Y Y	Purchase
E0562	NU EP	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	External ambulatory infusion pump, insulin	Y*	Purchase
E1340	NU	*(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	/*(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	***(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	***(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	02 concentrator, dual delivery port, capable of delivering 85% or [GREATER THAN] 02 concentration at the prescribed flow rate, each	Y	Purchase

E1391

02 concentrator, dual delivery port, 85% or [GREATER THAN] 02 concentration at the prescribed flow rate, each

Purchase

242.111Initial Rental of a DME Item for Individuals of All Ages

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.

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 other insurance pays at least 50% of the

Medicaid maximum allowable reimbursement amount.

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

Initial Rental of a DME Item for Individuals of All Ages (section 242.111)

Procedure Code	M1	M2	Description	All U21 21+
A7034*	*(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	Hydrocollatorunit, 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*	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	Hospital bed, variable height; hi-lo, with any type side rails, with mattress	21 +
E0260*	Hospital bed, semi-electric (head and foot adjustment), with any type side rails with mattress	U21
E0260*	KH	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	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	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	Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; four foot panel	U21
E0693	Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; six foot panel	U21
E0694	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
E0745*	Neuromuscular stimulator, electronic shock unit	U21
E0747*	Osteogenesis stimulator, electrical noninvasive, other than spinal applications	U21
E0779*	***(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	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	Standard wheelchair, fixed full-length arms, fixed or swing-away, detachable footrests	21 +
E1224*	Wheelchair with detachable arms, elevating legrests	U21
E1224*	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 for the same time period.

242.112Home Blood Glucose Monitor and Supplies - Pregnant Women

Only, All Ages

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

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

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

242.120Medical Supplies, All Ages

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

¹ These supplies must be prior authorized. Form AFMC-103 may be used for the request for prior authorization. View or print form AFMC-103 and instructions for completion.

Please note: Compression burn garments are manually priced.

Medical Supplies, All Ages (section 242.120)

Procedure Code	M1	M2	Description
A4206	NU	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	Sterile water/saline, 10 ml
A4217	NU	Sterile water/saline, 500 ml
A4221¹	NU	Supplies for maintenance of drug infusion catheter, per week (list drug separately)
A4222¹	NU	Supplies for external drug infusion pump, per cassette or bag (list drug separately)
A4253	NU	Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips
A4253	NU	UB	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	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	Adhesive remover wipes, any type, per 50
A4367	NU	Ostomy belt, each
A4368	NU	Ostomy filter, any type, each

A4369	NU	Ostomy skin barrier, liquid, (spray, brush, etc), peroz
A4371	NU	Ostomy skin barrier, power, per oz
A4394	NU	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, 4x4 inches or smaller, each
A4450	NU	U1	Tape, non-waterproof, per 18 square inches
A4450	NU	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	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	Alginate or other fiber gelling dressing, wound cover, pad size 16 sq. in. or less, each dressing
A6197	NU	UB	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	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	Alginate or other fiber gelling dressing, wound cover, pad size more than 48 sq. in., each dressing
A6203	NU	Composite dressing, pad size 16 sq. in. or less, with any size adhesive border, each dressing

A6204	NU	Composite dressing, pad size more than 16 sq. in. but less than 48 sq. in., with any size adhesive border, each dressing
A6205	NU	Composite dressing, pad size more than 48 sq. in., with any size adhesive border, each dressing
A6211	NU	Foam dressing, wound cover, pad size more than 48 sq. in., without adhesive border, each dressing
A6212	NU	Foam dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive border, each dressing
A6213	NU	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	Gauze, non-impregnated, non-sterile, pad size 16 sq. in. or less, without adhesive border, each dressing
A6219	NU	Gauze, non-impregnated, 16 sq. in. or less with any size adhesive border, each dressing
A6220	NU	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	Gauze, non-impregnated, pad size more than 48 sq. in., with any size adhesive border, each dressing
A6228	NU	Gauze, impregnated, water or normal saline, pad, size 16 sq. in. or less, without adhesive border, each dressing
A6229	NU	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	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	Hydrocolloid dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing
A6235	NU	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	Hydrocolloid dressing, wound cover, pad size more than 48 sq. in., without adhesive border, each dressing
A6237	NU	Hydrocolloid dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive border, each dressing
A6238	NU	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	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	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	Hydrogel dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing
A6243	NU	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	Hydrogel dressing, wound cover, pad size more than 48 sq. in. without adhesive border, each dressing
A6245	NU	Hydrogel dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive border, each dressing
A6246	NU	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	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	Hydrogel dressing, wound filler, gel, per fluid ounce
A6257	NU	Transparent film, 16 sq. in. or less, each dressing
A6258	NU	Transparent film, more than 16 sq. in., but less than or equal to 48 sq. in., each dressing
A6259	NU	Transparent film, more than 48 sq. in., each dressing
A6403	NU	Gauze, non-impregnated, sterile, pad size more than 16 sq. in. but less than 48 sq. in., without adhesive border, each dressing
A6404	NU	Gauze, non-impregnated, sterile, pad size more than 48 sq. in., without adhesive border, each dressing
A6441	NU	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	Conforming bandage, non-elastic, knitted/woven, non-sterile, width [GREATER THAN] or = 3 in & [LESS THAN] 5 in, per yd
A6444	NU	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	Conforming bandage, non-elastic, knitted/woven, sterile, width [GREATER THAN] or = 3 in & [LESS THAN] 5 in, per yd
A6447	NU	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	Light compression bandage, elastic, knitted/woven, width [GREATER THAN] or = 3 in & [LESS THAN] 5 in, per yd
A6450	NU	Light compression bandage, elastic, knitted/woven, width [GREATER THAN] or = 5 in, per yd
A6451	NU	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	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

242.121Food Thickeners, All Ages

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

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

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

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

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

242.122Jobst Stocking, All Ages

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 AFMC. View or print form AFMC-103 and instructions for completion.Documentation accompanying form AFMC-103 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	Description	Maximum Units
A6549	NU	Gradient compression stocking, NOS (Jobst); 1 unit = 1 stocking	Maximum 4 units per date of service

242.130Diapers and Underpads, 3 Years Old and Older

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

Modifiers in this section are indicated by the headings M1 and M2. Prior authorization is indicated by the heading PA. If prior authorization is required, that information is indicated with a "Y" in the column, or if not, an "N" is shown.

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

Diapers and Underpads, 3 Years Old and Older (section 242.130)

Procedure Code	M1	M2	Description	PA	Payment Method
A4335	EP	***(Small Child-Size Diaper) Incontinence supply; miscellaneous	N	Purchase
A4335	EP	U1	***(Medium Child-Size Diaper) Incontinence supply; miscellaneous	N	Purchase
A4335	EP	U2	***(Large Child-Size Diaper) Incontinence supply; miscellaneous	N	Purchase
A4335	NU EP	U1 U3	***Incontinence supply; miscellaneous (Under-Garment One size fits all)	N	Purchase
A4554	NU	Disposable underpads, all sizes (e.g., Chux's)	N	Purchase
T4521	NU	Adult-sized disposable incontinence product, brief/diaper, small, each	N	Purchase
T4522	NU	Adult-sized disposable incontinence product, brief/diaper, medium, each	N	Purchase
T4523	NU	Adult-sized disposable incontinence product, brief/diaper, large, each	N	Purchase
T4524	NU	Adult-sized disposable incontinence product, brief/diaper, extra large, each	N	Purchase
T4526	NU EP	Adult-sized disposable incontinence product, protective underwear/pull-on, medium size, each	N	Purchase
T4527	NU EP	Adult-sized disposable incontinence product, protective underwear/pull-on, large size, each	N	Purchase
T4528	NU EP	Adult-sized disposable incontinence product, protective underwear/pull-on, extra large size, each	N	Purchase

T4529	EP	Pediatric-sized disposable incontinence product, brief/diaper, small/medium size, each	N	Purchase
T4529	EP	U1	Pediatric-sized disposable incontinence product, brief/diaper, small/medium size, each	N	Purchase
T4530	EP	Pediatric-sized disposable incontinence product, brief/diaper, large size, each	N	Purchase
T4531	EP	Pediatric-sized disposable incontinence product, brief/diaper, reusable, small/medium size, each	N	Purchase
T4531	EP	U1	Pediatric-sized disposable incontinence product, brief/diaper, reusable, small/medium size, each	N	Purchase
T4532	EP	Pediatric-sized disposable incontinence product, brief/diaper, reusable, large size, each	N	Purchase
T4532	EP	U1	Pediatric-sized disposable incontinence product, brief/diaper, reusable, large size, each	N	Purchase
T4533	EP	Youth-sized disposable incontinence product, brief/diaper, each	N	Purchase
T4535	NU EP	Disposable liner/shield/guard/pad/undergarmentfor incontinence, each	N	Purchase
T4535	NU EP	U1 U1	Disposable liner/shield/guard/pad/undergarmentfor 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 212.100 of this manual for coverage information on diapers and underpads.

242.140Electronic Blood Pressure Monitor and Cuff, All Ages

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

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

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

Procedure Code	M1	M2	Description	PA	Payment Method
A4670	NU	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.

242.150Nutritional Formulae for Child Health Services (EPSDT)

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: The Women, Infant and Children program (WIC) must be accessed first for children from birth through five years of age.

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

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

Nutritional Formulae for Child Health Services (EPSDT) Beneficiaries Under 21 Years of Age (section 242.150)

Procedure Code	M1	M2	M3	Description	Covered Formulae
B4149 B4149	EP EP	BO	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	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 Benefiber and FOS				Fortison	Osmolite
Carnation Instant Breakfast-Lactose Free				Intraolite	Osmolite 1.0 CAL
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	Ultracal
Fibersource				Nutren 1.0
B4150 B4152 B4152	EP EP EP	U1 BO	BO	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 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 Pudding Ensure Pudding Boost Plus Carnation Instant Breakfast - Lactose Free Plus Comply Ensure Plus Ensure Plus HN Novasource 2.0 Nutren 1.5 Nutren 2.0 Scandishake Two-Cal HN

B4153 B4153	EP EP	BO	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 To I e rex Vital HN Vivonex Plus Vivonex TEN
B4154 B4154	EP EP	BO	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:
Ad vera				Impact with Fiber	Pulmocare
AminAid				IsoSourceVHN	Resource Diabetic
Choice DM/Boost Diabetic				Ketocal	Respalor
Forta Drink				Lipisorb	Similac 60/40
Glucerna				Lofenalac	Suplena
Glytrol				Nepro	Traumacal
Hepatic Aid				NutriHep	Trumaid Powder
Impact				Protain XL
B4155 B4155	EP EP	BO	Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g., glucose	Casec Powder Fructose Powder MCT Oil Moducal
Bill on paper (Indicate specific name of formula on claims.)				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 Liquid Procel Protein Power Provimin Sumacal

B4155 B4155	EP EP	U1 U1	BO	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	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	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	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

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

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

Kindercal with Fiber Pediasure Pediasure with Fiber

B4160 B4160

EP EP

U1 U1

Enfamil Premature Lipil

24 Cal Low Iron Enfamil Premature Lipil

24 Cal with Iron Similac Neosure Similac Neosure Advance

Special Care Advance 20

with Iron Special Care Advance 24

Special Care Advance 24

with Iron

B4161 B4161	EP EP	BO	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 ELECARE 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	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
l-Valex-1				Maxamum MSUD	Propimex-1
l-Valex-2				MaxamumXP	Propimex-2
Ketonex-1			MSUD Analog	XP Analog
Ketonex-2				MSUD1 and 2	Xphen, Try Analog
B4162 B4162	EP EP	U1 U1	BO	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 reimbursable maximum of 30 units per day. Supplies furnished by prosthetics providers in conjunction with the nutritional formula must be billed to Medicaid with the prosthetics medical supply codes. These formulae are covered as nutritional supplements rather than as the sole source of nutrition.

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

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

NOTE: If a specific formula is not listed but is prescribed as the result of the EPSDT

screening of an Arkansas Medicaid beneficiary, the provider may forward a copy of the screening and prescription, along with product information, to Utilization Review for consideration.

242.151Pedia-Pop

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

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

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

242.152Enteral Nutrition Infusion Pump and Enteral Feeding Pump Supply

Kit

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

The procedure codes require prior authorization from AFMC.

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

Procedure Code	M1	M2	Description	Maximum Units	PA	Payment Method
B4035	EP	Enteral feeding supply kit, pump fed, per day (1 unit = 1 day)	1per day	Y	Purchase
B9000	EP	Enteral nutrition infusion pump - without alarm (1 day = 1 unit)	1per day	Y	Rent to Purchase

B9002	EP	Enteral nutrition infusion pump-with alarm (1 day = 1 unit)	1 per day	Y	Rent to Purchase
E1340	EP	U2	***(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. Procedure codes B9000and B9002represent a new piece of equipment being reimbursed by Medicaid on the rent-to-purchase plan.

Codes B9000and B9002are 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 B9000and B9002.The prior authorization request must include the serial number of the infusion pump being provided to the beneficiary.

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

242.153MIC-KEY Skin Level Gastrostomy Tube (Mic-Key Button)

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. When a second modifier is listed, that modifier must be used in conjunction with EP.

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 Portw/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

242.154Nasogastric Tubing for Individuals Under Age 21

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

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

242.160Durable Medical Equipment, All Ages

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

* 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 used equipment.

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

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

Durable Medical Equipment, All Ages (section 242.160)

Procedure Code	M1	M2	PA	Description	Payment Method
A4635	NU EP UE	N	Underarm pad, crutch, replacement, each	Purchase

A4636	NU EP UE	N	Replacement, handgrip, cane, crutch, or walker, each	Purchase
A4637	3 CL LU ZUJD	N	Replacement, tip, cane, crutch, walker, each	Purchase
E0100	3 CL LU Z LU 3	N	Cane, includes canes of all materials, adjustable or fixed, with tip	Purchase
E0105	3 CL LLI Z LU 3	N	Cane, quad or three-prong, includes canes of all materials, adjustable or fixed, with tips	Purchase
E0110	3 CL LU ZLUD	N	Crutches, forearm, includes crutches of various materials, adjustable or fixed, pair, complete with tips and handgrips	Purchase
E0111	NU EP UE	U1	N	Crutch, forearm, includes crutches of various materials, adjustable or fixed, each, with tip and handgrip	Purchase
E0112	3 CL LU Z LU 3	N	Crutches, underarm, wood, adjustable or fixed, pair, with pads, tips and handgrips	Purchase
E0113	3 CL LU Z LU 3	N	Crutch, underarm, wood, adjustable or fixed, each, with pad, tip and handgrip	Purchase
E0114	3 CL LU Z LU 3	N	Crutches, underarm, other than wood, adjustable or fixed, pair, with pads, tips and handgrips	Purchase
E0116	3 CL LU Z LU 3	N	Crutch, underarm, other than wood, adjustable or fixed, each, with pad, tip and handgrip	Purchase
E0130	3 CL LU Z LU 3	N	Walker, rigid (pickup), adjustable or fixed height	Purchase
E0135	3 CL LU Z LU 3	N	Walker, folding (pickup), adjustable or fixed height	Purchase
E0140	NU EP	N	Walker, w/trunk support, adjustable or fixed height, any type	Purchase
E0141	3 CL LU Z LU 3	N	Walker, rigid, wheeled, adjustable or fixed height	Purchase
E0143	3 CL LU Z LU 3	N	Walker, folding, wheeled, adjustable or fixed height	Purchase

E0147	NU EP UE	N	Walker, heavy duty, multiple braking system, variable wheel resistance	Purchase
E0153	3 CL LU ZUJD	N	Platform attachment, forearm crutch, each	Purchase
E0154	3 CL LU Z LLI 3	N	Platform attachment, walker, each	Purchase
E0155	3 CL LLI Z LU 3	N	Wheel attachment, rigid pick-up walker, per pair seat attachment, walker	Purchase
E0156	NU EP	N	Seat attachment, walker	Purchase
E0157	3 CL LLI Z LU 3	N	Crutch attachment, walker, each	Purchase
E0158	3 CL LLI Z LU 3	N	Leg extensions for walker, per set of four (4)	Purchase
E0159	NU EP	N	Brake attachment for wheeled walker, replacement, each	Purchase
E0160	3 CL LLI Z LLI 3	N	Sitztype bath or equipment, portable, used with or without commode	Purchase
E0161	3 CL LLI Z LLI 3	N	Sitztype bath or equipment, portable, used with or without commode, with faucet attachment(s)	Purchase
E0163	3 CL LLI Z LLI 3	N	Commode chair, stationary, with fixed arms	Purchase
E0164	3 CL LLI Z LLI 3	N	Commode chair, mobile, with fixed arms	Purchase
E0166	3 CL LLI Z LLI 3	N	PO-Commode chair, mobile, w/detachable arms	Capped Rental
E0166	NU EP UE	U2 U2 U2	N	PO-Commode chair, mobile, w/detachable arms	Purchase
E0167	3 CL LLI Z LLI 3	N	Pail or pan for use with commode chair	Purchase

E0175	NU EP UE	N	Foot rest, for use with commode chair, each	Purchase
E0180	NU EP UE	N	Pressure pad, alternating with pump	Purchase
E0181	3 CL LU ZUJD	N	Pressure pad, alternating with pump, heavy duty	Capped Rental
E0182	3 CL LU Z LLI 3	U1	N	Pump for alternating pressure pad	Purchase
E0184	3 CL LLI Z LU 3	N	Dry pressure mattress	Purchase
E0185	3 CL LLI Z LU 3	N	Gel or gel-like pressure pad for mattress, standard mattress length and width	Purchase
E0186	NU EP	Y	Air pressure mattress	Purchase
E0187	NU EP	Y	Water pressure mattress	Purchase
E0189	3 CL LLI Z LU 3	N	Lambswool sheepskin pad, any size	Purchase
E0190	NU UE	N	Positioning cushion/pillow/wedge, any shape or size	Purchase
E0190	EP	N	Positioning cushion/pillow/wedge, any shape or size	Purchase
E0190	EP	U1	N	Positioning cushion/pillow/wedge, any shape or size	Purchase
E0190	EP	U2	N	Positioning cushion/pillow/wedge, any shape or size	Purchase
E0190	EP	U3	N	Positioning cushion/pillow/wedge, any shape or size	Purchase
E0190	EP	U4	N	Positioning cushion/pillow/wedge, any shape or size	Purchase
E0190	EP	U5	N	Positioning cushion/pillow/wedge, any shape or size	Purchase
E0190	EP	U6	N	Positioning cushion/pillow/wedge, any shape or size	Purchase
E0190	EP	U7	N	Positioning cushion/pillow/wedge, any shape or size	Purchase

E0190	EP	U8	N	Positioning cushion/pillow/wedge, any shape or size	Purchase
E0190	EP	U9	N	Positioning cushion/pillow/wedge, any shape or size	Purchase
E0190	KA	U1	N	Positioning cushion/pillow/wedge, any shape or size	Purchase
E0190	KA	U2	N	Positioning cushion/pillow/wedge, any shape or size	Purchase
E0190	KA	U3	N	Positioning cushion/pillow/wedge, any shape or size	Purchase
E0191	NU EP UE	N	Heel or elbow protector, each	Purchase
E0196	NU EP	N	Gel pressure mattress	Purchase
E0197	NU EP UE	N	Air pressure pad for mattress, standard mattress length and width	Purchase
E0198	NU EP	Y	Water pressure pad for mattress, standard mattress length and width	Purchase
E0200	NU EP UE	N	Heat lamp, without stand (table model), includes bulb, or infrared element	Capped Rental
E0202	NU EP UE	N	Phototherapy (bilirubin) light with photometer	Rental Only
E0205	NU EP UE	N	Heat lamp, with stand includes bulb, or infrared element	Capped Rental
E0217	NU EP UE	N	Water circulating heat pad with pump	Capped Rental
E0225	NU EP UE	N	Hydrocollator unit, includes pad	Capped Rental
E0235	NU EP UE	N	Paraffin bath unit, portable (see medical supply code A4265 for paraffin)	Purchase
E0236	NU EP UE	N	Pump for water circulating pad	Capped Rental
E0238	NU EP UE	N	Nonelectric heat pad, moist	Purchase

E0239	NU EP UE	N	Hydrocollator unit, portable	Capped Rental
E0240	NU EP NU EP NU EP NU EP	t- t- CM CM CO CO3 3 3 3 3 3	N	Bath/shower chair w/wo wheels, any size	Purchase
E0244	NU EP	Y	Raised toilet seat	Purchase
E0245***	NU EP	U1 U1	N	***(Bath Frame Support, Large) Tub stool or bench	Purchase
E0247	ZUJZLU	U1 U1	N	Transfer bench, tub/toilet, w/wo commode opening	Purchase
E0248	NU EP NU EP	U1 U1	N	Transfer bench, heavy duty, tub/toilet w/wo commode opening	Purchase
E0249	3 0_ LU ZUJD	N	Pad for water circulating heat unit	Purchase
E0250	UE	Y*	Hospital bed, fixed height, with any type side rails, with mattress	Capped Rental
E0250	NU EP	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	Y*	Hospital bed, variable height; hi-lo, with any type side rails, with mattress	Capped Rental
E0255	NU EP	U1	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	Y*	Hospital bed, semi-electric, head and foot adjustment, with any type side rails with mattress	Capped Rental
E0260	NU EP	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	N	Mattress, inner spring	Capped Rental
E0272	3 CL LU ZUJD	N	Mattress, foam rubber	Capped Rental
E0273	3 CL LU Z LLI 3	N	Bed board	Purchase
E0275	3 CL LLI Z LU 3	N	Bed pan, standard, metal or plastic	Purchase
E0276	3 CL LLI Z LU 3	N	Bed pan, fracture, metal or plastic	Purchase
E0280	3 CL LLI Z LU 3	N	Bed cradle, any type	Purchase
E0300	EP EP	RR	Y Y	Pediatric crib, hospital grade, fully enclosed	Purchase Rental Only
E0303	NU EP UE	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	N	Urinal; male, jug-type, any material	Purchase
E0326	3 CL LLI Z LLI 3	N	Urinal; female, jug-type, any material	Purchase
E0445***	NU EP	Y*	***(Pulse oximeter, including 4 disposable probes) Oximeter for measuring blood oxygen levels non-invasively	Rental Only
E0480	NU EP UE	N	Percussor, electric or pneumatic, home model	Capped Rental
E0565	NU EP UE	Y*	Compressor, air power source for equipment which is not self-contained or cylinder driven	Capped Rental
E0570	NU EP UE	Y	Nebulizer, with compressor	Purchase

E0585	NU EP UE	N	Nebulizer, with compressor and heater	Capped Rental
E0605	NU EP UE	N	Vaporizer, room type	Purchase
E0606	NU EP UE	N	Postural drainage board	Capped Rental
E0607***	NU EP	N	Home blood glucose monitor	Purchase
E0621	NU	N	Sling or seat, patient lift, canvas or nylon	Purchase
E0630	NU EP UE	Y*	Patient lift, hydraulic, with seat or sling	Capped Rental
E0650	NU EP UE	Y*	Pneumatic compressor, nonsegmental home model	Capped Rental
E0667	NU EP UE	Y*	Segmental pneumatic appliance for use with pneumatic compressor, full leg	Capped Rental
E0668	NU EP UE	Y*	Segmental pneumatic appliance for use with pneumatic compressor, full arm	Capped Rental
E0691	NU EP UE	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	N	Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; four foot panel	Rental Only
E0693	NU EP	N	Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; six foot panel	Rental Only
E0694	NU EP	N	Ultraviolet multidirectional light therapy system in six foot cabinet includes bulbs/lamps, timer and eye protection	Rental Only
E0720	NU EP UE	Y*	TENS, two lead, localized stimulation	Capped Rental
E0730	NU EP UE	Y*	Transcutaneous electrical nerve stimulation device four or more leads, for multiple nerve stimulation	Capped Rental

E0740	NU EP UE	N	Incontinence treatment system, pelvic floor stimulator, monitor, sensor and/or trainer	Purchase
E0745	NU EP UE	Y*	Neuromuscular stimulator, electronic shock unit	Capped Rental
E0747	NU EP UE	Y*	Osteogenesis stimulator, electrical noninvasive, other than spinal applications	Rental Only
E0748	NU EP	N	Osteogenesis stimulator, electrical noninvasive, spinal applications	Purchase
E0749	NU EP UE	Y*	Osteogenesis stimulator, electrical, surgically implanted	Purchase
E0779	NU	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	N	Traction frame, attached to headboard, cervical traction	Purchase
E0850	NU EP UE	N	Traction stand, freestanding, cervical traction	Purchase
E0860	NU EP UE	N	Traction equipment, overdoor, cervical	Purchase
E0870	NU EP UE	N	Traction frame, attached to footboard, extremity traction (e.g., Buck's)	Purchase
E0880	NU EP UE	N	Traction stand, freestanding, extremity traction (e.g., Buck's)	Purchase
E0890	NU EP UE	N	Traction frame, attached to footboard, pelvic traction	Purchase
E0900	NU EP UE	N	Traction stand, freestanding, pelvic traction (e.g., Buck's)	Purchase
E0910	NU EP UE	N	Trapeze bars, also known as Patient Helper, attached to bed, with grab bar	Capped Rental

E0920	NU EP UE	N	Fracture frame, attached to bed, includes weights	Capped Rental
E0930	NU EP UE	N	Fracture frame, freestanding, includes weights	Capped Rental
E0935	NU EP UE	Y*	Passive motion exercise device	Capped Rental
E0940	NU EP UE	N	Trapeze bar, freestanding, complete with grab bar	Capped Rental
E0941	NU EP UE	N	Gravity assisted traction device, any type	Capped Rental
E0942	NU EP UE	N	Cervical head harness/halter	Purchase
E0944	NU EP UE	N	Pelvic belt/harness/boot	Purchase
E0945	NU EP UE	N	Extremity belt/harness	Purchase
E0946	NU EP UE	N	Fracture frame, dual with cross bars, attached to bed (e.g., Balken, Four Poster)	Purchase
E0947	NU EP UE	N	Fracture frame, attachments for complex pelvic traction	Purchase
E0948	NU EP UE	N	Fracture frame, attachments for complex cervical traction	Purchase
E0950	NU EP UE	N	Wheelchair accessory, tray, each	Purchase
E1130*	NU EP UE	Y*	Standard wheelchair, fixed full-length arms, fixed or swing-away, detachable footrests	Capped Rental
E1140*	NU EP UE	Y*	Wheelchair, detachable arms, desk or full-length, swing-away, detachable footrests	Capped Rental
E1150*	NU EP UE	Y*	Wheelchair; detachable arms, desk or full-length, swing-away, detachable, elevating legrests	Capped Rental

E1160*	NU EP UE	Y*	Wheelchair; fixed full-length arms, swing-away, detachable, elevating legrests	Capped Rental
E1224*	NU EP UE	Y*	Wheelchair with detachable arms, elevating leg rests	Capped Rental
E1340	NU	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	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	N	Durable medical equipment, miscellaneous	Manually Priced
S8096***	NU EP	N	***(Peak flow meter used by asthmatic patients) Portable peak flow meter	Purchase
Z2211 (Bill on Paper)	NU EP	Y	Power Kit/Batteries	Purchase

Procedure codes E0250*, E0255*and E02604 must be billed when hospital beds are purchased for eligible Medicaid beneficiaries of all ages. The procedure codes 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.

The hospital beds must be new, not used. The procedure codes must be billed with modifier NU for individuals age 21 and over or modifier EP for individuals under the age of 21. 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* must also be used to bill for equipment that does not meet the purchase-only criteria. They are reimbursed on a capped rental basis. The capped rental items must be used until the equipment is no longer repairable or until it is no longer appropriate for the beneficiary as verified by the physician.

242.161Used Durable Medical Equipment, Age 21 and Over

Procedure codes found in this section must be billed either electronically or on paper with modifier UE for used equipment.

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

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

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

Used Durable Medical Equipment, Age 21 and Over (section 242.161)

Procedure Code	M1	M2	Description	PA	Payment Method
E0105	UE	Cane, quad or three-prong, includes canes of all materials, adjustable or fixed, with tips	N	Purchase
E0143	UE	***(Walker, folding, wheeled, with seat) Walker, folding, wheeled, adjustable or fixed height	N	Capped Rental
E0143	UE	Walker, folding, wheeled, adjustable or fixed height	N	Purchase
E0163	UE	Commode chair, stationary with fixed arms	N	Purchase
E0180	UE	Pressure pad, alternating with pump	N	Purchase
E0191	UE	Heel or elbow protector, each	N	Purchase
E0192	UE	Low pressure and positioning equalization pad for wheelchair	N	Purchase
E0202	UE	Phototherapy (bilirubin) light with photometer	N	Rental Only
E0255	UE	***(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	***(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	Patient lift, hydraulic, with seat or sling	Y*	Capped Rental
E0730	UE	Transcutaneous electrical nerve stimulation device, four or more leads, for multiple nerve stimulation	Y*	Capped Rental

E0910	UE	***(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	Standard wheelchair; fixed full-length arms, fixed or swing-away, detachable footrests	Y*	Capped Rental
E1224*	UE	***(Footrest wheelchair with detachable arms, elevating legrests) Wheelchair with detachable arms, elevating legrests	Y*	Capped Rental

242.170Apnea Monitors for Individuals Under 1 Year of Age

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.

Sections 212.300 and 222.200 contain information regarding specific coverage and restrictions.

* Prior authorization is not required when other insurance pays at least 50% of the

Medicaid maximum allowable reimbursement amount.

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

National Code	M1	M2	Local Code	Description	PA	Payment Method
E0618	EP	Apnea monitor, without recording feature	Y (on 31st day)*	Rental Only (Daily Rental)
E0619	EP	Apnea monitor, with recording feature	Y (on 31st day)*	Rental Only (Daily Rental)
E0619	***(lnitial setup of apnea monitor, includes 30 days rental) Apnea monitor, with recording feature	N	First 30 Days Rental
Bill on paper	EP	Z1684	Technical and lab services for setting up pneumogram or event recording (not including professional services)	N	Purchase

242.180Orthotic Appliances, All Ages

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

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

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

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

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

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

Orthotic Appliances, All Ages (section 242.180 )

Procedure Code	M1	M2	Description	All U21 21 +	PA 21 +	Payment Method
A5500"	NU	For diabetics only, fitting (including follow-up) custom preparation and supply of off-the-shelf depth-inlay shoe manufactured to accommodate multi-density insert(s), per shoe	21 +	N	Purchase
A5501"	NU	For diabetics only, fitting (including follow-up) custom preparation and supply of molded from cast(s) of patient's foot (custom molded shoe), per shoe	21 +	N	Purchase
A5503"	NU	For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with roller or rigid rocker bottom, per shoe	21 +	N	Purchase
A5504"	NU	For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with wedge(s), per shoe	21 +	N	Purchase
A5505"	NU	For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with metatarsal bar, per shoe	21 +	N	Purchase
A5506"	NU	For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with off-set heel(s), per shoe	21 +	N	Purchase

A5507	NU	For diabetics only, not otherwise specified modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe, per shoe	21 +	Y	Purchase
A5510"	NU	For diabetics only, direct formed, compression molded to patient's foot without external heat source, multiple-density insert(s) prefabricated, per shoe	21 +	N	Purchase
A5512	NU	For diabetics only, multiple density insert, direct formed, molded to foot after external heat source of 230 degrees Fahrenheit or higher, total contact with patient's foot, including arch, base layer minimum of % inch material of shore a 35 durometer of 3/16 inch material of shore a 40 durometer (or higher), prefabricated, each	21 +	Y	Purchase
A5513	NU	For diabetics only, multiple density insert, custom molded from model of patient's foot, total contact with patient's foot, including arch, base layer minimum of % inch material of shore a 35 durometer of 3/16 inch material of shore a 40 durometer (or higher), includes arch filler and other shaping material custom fabricated, each	21 +	Y	Purchase
L0100	NU EP	Cranial orthosis (helmet), with or without soft interface, molded to patient model	All	N	Purchase
L0110	NU EP	Cranial orthosis (helmet), with or without soft interface, non-molded	All	N	Purchase
L0120	NU EP	Cervical, flexible, nonadjustable (foam collar)	All	N	Purchase
L0130	NU EP	Cervical, flexible, thermoplastic collar, molded to patient	All	N	Purchase
L0140	NU EP	Cervical, semi-rigid, adjustable (plastic collar)	All	N	Purchase
L0150	NU EP	Cervical, semi-rigid, adjustable molded chin cup (plastic collar with mandibular/occipital piece)	All	N	Purchase
L0160	NU EP	Cervical, semi-rigid wire frame occipital/mandibular support	All	N	Purchase

L0170	NU EP	Cervical, collar, molded to patient model	All	N	Purchase
L0172	NU EP	Cervical, collar, semi-rigid thermoplastic foam, two piece	All	N	Purchase
L0174	NU EP	Cervical, collar, semi-rigid thermoplastic foam, two piece with thoracic extension	All	N	Purchase
L0180	NU EP	Cervical, multiple post collar, occipital/mandibular supports, adjustable	All	N	Purchase
L0190	NU EP	Cervical, multiple post collar, occipital/mandibular supports, adjustable cervical bars (Somi, Guilford, Taylor types)	All	N	Purchase
L0200	NU EP	Cervical, multiple post collar, occipital/mandibular supports, adjustable cervical bars, and thoracic extension	All	N	Purchase
L0210	NU EP	Thoracic, rib belt	All	N	Purchase
L0220	NU EP	Thoracic, rib belt, custom fabricated	All	N	Purchase
L0450	NU EP	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	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	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	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	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	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	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	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	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	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	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	TLSO, triplanar control, hyperextension, rigid anterior and lateral frame extends from symphysis pubis to sternal notch with two anterior components (one pubic and one sternal) posterior and lateral pads with straps and closures, limits spinal flexion, restricts gross trunk motion in sagittal, coronal and transverse planes, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment	All	N	Purchase
L0474	NU EP	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	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	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	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	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	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	TLSO, sagittal-coronal control, one-piece rigid plastic shell with overlapping reinforced anterior, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates at or before the T9 vertebra, anterior extends from symphysis pubis to xiphoid, anterior opening, restricts gross trunk motion in sagittal and coronal planes, prefabricated, includes fitting and adjustment	All	Y	Purchase
L0621	NU EP	SO, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, prefabricated, includes fitting and adjustment	All	N	Purchase
L0622	NU EP	SO, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricated	All	N	Purchase

L0623	NU EP	SO, flexible, provides pelvic-sacral support, with rigid or semi-rigid panels over the sacrum and abdomen, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, prefabricated, includes fitting and adjustment	All	N	Purchase
L0624	NU EP	SO, provides pelvic-sacral support, with rigid or semi-rigid panels over the sacrum and abdomen, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricated	All	N	Manually Priced
L0625	NU EP	LO, flexible, provides lumbar support, posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include pendulous abdomen design, shoulder straps, stays, prefabricated, includes fitting and adjustment	All	N	Purchase
L0626	NU EP	LO, sagittal control, with rigid posterior panel(s), posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment	All	N	Purchase
L0627	NU EP	LO, sagittal control, with rigid anterior and posterior panel(s), posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment	All	N	Purchase

L0628	NU EP	LSO, flexible, provides lumbosacral support, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include stays, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment	All	N	Purchase
L0629	NU EP	LSO, flexible, provides lumbo-sacral support, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include stays, shoulder straps, pendulous abdomen design, custom fabricated	All	N	Manually Priced
L0630	NU EP	LSO, sagittal control, with rigid posterior panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment	All	N	Purchase
L0631	NU EP	LSO, sagittal control, with rigid anterior and posterior panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment	All	N	Purchase
L0632	NU EP	LSO, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, custom fabricated	All	N	Manually Priced

L0633	NU EP	LSO, sagittal-coronal control, with rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment	All	N	Purchase
L0634	NU EP	LSO, sagittal-coronal control, with rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, custom fabricated	All	N	Manually Priced
L0635	NU EP	LSO, sagittal-coronal control, lumbar flexion, rigid posterior frame/panel(s), lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, prefabricated, includes fitting and adjustment	All	N	Purchase
L0636	NU EP	LSO, sagittal-coronal control, lumbar flexion, rigid posterior frame/panel(s), lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, custom fabricated	All	N	Purchase

L0637	NU EP	LSO, sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment	All	N	Purchase
L0638	NU EP	LSO, sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, custom fabricated	All	N	Purchase
L0639	NU EP	LSO, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xiphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, prefabricated, includes fitting and adjustment	All	N	Purchase
L0640	NU EP	LSO, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xiphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, custom fabricated	All	N	Purchase

L0700	NU EP	Cervical-thoracic-lumbar-sacral orthoses (CTLSO), anterior-posterior-lateral control, molded to patient model (Minerva type)	All	Y	Purchase
L0710	NU EP	CTLSO, anterior-posterior-lateral control, molded to patient model, with interface material (Minerva type)	All	Y	Purchase
L0810	NU EP	Halo procedure, cervical halo incorporated into jacket vest	All	Y	Purchase
L0820	NU EP	Halo procedure, cervical halo incorporated into plaster body jacket	All	Y	Purchase
L0830	NU EP	Halo procedure, cervical halo incorporated into Milwaukee type orthosis	All	Y	Purchase
L0859	NU EP	Addition to halo procedure, magnetic resonance image compatible system, rings and pins, any material	All	Y	Purchase
L0960	NU EP	Torso support, post surgical support, pads for post surgical support	All	N	Purchase
L0970	NU EP	TLSO, corset front	All	N	Purchase
L0972	NU EP	LSO, corset front	All	N	Purchase
L0974	NU EP	TLSO, full corset	All	N	Purchase
L0976	NU EP	LSO, full corset	All	N	Purchase
L0978	NU EP	Axillary crutch extension	All	N	Purchase
L0980	NU EP	Peroneal straps, pair	All	N	Purchase
L0982	NU EP	Stocking supporter grips, set of four (4)	All	N	Purchase
L0984	NU	Protective body sock, each	21 +	N	Purchase
L1000	NU EP	CTLSO (Milwaukee), inclusive of furnishing initial orthosis, including model	All	Y	Purchase
L1010	NU EP	TLSO or scoliosis orthosis, axilla sling	All	N	Purchase
L1020	NU EP	Addition to CTLSO or scoliosis orthosis, kyphosis pad	All	N	Purchase
L1025	NU EP	Addition to CTLSO or scoliosis orthosis, kyphosis pad, floating	All	N	Purchase

L1030	NU EP	Addition to CTLSO or scoliosis orthosis, lumbar bolster pad	All	N	Purchase
L1040	NU EP	Addition to CTLSO or scoliosis orthosis, lumbar or lumbar rib pad	All	N	Purchase
L1050	NU EP	Addition to CTLSO or scoliosis orthosis, sternal pad	All	N	Purchase
L1060	NU EP	Addition to CTLSO or scoliosis orthosis, thoracic pad	All	N	Purchase
L1070	NU EP	Addition to CTLSO or scoliosis orthosis, trapezius sling	All	N	Purchase
L1080	NU EP	Addition to CTLSO or scoliosis orthosis, outrigger	All	N	Purchase
L1085	NU EP	Addition to CTLSO or scoliosis orthosis, outrigger, bilateral with vertical extensions	All	N	Purchase
L1090	NU EP	Addition to CTLSO or scoliosis orthosis, lumbar sling	All	N	Purchase
L1100	NU EP	Addition to CTLSO or scoliosis orthosis, ring flange, plastic or leather	All	N	Purchase
L1110	NU EP	Addition to CTLSO or scoliosis orthosis, ring flange, plastic or leather, molded to patient model	All	N	Purchase
L1120	NU EP	Addition to CTLSO, scoliosis orthosis, cover for upright, each	All	N	Purchase
L1200	NU EP	Thoracic-lumbar-sacral-orthosis (TLSO), inclusive of furnishing initial orthosis only	All	Y	Purchase
L1210	NU EP	Addition to TLSO (low profile), lateral thoracic extension	All	N	Purchase
L1220	NU EP	Addition to TLSO (low profile), anterior thoracic extension	All	N	Purchase
L1230	NU EP	Addition to TLSO (low profile), Milwaukee type superstructure	All	N	Purchase
L1240	NU EP	Addition to TLSO (low profile), lumbar derotation pad	All	N	Purchase
L1250	NU EP	Addition to TLSO (low profile), anterior ASIS pad	All	N	Purchase
L1260	NU EP	Addition to TLSO (low profile), anterior thoracic derotation pad	All	N	Purchase
L1270	NU EP	Addition to TLSO (low profile), abdominal pad	All	N	Purchase

L1280	NU EP	Addition to TLSO (low profile), rib gusset (elastic), each	All	N	Purchase
L1290	NU EP	Addition to TLSO (low profile), lateral trochanteric pad	All	N	Purchase
L1300	NU EP	Other scoliosis procedure, body jacket molded to patient model	All	Y	Purchase
L1310	NU EP	Other scoliosis procedure, postoperative body jacket	All	Y	Purchase
L1499	NU EP	Spinal orthosis, not otherwise specified. ***(The manufacturer's invoice must be attached to all claims.)	All	Y	Manually Priced
L1500	NU EP	THKAO, mobility frame (Newington, Parapodium types)	All	Y	Purchase
L1510	NU EP	THKAO, standing frame, with or without tray and accessories	All	Y	Purchase
L1520	NU EP	THKAO, swivel walker	All	Y	Purchase
L1600	NU EP	HO, abduction control of hip joints, flexible, Frejka type with cover, prefabricated, includes fitting and adjustment	All	N	Purchase
L1610	NU EP	HO, abduction control of hip joints, flexible (Frejka cover only), prefabricated, includes fitting and adjustment	All	N	Purchase
L1620	NU EP	HO, abduction control of hip joints, flexible (Pavlik harness), prefabricated, includes fitting and adjustment	All	N	Purchase
L1630	NU EP	HO, abduction control of hip joints, semi-flexible (Von Rosen type), custom fabricated	All	N	Purchase
L1640	NU EP	HO, abduction control of hip joints, static, pelvic band or spreader bar, thigh cuffs, custom fabricated	All	N	Purchase
L1650	NU EP	HO, abduction control of hip joints, static, adjustable, custom fitted (llfled type), prefabricated, includes fitting and adjustment	All	N	Purchase
L1660	NU EP	HO, abduction control of hip joints, static, plastic, prefabricated, includes fitting and adjustment	All	N	Purchase

L1680	NU EP	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	HO, abduction control of hip joint, post operative hip abduction type, custom fabricated	All	Y	Purchase
L1686	NU EP	HO, abduction control of hip joint, post operative hip abduction type, prefabricated, includes fitting and adjustments	All	Y	Purchase
L1690	NU	Combination, bilateral, lumbo-sacral, hip, femur orthosis providing adduction and internal rotation control, prefabricated, includes fitting and adjustment	21 +	Y	Purchase
L1700	NU EP	Legg Perthes orthosis (Toronto type), custom fabricated	All	Y	Purchase
L1710	NU EP	Legg Perthes orthosis (Newington type), custom fabricated	All	Y	Purchase
L1720	NU EP	Legg Perthes orthosis, trilateral (Tachdijan type), custom fabricated	All	Y	Purchase
L1730	NU EP	Legg Perthes orthosis (Scottish Rite type) custom fabricated	All	Y	Purchase
L1750	NU EP	Legg Perthes orthosis, Legg Perthes sling (Sam Brown type), prefabricated, includes fitting and adjustment	All	Y	Purchase
L1755	NU EP	Legg Perthes orthosis (Patten bottom type), custom fabricated	All	Y	Purchase
L1800	NU EP	KO, elastic with stays, prefabricated, includes fitting and adjustment	All	N	Purchase
L1810	NU EP	KO, elastic with joints, prefabricated, includes fitting and adjustment	All	N	Purchase
L1815	NU EP	KO, elastic or other elastic type material with condylar pad(s), prefabricated, includes fitting and adjustment	All	N	Purchase
L1820	NU EP	KO, elastic with condyle pads and joints, prefabricated, includes fitting and adjustment	All	N	Purchase
L1825	NU EP	KO, elastic knee cap. prefabricated, includes fitting and adjustment	All	N	Purchase

L1830	NU EP	KO, immobilizer, canvas longitudinal, prefabricated, includes fitting and adjustment	All	N	Purchase
L1832	NU EP	KO, adjustable knee joints, positional orthosis, rigid support, prefabricated, includes fitting and adjustment rigid support	All	N	Purchase
L1834	NU EP	KO, without knee joint, rigid, custom fabricated	All	N	Purchase
L1840	NU EP	KO, derotation, medial-lateral, anterior cruciate ligament, custom fabricated	All	Y	Purchase
L1843	NU	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	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	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	KO, double upright, thigh and calf, with adjustable flexion and extension joint, medial-lateral and rotation control, custom fabricated	All	Y	Purchase
L1847	NU	Knee orthosis, double upright with adjustable joint, with inflatable air support chamber(s) prefabricated, includes fitting and adjustment	21 +	N	Purchase
L1850	NU EP	KO, Swedish type, prefabricated, includes fitting and adjustment	All	N	Purchase
L1855	NU EP	KO, molded plastic, thigh and calf sections, with double upright knee joints, custom fabricated	All	Y	Purchase
L1858	NU EP	KO, molded plastic, polycentric knee joints, pneumatic knee pads (CTI), custom fabricated	All	Y	Purchase

L1860	NU EP	KO, modification of supracondylar prosthetic socket, custom fabricated (SK)	All	Y	Purchase
L1870	NU EP	KO, double upright, thigh and calf lacers, with knee joints, custom fabricated	All	Y	Purchase
L1880	NU EP	KO, double upright, nonmolded thigh and calf cuff/lacers with knee joints, custom fabricated	All	N	Purchase
L1900	NU EP	AFO, spring wire, dorsiflexion assist calf band, custom fabricated	All	N	Purchase
L1902	NU EP	AFO, ankle gauntlet, prefabricated, includes fitting and adjustment	All	N	Purchase
L1904	NU EP	AFO, molded ankle gauntlet, custom fabricated	All	N	Purchase
L1906	NU EP	AFO, multigamentus ankle support, prefabricated, includes fitting and adjustment	All	N	Purchase
L1907	NU EP	AFO, supramalleolar with straps, with or without interface/pads, custom fabricated	All	N	Purchase
L1910	NU EP	AFO, posterior, single bar, clasp attachment to shoe counter prefabricated, includes fitting and adjustment	All	N	Purchase
L1920	NU EP	AFO, single upright with static or adjustable stop (Phelps or Perlstein type), custom fabricated	All	N	Purchase
L1920	EP	***(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	AFO, plastic or other material, prefabricated, includes fitting and adjustment	All	N	Purchase
L1932	NU EP	AFO, rigid anterior tibial section, total carbon fiber or equal material, prefabricated, includes fitting and adjustment	All	N	Purchase
L1940	NU EP	AFO, plastic or other material, custom-fabricated	All	N	Purchase
L1945	NU EP	AFO, molded to patient model, plastic, rigid anterior tibial section (floor reaction), custom fabricated	All	Y	Purchase

L1950	NU EP	AFO, spiral (Institute of Rehabilitative Medicine type), plastic, custom fabricated	All	N	Purchase
L1960	NU EP	AFO, posterior solid ankle, plastic, custom fabricated	All	N	Purchase
L1970	NU EP	AFO, plastic, with ankle joint, custom fabricated	All	N	Purchase
L1980	NU EP	AFO, single upright free plantar dorsiflexion, solid stirrup, calf band/cuff (single bar "BK" orthosis), custom fabricated	All	N	Purchase
L1990	NU EP	AFO, double upright free plantar dorsiflexion, solid stirrup, calf band/cuff (double bar "BK" orthosis), custom fabricated	All	N	Purchase
L2000	NU EP	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	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	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	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	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	KAFO, full plastic, static prefabricated (pediatric size) prefabricated, includes fitting and adjustment	21 +	N	Purchase
L2036	NU EP	KAFO, full plastic, double upright, free knee, custom fabricated	All	Y	Purchase
L2037	NU EP	KAFO, full plastic, single upright, free knee, custom fabricated	All	Y	Purchase

L2038	NU EP	KAFO, full plastic, without knee joint, multi-axis ankle, (Lively orthosis or equal), custom fabricated	All	Y	Purchase
L2039	NU	KAFO, full plastic, single upright, poly-axial hinge, medial lateral rotation control, custom fabricated	21 +	Y	Purchase
L2040	NU EP	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	***(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	HKAFO, torsion control, bilateral torsion cables, hip joint, pelvic band/belt, custom fabricated	All	N	Purchase
L2060	NU EP	HKAFO, torsion control, bilateral torsion cables, ball bearing hip joint, pelvic band/belt, custom fabricated	All	N	Purchase
L2070	NU EP	HKAFO, torsion control, unilateral rotation straps, pelvic band/belt, custom fabricated	All	N	Purchase
L2080	NU EP	HKAFO, torsion control, unilateral torsion cable, hip joint, pelvic band/belt, custom fabricated	All	N	Purchase
L2090	NU EP	HKAFO, torsion control, unilateral torsion cable, ball bearing hip joint, pelvic band/belt, custom fabricated	All	N	Purchase
L2106	NU EP	AFO, fracture orthosis, tibial fracture cast orthosis, thermoplastic type casting material, custom fabricated	All	N	Purchase
L2108	NU EP	AFO, fracture orthosis, tibial fracture cast orthosis, custom fabricated	All	Y	Purchase
L2112	NU EP	AFO, fracture orthosis, tibial fracture orthosis, soft, prefabricated, includes fitting and adjustment	All	N	Purchase
L2114	NU EP	AFO, fracture orthosis, tibial fracture orthosis, semi-rigid, prefabricated, includes fitting and adjustment	All	N	Purchase

L2116	NU EP	AFO, fracture orthosis, tibial fracture orthosis, rigid, prefabricated, includes fitting and adjustment	All	N	Purchase
L2126	NU EP	KAFO, fracture orthosis, femoral fracture cast orthosis, thermoplastic type casting material, molded to patient	All	Y	Purchase
L2128	NU EP	KAFO, fracture orthosis, femoral fracture cast orthosis, thermoplastic type casting material, custom fabricated	All	Y	Purchase
L2132	NU EP	KAFO, fracture orthosis, femoral fracture cast orthosis, soft, prefabricated, includes fitting and adjustment	All	Y	Purchase
L2134	NU EP	KAFO, fracture orthosis, femoral fracture cast orthosis, semi-rigid custom fitted	All	Y	Purchase
L2136	NU EP	KAFO, fracture orthosis, femoral fracture cast orthosis, rigid, prefabricated, includes fitting and adjustment	All	Y	Purchase
L2180	NU EP	Addition to lower extremity fracture orthosis, plastic shoe insert with ankle joints	All	N	Purchase
L2182	NU EP	Addition to lower extremity fracture orthosis, drop lock knee joint	All	N	Purchase
L2184	NU EP	Addition to lower extremity fracture orthosis, limited motion knee joint	All	N	Purchase
L2186	NU EP	Addition to lower extremity fracture orthosis, adjustable motion knee joint (Lerman type)	All	N	Purchase
L2188	NU EP	Addition to lower extremity fracture orthosis, quadrilateral brim	All	N	Purchase
L2190	NU EP	Addition to lower extremity fracture orthosis, waist belt	All	N	Purchase
L2192	NU EP	Addition to lower extremity fracture orthosis, hip joint, pelvic band, thigh flange, and pelvic belt	All	N	Purchase
L2200	NU EP	Additions to lower extremity, dorsiflexion and plantar flexion	All	N	Purchase
L2210	NU EP	Addition to lower extremity, dorsiflexion assist (plantar flexion resist), each joint	All	N	Purchase

L2220	NU EP	Addition to lower extremity, dorsiflexion and plantar flexion assist/resist, each joint	All	N	Purchase
L2230	NU EP	Addition to lower extremity, split flat caliper stirrups and plate attachment	All	N	Purchase
L2232	NU EP	Addition to lower extremity orthosis, rocker bottom for total contact ankle foot orthosis, for custom fabricated orthosis only	All	N	Manually Priced
L2240	NU EP	Addition to lower extremity, round caliper and plate attachment	All	N	Purchase
L2250	NU EP	Addition to lower extremity, foot plate, molded to patient model, stirrup attachment	All	N	Purchase
L2260	NU EP	Addition to lower extremity, reinforced solid stirrup (Scott-Craig type)	All	N	Purchase
L2265	NU EP	Addition to lower extremity, long tongue stirrup	All	N	Purchase
L2270	NU EP	Addition to lower extremity, varus/valgus correction ("T") strap, padded/lined or malleolus pad	All	N	Purchase
L2275	NU	Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined	21 +	N	Purchase
L2280	NU EP	Addition to lower extremity, molded inner boot	All	N	Purchase
L2300	NU EP	Addition to lower extremity, abduction bar (bilateral hip involvement), jointed, adjustable	All	N	Purchase
L2310	NU EP	Addition to lower extremity, abduction bar straight	All	N	Purchase
L2320	NU EP	Addition to lower extremity, nonmolded lacer	All	N	Purchase
L2330	NU EP	Addition to lower extremity, lacer molded to patient model	All	N	Purchase
L2335	NU EP	Addition to lower extremity, anterior swing band	All	N	Purchase
L2340	NU EP	Addition to lower extremity, pretidial shell, molded to patient model	All	N	Purchase
L2350	NU EP	Addition to lower extremity, prosthetic type, (BK) socket, molded to patient model, (used for "PTB" "AFO" orthoses)	All	Y	Purchase

L2360	NU EP	Addition to lower extremity, extended steel shank	All	N	Purchase
L2370	NU EP	Addition to lower extremity, Patten bottom	All	N	Purchase
L2375	NU EP	Addition to lower extremity, torsion control, ankle joint and half solid stirrup	All	N	Purchase
L2380	NU EP	Addition to lower extremity, torsion control, straight knee joint, each joint	All	N	Purchase
L2385	NU EP	Addition to lower extremity, straight knee joint, heavy duty, each joint	All	N	Purchase
L2390	NU EP	Addition to lower extremity, offset knee joint, each joint	All	N	Purchase
L2395	NU EP	Addition to lower extremity, offset knee joint, heavy duty, each joint	All	N	Purchase
L2397	NU	Addition to lower extremity orthosis, suspension sleeve	21 +	N	Purchase
L2405	NU EP	Addition to knee joint, lock; drop, stance or swing phase, each joint	All	N	Purchase
L2415	NU EP	Addition to knee lock with integrated release mechanism , (bail, cable or equal, any material, each joint	All	N	Purchase
L2425	NU EP	Addition to knee joint, disc or dial lock for adjustable knee flexion, each joint	All	N	Purchase
L2430	NU EP	Addition to knee joint, ratchet lock for active and progressive knee extension, each joint	All	N	Purchase
L2492	NU EP	Addition to knee joint, lift loop for drop lock ring	All	N	Purchase
L2500	NU EP	Addition to lower extremity, thigh/weight bearing, gulteal/ischial weight bearing, ring	All	N	Purchase
L2510	NU EP	Addition to lower extremity, thigh/weight bearing, quadrilateral brim, molded to patient model	All	N	Purchase
L2520	NU EP	Addition to lower extremity, thigh/weight bearing, quadrilateral brim, custom fitted	All	N	Purchase
L2525	NU EP	Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim molded to patient model	All	N	Purchase

L2526	NU EP	Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim, custom fitted	All	N	Purchase
L2530	NU EP	Addition to lower extremity, thigh/weight bearing, lacer, non-molded	All	N	Purchase
L2540	NU EP	Addition to lower extremity, thigh/weight bearing, lacer, molded to patient model	All	N	Purchase
L2550	NU EP	Addition to lower extremity, thigh/weight bearing, high roll cuff	All	N	Purchase
L2570	NU EP	Addition to lower extremity, pelvic control, hip joint, clevis type two position joint, each	All	N	Purchase
L2580	NU EP	Addition to lower extremity, pelvic control, pelvic sling	All	N	Purchase
L2600	NU EP	Addition to lower extremity, pelvic control, hip joint, Clevis type, or thrust bearing free, each	All	N	Purchase
L2610	NU EP	Addition to lower extremity, pelvic control, hip joint, Clevis or thrust bearing, lock, each	All	N	Purchase
L2620	NU EP	Addition to lower extremity, pelvic control, hip joint, heavy duty, each	All	N	Purchase
L2622	NU EP	Addition to lower extremity, pelvic control, hip joint, adjustable flexion, each	All	N	Purchase
L2624	NU EP	Addition to lower extremity, pelvic control, hip joint, adjustable flexion, extension, abduction control, each	All	N	Purchase
L2627	NU EP	Addition to lower extremity, pelvic control, plastic, molded to patient model, reciprocating hip joint and cables	All	N	Purchase
L2628	NU EP	Addition to lower extremity, pelvic control, metal frame, reciprocating hip joint and cables	All	N	Purchase
L2630	NU EP	Addition to lower extremity, pelvic control, band and belt unilateral	All	N	Purchase
L2640	NU EP	Addition to lower extremity, pelvic control, band and belt bilateral	All	N	Purchase
L2650	NU EP	Addition to lower extremity, pelvic and thoracic control, gluteal pad, each	All	N	Purchase

L2660	NU EP	Addition to lower extremity, thoracic control, thoracic band	All	N	Purchase
L2670	NU EP	Addition to lower extremity, thoracic control, paraspinal uprights	All	N	Purchase
L2680	NU EP	Addition to lower extremity, thoracic control, lateral support uprights	All	N	Purchase
L2750	NU EP	Addition to lower extremity orthosis, plating chrome or nickel, per bar	All	N	Purchase
L2755	NU	Addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepreg composite, per segment	21 +	N	Purchase
L2755	NU EP	***(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	Addition to lower extremity orthosis, extension, per extension, per bar (for linear adjustment for growth)	All	N	Purchase
L2770	NU EP	Addition to lower extremity orthosis, any material, per bar or joint	All	N	Purchase
L2780	NU EP	Addition to lower extremity orthosis, non-corrosive finish, per bar	All	N	Purchase
L2785	NU EP	Addition to lower extremity orthosis, drop lock retainer, each	All	N	Purchase
L2795	NU EP	Addition to lower extremity orthosis, knee control, full kneecap	All	N	Purchase
L2800	NU EP	Addition to lower extremity orthosis, knee control, kneecap, medial or lateral pull	All	N	Purchase
L2810	NU EP	Addition to lower extremity orthosis, knee control, condylar pad	All	N	Purchase
L2810	EP	***(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	Addition to lower extremity orthosis, soft interface for molded plastic, below knee section	All	N	Purchase
L2830	NU EP	Addition to lower extremity orthosis, soft interface for molded plastic, above knee section	All	N	Purchase

L2840	NU EP	Addition to lower extremity orthosis, tibial length sock, fracture or equal, each	All	N	Purchase
L2850	NU EP	Addition to lower extremity orthosis, femoral length sock, fracture or equal, each	All	N	Purchase
L2999	NU EP	Lower extremity orthoses, NOS	All	N	Manually Priced
L2999	NU EP	***(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	Foot insert, removable, molded to patient model, "UCB" type, Berkeley shell, each	All	N	Purchase
L3002	NU EP	Foot insert, removable, molded to patient model, Plastazote or equal, each	All	N	Manually Priced
L3010	NU EP	Foot insert, removable, molded to patient model, longitudinal arch support, each	All	N	Purchase
L3020	NU EP	Foot insert, removable, molded to patient model, longitudinaMmetatarsal support, each	All	N	Purchase
L3030	NU EP	Foot insert, removable, formed to patient foot, each	All	N	Purchase
L3040	NU EP	Foot, arch support, removable, premolded, longitudinal, each	All	N	Purchase
L3050	NU EP	Foot, arch support, removable, premolded, metatarsal, each	All	N	Purchase
L3060	NU EP	Foot, arch support, removable, premolded, longitudinal/metatarsal, each	All	N	Purchase
L3070	NU EP	Foot, arch support, non-removable, attached to shoe, longitudinal, each	All	N	Purchase
L3080	NU EP	Foot, arch support, non-removable, attached to shoe, metatarsal, each	All	N	Purchase
L3090	NU EP	Foot, arch support, non-removable, attached to shoe, longitudinal/\|metatarsal, each	All	N	Purchase
L3100	NU EP	Hallus-valgus night dynamic splint	All	N	Purchase

L3140	NU EP	UB	***(Bebox foot orthosis club foot abduction orthosis) Foot, abduction rotation bar, including shoes	All	N	Manually Priced Purchase
L3140	NU	***(Don Joy knee orthosis) Foot, abduction rotation bar, including shoes	21 +	Y	Manually Priced
L3150	NU EP	Foot, abduction rotation bar, without shoes	All	N	Purchase
L3150	EP	***(Custom night "A" frame-KAFO, torsion control, bilateral night "A" frame) Foot, abduction rotation bar, without shoes	U21	N/A	Purchase
L3170	NU EP	Foot, plastic heel stabilizer	All	N	Purchase
L3202	EP	Orthopedic shoe, oxford with supinator or pronator, child	U21	N/A	Purchase
L3204	EP	Orthopedic shoe, high-top with supinator or pronator, infant	U21	N/A	Purchase
L3204	NU EP	***(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	***(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	***(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	***(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	***(Reverse last closed toe) Orthopedic shoe, high-top with supinator or pronator, infant	All	N	Manually Priced Purchase
L3204	NU	***(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	***(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	***(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	***(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	***(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	***(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	***(Reverse last closed toe) Orthopedic shoe, high-top with supinator or pronator, child	All	N	Manually Priced Purchase
L3206	NU	***(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	***(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	***(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	***(Straight last high-top shoe, each, size 8¹/4-12) Orthopedic shoe, high-top with supinator or pronator, junior	All	N	Manually Priced Purchase
L3207	NU EP	U1	***(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	***(Regular last high-top shoe, each, size 8¹/4-12) Orthopedic shoe, high-top with supinator or pronator, junior	All	N	Purchase
L3207	NU EP	U1	***(Reverse last closed toe) Orthopedic shoe, high-top with supinator or pronator, junior	All	N	Manually Priced Purchase
L3207	NU	***(Orthopedic shoe, high-top, normal last, each, size 3-8) Orthopedic shoe, high-top with supinator or pronator, junior	21 +	N	Manually Priced

L3207

L3208 L3209 L3215

L3216

L3217

L3219 L3221 L3222

L3222

EP NU

NU EP

EP NU

NU EP

EP NU

U1 U1

***(Orthopedic shoe, high-top, normal last, each, size 8¹/2-12) Orthopedic shoe, high-top with supinator or pronator, junior

Surgical boot, each, infant

Surgical boot, each, child

Orthopedic footwear, woman's shoes, oxford

Orthopedic footwear, woman's shoes, depth inlay

***(Straight last high-top shoe, each, size 2-8) Orthopedic footwear, woman's shoes, high-top, depth inlay

***(Straight last high-top shoe, each, size8¹/2-12) Orthopedic footwear, woman's shoes, high-top, depth inlay

***(Regular last high-top shoe, each, size 3-6) Orthopedic footwear, woman's shoes, high-top, depth inlay

***(Regular last high-top shoe, each, size8¹/2-12) Orthopedic footwear, woman's shoes, high-top, depth inlay

***(Reverse last closed toe) Orthopedic footwear, woman's shoes, high-top, depth inlay

Orthopedic footwear, man's shoes, oxford

Orthopedic footwear, man's shoes, depth inlay

***(Straight last high-top shoe, each, size 2-8) Orthopedic footwear, man's shoes, high-top, depth inlay

***(Straight last high-top shoe, each, size8¹/2-12) Orthopedic footwear, man's shoes, high-top, depth inlay

All

U21 U21 All

All

All All All

All

N/A N/A Y

Y Y N

Manually Priced

Purchase

Manually Priced

Purchase

Manually Priced

Purchase

Manually Priced

Purchase

Manually Priced

Purchase

Manually Priced

Purchase

Manually Priced

Purchase

Manually Priced

Purchase

Manually Priced

Purchase

Manually Priced

Purchase

L3222	NU EP	U1	***(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	***(Regular last high-top shoe, each, size8¹/2-12) Orthopedic footwear, man's shoes, high-top, depth inlay	All	N	Purchase
L3222	NU EP	U1	***(Reverse last closed toe) Orthopedic footwear, man's shoes, high-top, depth inlay	All	N	Manually Priced Purchase
L3224	NU	Orthopedic footwear, woman's shoe, Oxford, used as an integral part of a brace (orthosis)	21 +	N	Purchase
L3225	NU	Orthopedic footwear, man's shoe, oxford, used as an integral part of a brace (orthosis)	21 +	N	Purchase
L3230	NU EP	Orthopedic footwear, custom shoes, depth inlay	All	Y	Purchase
L3250	NU EP	Orthopedic footwear, custom molded shoe, removable inner molded, prosthetic shoe, each	All	Y	Manually Priced
L3253	NU EP	Foot, molded shoe Plastazote (or similar), custom fitted, each	All	Y	Purchase
L3257	NU EP	Orthopedic footwear, additional charge for split size	All	Y	Purchase
L3260	NU EP	Surgical boot/shoe, each	All	N	Purchase
L3265	NU EP	Plastazote sandal, each	All	N	Purchase
L3310	NU EP	Lift, elevation, heel and sole, neoprene, per inch	All	N	Purchase
L3332	NU EP	Lift, elevation, inside shoe, tapered, up to one-half inch	All	N	Purchase
L3334	NU EP	Lift, elevation, heel, per inch	All	N	Purchase
L3350	NU EP	Heel wedge	All	N	Purchase
L3360	NU EP	Sole wedge, outside sole	All	N	Purchase
L3370	NU EP	Sole wedge, between sole	All	N	Purchase
L3400	NU EP	Metatarsal bar wedge, rocker	All	N	Purchase

L3420	NU EP	Full sole and heel wedge, between sole	All	N	Purchase
L3450	NU EP	Heel, SACH cushion type	All	N	Purchase
L3455	NU EP	Heel, new leather, standard	All	N	Purchase
L3465	NU EP	Heel, Thomas with wedge	All	N	Purchase
L3540	NU EP	Orthopedic shoe addition, sole full	All	N	Purchase
L3580	NU EP	Orthopedic shoe addition, convert instep to velcro closure	All	N	Purchase
L3590	NU EP	Orthopedic shoe addition, convert firm shoe counter to soft counter	All	N	Purchase
L3600	NU EP	Transfer for an orthosis from one shoe to another, caliper plate, existing	All	N	Purchase
L3620	NU EP	Transfer of an orthosis from one shoe to another, solid stirrup, existing	All	N	Purchase
L3630	NU EP	Transfer of an orthosis from one shoe to another, solid stirrup, new	All	N	Purchase
L3649	EP	Orthopedic shoe, modification, addition or transfer, NOS	U21	N/A	Manually Priced
L3649	NU EP	U1	***(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	***(Orthopedic footwear, wooden sole shoe, each) Orthopedic shoe, modification, addition or transfer, NOS	All	N	Manually Priced Purchase
L3650	NU EP	SO, figure of eight design abduction re-strainer prefabricated, includes fitting and adjustment	All	N	Purchase
L3660	NU EP	SO, figure of eight design, abduction restrainer, canvas and webbing, prefabricated, includes fitting and adjustment	All	N	Purchase
L3670	NU EP	SO, acromio/clavicular (canvas and webbing type) prefabricated, includes fitting and adjustment	All	N	Purchase

L3675	NU	SO, vest type abduction restrainer, canvas webbing type, or equal, prefabricated, includes fitting and adjustment	21 +	N	Purchase
L3700	NU EP	Elbow orthoses (EO), elastic with stays, prefabricated, includes fitting and adjustment	All	N	Purchase
L3710	NU EP	EO, elastic with metal joints, prefabricated, includes fitting and adjustment	All	N	Purchase
L3720	NU EP	EO, double upright with forearm/arm cuffs, free motion, custom fabricated	All	N	Purchase
L3730	NU EP	EO, double upright with forearm/arm cuffs, extension/flexion assist, custom fabricated	All	Y	Purchase
L3740	NU EP	EO, double upright with forearm/arm cuffs, adjustable position lock with active control, custom fabricated	All	Y	Purchase
L3800	NU EP	WHFO, short opponens, no attachments, custom fabricated	All	N	Purchase
L3805	NU EP	WHFO, long opponens, no attachment, custom fabricated	All	N	Purchase
L3807	NU EP	WHFO, without joint(s), prefabricated, includes fitting and adjustments, any type	All	N	Purchase
L3810	NU EP	WHFO, addition to short and long opponens, thumb abduction ("C") bar	All	N	Purchase
L3815	NU EP	WHFO, addition to short and long opponens, second M.P. abduction assist	All	N	Purchase
L3820	NU EP	WHFO, addition to short and long opponens, I.P. extension assist, with M.P. extension stop	All	N	Purchase
L3825	NU EP	WHFO, addition to short and long opponens, M.P. extension stop	All	N	Purchase
L3830	NU EP	WHFO, addition to short and long opponens, M.P. extension assist	All	N	Purchase
L3835	NU EP	WHFO, addition to short and long opponens, M.P. spring extension assist	All	N	Purchase
L3840	NU EP	WHFO, addition to short and long opponens, spring swivel thumb	All	N	Purchase

L3845	NU EP	WHFO, addition to short and long opponens, thumb I.P. extension assist, with M.P. stop	All	N	Purchase
L3850	NU EP	WHO, addition to short and long opponens, action wrist with dorsiflexion assist	All	N	Purchase
L3855	NU EP	WHFO, addition to short and long opponens, adjustable M.P. flexion control	All	N	Purchase
L3860	NU EP	WHFO, addition to short and long opponens, adjustable M.P. flexion control and LP.	All	N	Purchase
L3900	NU EP	WHFO, dynamic flexor hinge, reciprocal wrist extension/flexion, finger flexion/extension, wrist or finger driven, custom fabricated	All	Y	Purchase
L3901	NU EP	WHFO, dynamic flexor hinge, reciprocal wrist extension/flexion, finger flexion/extension, cable driven, custom fabricated	All	Y	Purchase
L3902	NU EP	WHFO, external powered, compressed gas, custom fabricated	All	Y	Purchase
L3904	NU EP	WHFO, external powered, electric, custom fabricated	All	Y	Purchase
L3906**	NU EP	WHFO, wrist gauntlet, molded to patient model, custom fabricated	All	N	Purchase
L3907**	NU EP	WHFO, wrist gauntlet with thumb spica, molded to patient model, custom fabricated	All	N	Purchase
L3908	NU EP	WHFO, wrist extension control cock-up, nonmolded, prefabricated, includes fitting and adjustment	All	N	Purchase
L3910	NU EP	WHFO, Swanson design, prefabricated, includes fitting and adjustment	All	N	Purchase
L3912	NU EP	HFO, flexion glove with elastic finger control, prefabricated, includes fitting and adjustment	All	N	Purchase
L3914	NU EP	WHO, wrist extension (cock-up) prefabricated, includes fitting and adjustment	All	N	Purchase
L3916	NU EP	WHFO, wrist extension (cock-up), with outrigger, prefabricated, includes fitting and adjustment	All	N	Purchase

L3918	NU EP	HFO, knuckle bender prefabricated, includes fitting and adjustment	All	N	Purchase
L3920	NU EP	HFO, knuckle bender, with outrigger prefabricated, includes fitting and adjustment	All	N	Purchase
L3922	NU EP	HFO, knuckle bender, two segment to flex joints prefabricated, includes fitting and adjustment	All	N	Purchase
L3924	NU EP	WHFO, Oppenheimer, prefabricated, includes fitting and adjustment	All	N	Purchase
L3926	NU EP	WHFO, Thomas suspension, prefabricated, includes fitting and adjustment	All	N	Purchase
L3928	NU EP	HFO, finger extension, with lock spring, prefabricated, includes fitting and adjustment	All	N	Purchase
L3930	NU EP	WHFO, finger extension, with wrist support, prefabricated, includes fitting and adjustment	All	N	Purchase
L3932	NU EP	FO, safety pin, spring wire, prefabricated, includes fitting and adjustment	All	N	Purchase
L3934	NU EP	FO, safety pin, modified, prefabricated, includes fitting and adjustment	All	N	Purchase
L3936	NU EP	WHFO, Palmer prefabricated, includes fitting and adjustment	All	N	Purchase
L3938	NU EP	WHFO, Dorsal wrist, prefabricated, includes fitting and adjustment	All	N	Purchase
L3940	NU EP	WHFO, Dorsal wrist, with outrigger attachment, prefabricated, includes fitting and adjustment	All	N	Purchase
L3942	NU EP	HFO, reverse knuckle bender, prefabricated, includes fitting and adjustment	All	N	Purchase
L3944	NU EP	HFO, reverse knuckle bender, with outrigger, prefabricated, includes fitting and adjustment	All	N	Purchase
L3946	NU EP	HFO, composite elastic, prefabricated, includes fitting and adjustment	All	N	Purchase
L3948	NU EP	FO, finger knuckle bender, prefabricated, includes fitting and adjustment	All	N	Purchase

L3950	NU EP	WHFO, combination Oppenheimer, with knuckle bender and two attachments, prefabricated, includes fitting and adjustment	All	N	Purchase
L3952	NU EP	WHFO, combination Oppenheimer, with reverse knuckle and two attachments, prefabricated, includes fitting and adjustment	All	N	Purchase
L3954	NU EP	HFO, spreading hand, prefabricated, includes fitting and adjustment	All	N	Purchase
L3956	NU	Addition of joint to upper extremity orthosis, any material; per joint	21 +	N	Purchase
L3960	NU EP	SEWHO, abduction, positioning, airplane design, prefabricated, includes fitting and adjustment	All	Y	Purchase
L3962	NU EP	SEWHO, abduction positioning, Erb's palsy design, prefabricated, includes fitting and adjustment	All	N	Purchase
L3963	NU EP	SEWHO, molded shoulder, arm, forearm, and wrist, with articulating elbow joint, custom fabricated	All	Y	Purchase
L3964	NU EP	SEO, mobile arm supports attached to wheelchair, balanced, adjustable, prefabricated, includes fitting and adjustment	All	N	Purchase
L3965	NU EP	SEO mobile arm support attached to wheelchair, balanced, adjustable Rancho type, prefabricated, includes fitting and adjustment	All	Y	Purchase
L3966	NU EP	SEO, mobile arm support attached to wheelchair, balanced, reclining, prefabricated, includes fitting and adjustment	All	Y	Purchase
L3968	NU EP	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	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	SEO, addition to mobile arm support elevating proximal arm	All	N	Purchase
L3972	NU EP	SEO , addition to mobile arm support, offset or lateral rocker arm with elastic balance control	All	N	Purchase
L3974	NU EP	SEO, addition to mobile arm support, supinator	All	N	Purchase
L3980	NU EP	Upper extremity fracture orthosis, humeral, prefabricated, includes fitting and adjustment	All	N	Purchase
L3982	NU EP	Upper extremity fracture orthosis, radius/ulnar prefabricated, includes fitting and adjustment	All	N	Purchase
L3984	NU EP	Upper extremity fracture orthosis, wrist, prefabricated, includes fitting and adjustment	All	N	Purchase
L3985	NU EP	Upper extremity fracture orthosis, forearm, hand with wrist hinge, custom fabricated	All	N	Purchase
L3986	NU EP	Upper extremity fracture orthosis, combination of humeral, radius/ulnar, wrist (example - Colles' fracture), custom fabricated	All	N	Purchase
L3995	NU EP	Addition to upper extremity orthosis sock, fracture or equal, each	All	N	Purchase
L3999	EP	Upper limb orthosis, NOS	U21	N/A	Manually Priced
L3999	NU EP	***(The manufacturer's invoice must be attached to all claims.) Upper limb orthosis, NOS	All	Y	Manually Priced Manually Priced
L4000	NU EP	Replace girdle for spinal orthosis (CTLSO or SO)	All	Y	Purchase
L4002	NU EP	Replace strap, any orthosis, includes all components, any length, any type	All	N	Manually Priced
L4010	NU EP	Replace trilateral socket brim	All	N	Purchase
L4020	NU EP	Replace quadrilateral socket brim, molded to patient model	All	N	Purchase
L4030	NU EP	Replace quadrilateral socket brim, custom fitted	All	N	Purchase
L4040	NU EP	Replace molded thigh lacer	All	N	Purchase

L4045	NU EP	Replace nonmolded thigh lacer	All	N	Purchase
L4050	NU EP	Replace molded calf lacer	All	N	Purchase
L4055	NU EP	Replace nonmolded calf lacer	All	N	Purchase
L4060	NU EP	Replace high roll cuff	All	N	Purchase
L4070	NU EP	Replace proximal and distal upright for KAFO	All	N	Purchase
L4080	NU EP	Replace metal bands KAFO, proximal thigh	All	N	Purchase
L4090	EP	***(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	Replace metal bands KAFO-AFO, calf or distal thigh	All	N	Purchase
L4100	NU EP	Replace leather cuff KAFO, proximal thigh	All	N	Purchase
L4110	NU EP	Replace leather cuff KAFO-AFO, calf or distal thigh	All	N	Purchase
L4130	NU EP	Replace pretibial shell	All	N	Purchase
L4205	NU EP	Repair of orthotic device, labor component, per 15 minutes	All	Y	Manually Priced Purchase
L4210	NU EP	Repair of orthotic device, repair or replace minor parts	All	Y	Manually Priced Purchase
L4350	NU EP	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	Walking boot, pneumatic with or without joints, with or without interface material, prefabricated, includes fitting and adjustment	All	N	Purchase
L4370	NU EP	Pneumatic full leg splint, prefabricated, includes fitting and adjustment	All	N	Purchase

L4380	NU EP	Pneumatic knee splint, prefabricated, includes fitting and adjustment	All	N	Purchase
L4392	Replacement soft interface material, static AFO	21 +	N	Purchase
L4394	NU	Replace soft interface material, foot drop splint	21 +	N	Purchase
L4396	NU	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	Foot drop splint, recumbent positioning device, prefabricated, includes fitting and adjustment	21 +	N	Purchase
L5999	NU EP	*(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	*(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	Repair of prosthetic device, hourly rate	All	Y	Manually Priced Purchase
L7520	NU EP	Repair prosthetic device, labor component, per 15 minutes	All	Y	Manually Priced Purchase
L8499	NU EP	*(Unlisted Prosthetic Devices or Orthotic Appliances; the manufacturer's invoice must be attached to all claims.)**Unlisted procedure for miscellaneous prosthetic services	All	Y	Manually Priced Purchase

242.180Orthotic Appliances, All Ages

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

** 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	Description	All U21 21 +	PA 21 +	Payment Method
A5500"	NU	For diabetics only, fitting (including follow-up) custom preparation and supply of off-the-shelf depth-inlay shoe manufactured to accommodate multi-density insert(s), per shoe	21 +	N	Purchase
A5501"	NU	For diabetics only, fitting (including follow-up) custom preparation and supply of molded from cast(s) of patient's foot (custom molded shoe), per shoe	21 +	N	Purchase
A5503"	NU	For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with roller or rigid rocker bottom, per shoe	21 +	N	Purchase
A5504"	NU	For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with wedge(s), per shoe	21 +	N	Purchase
A5505"	NU	For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with metatarsal bar, per shoe	21 +	N	Purchase
A5506"	NU	For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with off-set heel(s), per shoe	21 +	N	Purchase

A5507	NU	For diabetics only, not otherwise specified modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe, per shoe	21 +	Y	Purchase
A5510"	NU	For diabetics only, direct formed, compression molded to patient's foot without external heat source, multiple-density insert(s) prefabricated, per shoe	21 +	N	Purchase
A5512	NU	For diabetics only, multiple density insert, direct formed, molded to foot after external heat source of 230 degrees Fahrenheit or higher, total contact with patient's foot, including arch, base layer minimum of % inch material of shore a 35 durometer of 3/16 inch material of shore a 40 durometer (or higher), prefabricated, each	21 +	Y	Purchase
A5513	NU	For diabetics only, multiple density insert, custom molded from model of patient's foot, total contact with patient's foot, including arch, base layer minimum of % inch material of shore a 35 durometer of 3/16 inch material of shore a 40 durometer (or higher), includes arch filler and other shaping material custom fabricated, each	21 +	Y	Purchase
L0100	NU EP	Cranial orthosis (helmet), with or without soft interface, molded to patient model	All	N	Purchase
L0110	NU EP	Cranial orthosis (helmet), with or without soft interface, non-molded	All	N	Purchase
L0120	NU EP	Cervical, flexible, nonadjustable (foam collar)	All	N	Purchase
L0130	NU EP	Cervical, flexible, thermoplastic collar, molded to patient	All	N	Purchase
L0140	NU EP	Cervical, semi-rigid, adjustable (plastic collar)	All	N	Purchase
L0150	NU EP	Cervical, semi-rigid, adjustable molded chin cup (plastic collar with mandibular/occipital piece)	All	N	Purchase
L0160	NU EP	Cervical, semi-rigid wire frame occipital/mandibular support	All	N	Purchase

L0170	NU EP	Cervical, collar, molded to patient model	All	N	Purchase
L0172	NU EP	Cervical, collar, semi-rigid thermoplastic foam, two piece	All	N	Purchase
L0174	NU EP	Cervical, collar, semi-rigid thermoplastic foam, two piece with thoracic extension	All	N	Purchase
L0180	NU EP	Cervical, multiple post collar, occipital/mandibular supports, adjustable	All	N	Purchase
L0190	NU EP	Cervical, multiple post collar, occipital/mandibular supports, adjustable cervical bars (Somi, Guilford, Taylor types)	All	N	Purchase
L0200	NU EP	Cervical, multiple post collar, occipital/mandibular supports, adjustable cervical bars, and thoracic extension	All	N	Purchase
L0210	NU EP	Thoracic, rib belt	All	N	Purchase
L0220	NU EP	Thoracic, rib belt, custom fabricated	All	N	Purchase
L0450	NU EP	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	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	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	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	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	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	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	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	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	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	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	TLSO, triplanar control, hyperextension, rigid anterior and lateral frame extends from symphysis pubis to sternal notch with two anterior components (one pubic and one sternal) posterior and lateral pads with straps and closures, limits spinal flexion, restricts gross trunk motion in sagittal, coronal and transverse planes, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment	All	N	Purchase
L0474	NU EP	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	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	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	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	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	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	TLSO, sagittal-coronal control, one-piece rigid plastic shell with overlapping reinforced anterior, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates at or before the T9 vertebra, anterior extends from symphysis pubis to xiphoid, anterior opening, restricts gross trunk motion in sagittal and coronal planes, prefabricated, includes fitting and adjustment	All	Y	Purchase
L0621	NU EP	SO, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, prefabricated, includes fitting and adjustment	All	N	Purchase
L0622	NU EP	SO, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricated	All	N	Purchase

L0623	NU EP	SO, flexible, provides pelvic-sacral support, with rigid or semi-rigid panels over the sacrum and abdomen, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, prefabricated, includes fitting and adjustment	All	N	Purchase
L0624	NU EP	SO, provides pelvic-sacral support, with rigid or semi-rigid panels over the sacrum and abdomen, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricated	All	N	Manually Priced
L0625	NU EP	LO, flexible, provides lumbar support, posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include pendulous abdomen design, shoulder straps, stays, prefabricated, includes fitting and adjustment	All	N	Purchase
L0626	NU EP	LO, sagittal control, with rigid posterior panel(s), posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment	All	N	Purchase
L0627	NU EP	LO, sagittal control, with rigid anterior and posterior panel(s), posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment	All	N	Purchase

L0628	NU EP	LSO, flexible, provides lumbosacral support, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include stays, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment	All	N	Purchase
L0629	NU EP	LSO, flexible, provides lumbo-sacral support, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include stays, shoulder straps, pendulous abdomen design, custom fabricated	All	N	Manually Priced
L0630	NU EP	LSO, sagittal control, with rigid posterior panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment	All	N	Purchase
L0631	NU EP	LSO, sagittal control, with rigid anterior and posterior panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment	All	N	Purchase
L0632	NU EP	LSO, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, custom fabricated	All	N	Manually Priced

L0633	NU EP	LSO, sagittal-coronal control, with rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment	All	N	Purchase
L0634	NU EP	LSO, sagittal-coronal control, with rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, custom fabricated	All	N	Manually Priced
L0635	NU EP	LSO, sagittal-coronal control, lumbar flexion, rigid posterior frame/panel(s), lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, prefabricated, includes fitting and adjustment	All	N	Purchase
L0636	NU EP	LSO, sagittal-coronal control, lumbar flexion, rigid posterior frame/panel(s), lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, custom fabricated	All	N	Purchase

L0637	NU EP	LSO, sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment	All	N	Purchase
L0638	NU EP	LSO, sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, custom fabricated	All	N	Purchase
L0639	NU EP	LSO, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xiphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, prefabricated, includes fitting and adjustment	All	N	Purchase
L0640	NU EP	LSO, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xiphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, custom fabricated	All	N	Purchase

L0700	NU EP	Cervical-thoracic-lumbar-sacral orthoses (CTLSO), anterior-posterior-lateral control, molded to patient model (Minerva type)	All	Y	Purchase
L0710	NU EP	CTLSO, anterior-posterior-lateral control, molded to patient model, with interface material (Minerva type)	All	Y	Purchase
L0810	NU EP	Halo procedure, cervical halo incorporated into jacket vest	All	Y	Purchase
L0820	NU EP	Halo procedure, cervical halo incorporated into plaster body jacket	All	Y	Purchase
L0830	NU EP	Halo procedure, cervical halo incorporated into Milwaukee type orthosis	All	Y	Purchase
L0859	NU EP	Addition to halo procedure, magnetic resonance image compatible system, rings and pins, any material	All	Y	Purchase
L0960	NU EP	Torso support, post surgical support, pads for post surgical support	All	N	Purchase
L0970	NU EP	TLSO, corset front	All	N	Purchase
L0972	NU EP	LSO, corset front	All	N	Purchase
L0974	NU EP	TLSO, full corset	All	N	Purchase
L0976	NU EP	LSO, full corset	All	N	Purchase
L0978	NU EP	Axillary crutch extension	All	N	Purchase
L0980	NU EP	Peroneal straps, pair	All	N	Purchase
L0982	NU EP	Stocking supporter grips, set of four (4)	All	N	Purchase
L0984	NU	Protective body sock, each	21 +	N	Purchase
L1000	NU EP	CTLSO (Milwaukee), inclusive of furnishing initial orthosis, including model	All	Y	Purchase
L1010	NU EP	TLSO or scoliosis orthosis, axilla sling	All	N	Purchase
L1020	NU EP	Addition to CTLSO or scoliosis orthosis, kyphosis pad	All	N	Purchase
L1025	NU EP	Addition to CTLSO or scoliosis orthosis, kyphosis pad, floating	All	N	Purchase

L1030	NU EP	Addition to CTLSO or scoliosis orthosis, lumbar bolster pad	All	N	Purchase
L1040	NU EP	Addition to CTLSO or scoliosis orthosis, lumbar or lumbar rib pad	All	N	Purchase
L1050	NU EP	Addition to CTLSO or scoliosis orthosis, sternal pad	All	N	Purchase
L1060	NU EP	Addition to CTLSO or scoliosis orthosis, thoracic pad	All	N	Purchase
L1070	NU EP	Addition to CTLSO or scoliosis orthosis, trapezius sling	All	N	Purchase
L1080	NU EP	Addition to CTLSO or scoliosis orthosis, outrigger	All	N	Purchase
L1085	NU EP	Addition to CTLSO or scoliosis orthosis, outrigger, bilateral with vertical extensions	All	N	Purchase
L1090	NU EP	Addition to CTLSO or scoliosis orthosis, lumbar sling	All	N	Purchase
L1100	NU EP	Addition to CTLSO or scoliosis orthosis, ring flange, plastic or leather	All	N	Purchase
L1110	NU EP	Addition to CTLSO or scoliosis orthosis, ring flange, plastic or leather, molded to patient model	All	N	Purchase
L1120	NU EP	Addition to CTLSO, scoliosis orthosis, cover for upright, each	All	N	Purchase
L1200	NU EP	Thoracic-lumbar-sacral-orthosis (TLSO), inclusive of furnishing initial orthosis only	All	Y	Purchase
L1210	NU EP	Addition to TLSO (low profile), lateral thoracic extension	All	N	Purchase
L1220	NU EP	Addition to TLSO (low profile), anterior thoracic extension	All	N	Purchase
L1230	NU EP	Addition to TLSO (low profile), Milwaukee type superstructure	All	N	Purchase
L1240	NU EP	Addition to TLSO (low profile), lumbar derotation pad	All	N	Purchase
L1250	NU EP	Addition to TLSO (low profile), anterior ASIS pad	All	N	Purchase
L1260	NU EP	Addition to TLSO (low profile), anterior thoracic derotation pad	All	N	Purchase
L1270	NU EP	Addition to TLSO (low profile), abdominal pad	All	N	Purchase

L1280	NU EP	Addition to TLSO (low profile), rib gusset (elastic), each	All	N	Purchase
L1290	NU EP	Addition to TLSO (low profile), lateral trochanteric pad	All	N	Purchase
L1300	NU EP	Other scoliosis procedure, body jacket molded to patient model	All	Y	Purchase
L1310	NU EP	Other scoliosis procedure, postoperative body jacket	All	Y	Purchase
L1499	NU EP	Spinal orthosis, not otherwise specified. ***(The manufacturer's invoice must be attached to all claims.)	All	Y	Manually Priced
L1500	NU EP	THKAO, mobility frame (Newington, Parapodium types)	All	Y	Purchase
L1510	NU EP	THKAO, standing frame, with or without tray and accessories	All	Y	Purchase
L1520	NU EP	THKAO, swivel walker	All	Y	Purchase
L1600	NU EP	HO, abduction control of hip joints, flexible, Frejka type with cover, prefabricated, includes fitting and adjustment	All	N	Purchase
L1610	NU EP	HO, abduction control of hip joints, flexible (Frejka cover only), prefabricated, includes fitting and adjustment	All	N	Purchase
L1620	NU EP	HO, abduction control of hip joints, flexible (Pavlik harness), prefabricated, includes fitting and adjustment	All	N	Purchase
L1630	NU EP	HO, abduction control of hip joints, semi-flexible (Von Rosen type), custom fabricated	All	N	Purchase
L1640	NU EP	HO, abduction control of hip joints, static, pelvic band or spreader bar, thigh cuffs, custom fabricated	All	N	Purchase
L1650	NU EP	HO, abduction control of hip joints, static, adjustable, custom fitted (llfled type), prefabricated, includes fitting and adjustment	All	N	Purchase
L1660	NU EP	HO, abduction control of hip joints, static, plastic, prefabricated, includes fitting and adjustment	All	N	Purchase

L1680	NU EP	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	HO, abduction control of hip joint, post operative hip abduction type, custom fabricated	All	Y	Purchase
L1686	NU EP	HO, abduction control of hip joint, post operative hip abduction type, prefabricated, includes fitting and adjustments	All	Y	Purchase
L1690	NU	Combination, bilateral, lumbo-sacral, hip, femur orthosis providing adduction and internal rotation control, prefabricated, includes fitting and adjustment	21 +	Y	Purchase
L1700	NU EP	Legg Perthes orthosis (Toronto type), custom fabricated	All	Y	Purchase
L1710	NU EP	Legg Perthes orthosis (Newington type), custom fabricated	All	Y	Purchase
L1720	NU EP	Legg Perthes orthosis, trilateral (Tachdijan type), custom fabricated	All	Y	Purchase
L1730	NU EP	Legg Perthes orthosis (Scottish Rite type) custom fabricated	All	Y	Purchase
L1750	NU EP	Legg Perthes orthosis, Legg Perthes sling (Sam Brown type), prefabricated, includes fitting and adjustment	All	Y	Purchase
L1755	NU EP	Legg Perthes orthosis (Patten bottom type), custom fabricated	All	Y	Purchase
L1800	NU EP	KO, elastic with stays, prefabricated, includes fitting and adjustment	All	N	Purchase
L1810	NU EP	KO, elastic with joints, prefabricated, includes fitting and adjustment	All	N	Purchase
L1815	NU EP	KO, elastic or other elastic type material with condylar pad(s), prefabricated, includes fitting and adjustment	All	N	Purchase
L1820	NU EP	KO, elastic with condyle pads and joints, prefabricated, includes fitting and adjustment	All	N	Purchase
L1825	NU EP	KO, elastic knee cap. prefabricated, includes fitting and adjustment	All	N	Purchase

L1830	NU EP	KO, immobilizer, canvas longitudinal, prefabricated, includes fitting and adjustment	All	N	Purchase
L1832	NU EP	KO, adjustable knee joints, positional orthosis, rigid support, prefabricated, includes fitting and adjustment rigid support	All	N	Purchase
L1834	NU EP	KO, without knee joint, rigid, custom fabricated	All	N	Purchase
L1840	NU EP	KO, derotation, medial-lateral, anterior cruciate ligament, custom fabricated	All	Y	Purchase
L1843	NU	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	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	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	KO, double upright, thigh and calf, with adjustable flexion and extension joint, medial-lateral and rotation control, custom fabricated	All	Y	Purchase
L1847	NU	Knee orthosis, double upright with adjustable joint, with inflatable air support chamber(s) prefabricated, includes fitting and adjustment	21 +	N	Purchase
L1850	NU EP	KO, Swedish type, prefabricated, includes fitting and adjustment	All	N	Purchase
L1855	NU EP	KO, molded plastic, thigh and calf sections, with double upright knee joints, custom fabricated	All	Y	Purchase
L1858	NU EP	KO, molded plastic, polycentric knee joints, pneumatic knee pads (CTI), custom fabricated	All	Y	Purchase

L1860	NU EP	KO, modification of supracondylar prosthetic socket, custom fabricated (SK)	All	Y	Purchase
L1870	NU EP	KO, double upright, thigh and calf lacers, with knee joints, custom fabricated	All	Y	Purchase
L1880	NU EP	KO, double upright, nonmolded thigh and calf cuff/lacers with knee joints, custom fabricated	All	N	Purchase
L1900	NU EP	AFO, spring wire, dorsiflexion assist calf band, custom fabricated	All	N	Purchase
L1902	NU EP	AFO, ankle gauntlet, prefabricated, includes fitting and adjustment	All	N	Purchase
L1904	NU EP	AFO, molded ankle gauntlet, custom fabricated	All	N	Purchase
L1906	NU EP	AFO, multigamentus ankle support, prefabricated, includes fitting and adjustment	All	N	Purchase
L1907	NU EP	AFO, supramalleolar with straps, with or without interface/pads, custom fabricated	All	N	Purchase
L1910	NU EP	AFO, posterior, single bar, clasp attachment to shoe counter prefabricated, includes fitting and adjustment	All	N	Purchase
L1920	NU EP	AFO, single upright with static or adjustable stop (Phelps or Perlstein type), custom fabricated	All	N	Purchase
L1920	EP	***(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	AFO, plastic or other material, prefabricated, includes fitting and adjustment	All	N	Purchase
L1932	NU EP	AFO, rigid anterior tibial section, total carbon fiber or equal material, prefabricated, includes fitting and adjustment	All	N	Purchase
L1940	NU EP	AFO, plastic or other material, custom-fabricated	All	N	Purchase
L1945	NU EP	AFO, molded to patient model, plastic, rigid anterior tibial section (floor reaction), custom fabricated	All	Y	Purchase

L1950	NU EP	AFO, spiral (Institute of Rehabilitative Medicine type), plastic, custom fabricated	All	N	Purchase
L1960	NU EP	AFO, posterior solid ankle, plastic, custom fabricated	All	N	Purchase
L1970	NU EP	AFO, plastic, with ankle joint, custom fabricated	All	N	Purchase
L1980	NU EP	AFO, single upright free plantar dorsiflexion, solid stirrup, calf band/cuff (single bar "BK" orthosis), custom fabricated	All	N	Purchase
L1990	NU EP	AFO, double upright free plantar dorsiflexion, solid stirrup, calf band/cuff (double bar "BK" orthosis), custom fabricated	All	N	Purchase
L2000	NU EP	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	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	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	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	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	KAFO, full plastic, static prefabricated (pediatric size) prefabricated, includes fitting and adjustment	21 +	N	Purchase
L2036	NU EP	KAFO, full plastic, double upright, free knee, custom fabricated	All	Y	Purchase
L2037	NU EP	KAFO, full plastic, single upright, free knee, custom fabricated	All	Y	Purchase

L2038	NU EP	KAFO, full plastic, without knee joint, multi-axis ankle, (Lively orthosis or equal), custom fabricated	All	Y	Purchase
L2039	NU	KAFO, full plastic, single upright, poly-axial hinge, medial lateral rotation control, custom fabricated	21 +	Y	Purchase
L2040	NU EP	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	***(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	HKAFO, torsion control, bilateral torsion cables, hip joint, pelvic band/belt, custom fabricated	All	N	Purchase
L2060	NU EP	HKAFO, torsion control, bilateral torsion cables, ball bearing hip joint, pelvic band/belt, custom fabricated	All	N	Purchase
L2070	NU EP	HKAFO, torsion control, unilateral rotation straps, pelvic band/belt, custom fabricated	All	N	Purchase
L2080	NU EP	HKAFO, torsion control, unilateral torsion cable, hip joint, pelvic band/belt, custom fabricated	All	N	Purchase
L2090	NU EP	HKAFO, torsion control, unilateral torsion cable, ball bearing hip joint, pelvic band/belt, custom fabricated	All	N	Purchase
L2106	NU EP	AFO, fracture orthosis, tibial fracture cast orthosis, thermoplastic type casting material, custom fabricated	All	N	Purchase
L2108	NU EP	AFO, fracture orthosis, tibial fracture cast orthosis, custom fabricated	All	Y	Purchase
L2112	NU EP	AFO, fracture orthosis, tibial fracture orthosis, soft, prefabricated, includes fitting and adjustment	All	N	Purchase
L2114	NU EP	AFO, fracture orthosis, tibial fracture orthosis, semi-rigid, prefabricated, includes fitting and adjustment	All	N	Purchase

L2116	NU EP	AFO, fracture orthosis, tibial fracture orthosis, rigid, prefabricated, includes fitting and adjustment	All	N	Purchase
L2126	NU EP	KAFO, fracture orthosis, femoral fracture cast orthosis, thermoplastic type casting material, molded to patient	All	Y	Purchase
L2128	NU EP	KAFO, fracture orthosis, femoral fracture cast orthosis, thermoplastic type casting material, custom fabricated	All	Y	Purchase
L2132	NU EP	KAFO, fracture orthosis, femoral fracture cast orthosis, soft, prefabricated, includes fitting and adjustment	All	Y	Purchase
L2134	NU EP	KAFO, fracture orthosis, femoral fracture cast orthosis, semi-rigid custom fitted	All	Y	Purchase
L2136	NU EP	KAFO, fracture orthosis, femoral fracture cast orthosis, rigid, prefabricated, includes fitting and adjustment	All	Y	Purchase
L2180	NU EP	Addition to lower extremity fracture orthosis, plastic shoe insert with ankle joints	All	N	Purchase
L2182	NU EP	Addition to lower extremity fracture orthosis, drop lock knee joint	All	N	Purchase
L2184	NU EP	Addition to lower extremity fracture orthosis, limited motion knee joint	All	N	Purchase
L2186	NU EP	Addition to lower extremity fracture orthosis, adjustable motion knee joint (Lerman type)	All	N	Purchase
L2188	NU EP	Addition to lower extremity fracture orthosis, quadrilateral brim	All	N	Purchase
L2190	NU EP	Addition to lower extremity fracture orthosis, waist belt	All	N	Purchase
L2192	NU EP	Addition to lower extremity fracture orthosis, hip joint, pelvic band, thigh flange, and pelvic belt	All	N	Purchase
L2200	NU EP	Additions to lower extremity, dorsiflexion and plantar flexion	All	N	Purchase
L2210	NU EP	Addition to lower extremity, dorsiflexion assist (plantar flexion resist), each joint	All	N	Purchase

L2220	NU EP	Addition to lower extremity, dorsiflexion and plantar flexion assist/resist, each joint	All	N	Purchase
L2230	NU EP	Addition to lower extremity, split flat caliper stirrups and plate attachment	All	N	Purchase
L2232	NU EP	Addition to lower extremity orthosis, rocker bottom for total contact ankle foot orthosis, for custom fabricated orthosis only	All	N	Manually Priced
L2240	NU EP	Addition to lower extremity, round caliper and plate attachment	All	N	Purchase
L2250	NU EP	Addition to lower extremity, foot plate, molded to patient model, stirrup attachment	All	N	Purchase
L2260	NU EP	Addition to lower extremity, reinforced solid stirrup (Scott-Craig type)	All	N	Purchase
L2265	NU EP	Addition to lower extremity, long tongue stirrup	All	N	Purchase
L2270	NU EP	Addition to lower extremity, varus/valgus correction ("T") strap, padded/lined or malleolus pad	All	N	Purchase
L2275	NU	Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined	21 +	N	Purchase
L2280	NU EP	Addition to lower extremity, molded inner boot	All	N	Purchase
L2300	NU EP	Addition to lower extremity, abduction bar (bilateral hip involvement), jointed, adjustable	All	N	Purchase
L2310	NU EP	Addition to lower extremity, abduction bar straight	All	N	Purchase
L2320	NU EP	Addition to lower extremity, nonmolded lacer	All	N	Purchase
L2330	NU EP	Addition to lower extremity, lacer molded to patient model	All	N	Purchase
L2335	NU EP	Addition to lower extremity, anterior swing band	All	N	Purchase
L2340	NU EP	Addition to lower extremity, pretidial shell, molded to patient model	All	N	Purchase
L2350	NU EP	Addition to lower extremity, prosthetic type, (BK) socket, molded to patient model, (used for "PTB" "AFO" orthoses)	All	Y	Purchase

L2360	NU EP	Addition to lower extremity, extended steel shank	All	N	Purchase
L2370	NU EP	Addition to lower extremity, Patten bottom	All	N	Purchase
L2375	NU EP	Addition to lower extremity, torsion control, ankle joint and half solid stirrup	All	N	Purchase
L2380	NU EP	Addition to lower extremity, torsion control, straight knee joint, each joint	All	N	Purchase
L2385	NU EP	Addition to lower extremity, straight knee joint, heavy duty, each joint	All	N	Purchase
L2390	NU EP	Addition to lower extremity, offset knee joint, each joint	All	N	Purchase
L2395	NU EP	Addition to lower extremity, offset knee joint, heavy duty, each joint	All	N	Purchase
L2397	NU	Addition to lower extremity orthosis, suspension sleeve	21 +	N	Purchase
L2405	NU EP	Addition to knee joint, lock; drop, stance or swing phase, each joint	All	N	Purchase
L2415	NU EP	Addition to knee lock with integrated release mechanism , (bail, cable or equal, any material, each joint	All	N	Purchase
L2425	NU EP	Addition to knee joint, disc or dial lock for adjustable knee flexion, each joint	All	N	Purchase
L2430	NU EP	Addition to knee joint, ratchet lock for active and progressive knee extension, each joint	All	N	Purchase
L2492	NU EP	Addition to knee joint, lift loop for drop lock ring	All	N	Purchase
L2500	NU EP	Addition to lower extremity, thigh/weight bearing, gulteal/ischial weight bearing, ring	All	N	Purchase
L2510	NU EP	Addition to lower extremity, thigh/weight bearing, quadrilateral brim, molded to patient model	All	N	Purchase
L2520	NU EP	Addition to lower extremity, thigh/weight bearing, quadrilateral brim, custom fitted	All	N	Purchase
L2525	NU EP	Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim molded to patient model	All	N	Purchase

L2526	NU EP	Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim, custom fitted	All	N	Purchase
L2530	NU EP	Addition to lower extremity, thigh/weight bearing, lacer, non-molded	All	N	Purchase
L2540	NU EP	Addition to lower extremity, thigh/weight bearing, lacer, molded to patient model	All	N	Purchase
L2550	NU EP	Addition to lower extremity, thigh/weight bearing, high roll cuff	All	N	Purchase
L2570	NU EP	Addition to lower extremity, pelvic control, hip joint, clevis type two position joint, each	All	N	Purchase
L2580	NU EP	Addition to lower extremity, pelvic control, pelvic sling	All	N	Purchase
L2600	NU EP	Addition to lower extremity, pelvic control, hip joint, Clevis type, or thrust bearing free, each	All	N	Purchase
L2610	NU EP	Addition to lower extremity, pelvic control, hip joint, Clevis or thrust bearing, lock, each	All	N	Purchase
L2620	NU EP	Addition to lower extremity, pelvic control, hip joint, heavy duty, each	All	N	Purchase
L2622	NU EP	Addition to lower extremity, pelvic control, hip joint, adjustable flexion, each	All	N	Purchase
L2624	NU EP	Addition to lower extremity, pelvic control, hip joint, adjustable flexion, extension, abduction control, each	All	N	Purchase
L2627	NU EP	Addition to lower extremity, pelvic control, plastic, molded to patient model, reciprocating hip joint and cables	All	N	Purchase
L2628	NU EP	Addition to lower extremity, pelvic control, metal frame, reciprocating hip joint and cables	All	N	Purchase
L2630	NU EP	Addition to lower extremity, pelvic control, band and belt unilateral	All	N	Purchase
L2640	NU EP	Addition to lower extremity, pelvic control, band and belt bilateral	All	N	Purchase
L2650	NU EP	Addition to lower extremity, pelvic and thoracic control, gluteal pad, each	All	N	Purchase

L2660	NU EP	Addition to lower extremity, thoracic control, thoracic band	All	N	Purchase
L2670	NU EP	Addition to lower extremity, thoracic control, paraspinal uprights	All	N	Purchase
L2680	NU EP	Addition to lower extremity, thoracic control, lateral support uprights	All	N	Purchase
L2750	NU EP	Addition to lower extremity orthosis, plating chrome or nickel, per bar	All	N	Purchase
L2755	NU	Addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepreg composite, per segment	21 +	N	Purchase
L2755	NU EP	***(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	Addition to lower extremity orthosis, extension, per extension, per bar (for linear adjustment for growth)	All	N	Purchase
L2770	NU EP	Addition to lower extremity orthosis, any material, per bar or joint	All	N	Purchase
L2780	NU EP	Addition to lower extremity orthosis, non-corrosive finish, per bar	All	N	Purchase
L2785	NU EP	Addition to lower extremity orthosis, drop lock retainer, each	All	N	Purchase
L2795	NU EP	Addition to lower extremity orthosis, knee control, full kneecap	All	N	Purchase
L2800	NU EP	Addition to lower extremity orthosis, knee control, kneecap, medial or lateral pull	All	N	Purchase
L2810	NU EP	Addition to lower extremity orthosis, knee control, condylar pad	All	N	Purchase
L2810	EP	***(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	Addition to lower extremity orthosis, soft interface for molded plastic, below knee section	All	N	Purchase
L2830	NU EP	Addition to lower extremity orthosis, soft interface for molded plastic, above knee section	All	N	Purchase

L2840	NU EP	Addition to lower extremity orthosis, tibial length sock, fracture or equal, each	All	N	Purchase
L2850	NU EP	Addition to lower extremity orthosis, femoral length sock, fracture or equal, each	All	N	Purchase
L2999	NU EP	Lower extremity orthoses, NOS	All	N	Manually Priced
L2999	NU EP	***(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	Foot insert, removable, molded to patient model, "UCB" type, Berkeley shell, each	All	N	Purchase
L3002	NU EP	Foot insert, removable, molded to patient model, Plastazote or equal, each	All	N	Manually Priced
L3010	NU EP	Foot insert, removable, molded to patient model, longitudinal arch support, each	All	N	Purchase
L3020	NU EP	Foot insert, removable, molded to patient model, longitudinaMmetatarsal support, each	All	N	Purchase
L3030	NU EP	Foot insert, removable, formed to patient foot, each	All	N	Purchase
L3040	NU EP	Foot, arch support, removable, premolded, longitudinal, each	All	N	Purchase
L3050	NU EP	Foot, arch support, removable, premolded, metatarsal, each	All	N	Purchase
L3060	NU EP	Foot, arch support, removable, premolded, longitudinal/metatarsal, each	All	N	Purchase
L3070	NU EP	Foot, arch support, non-removable, attached to shoe, longitudinal, each	All	N	Purchase
L3080	NU EP	Foot, arch support, non-removable, attached to shoe, metatarsal, each	All	N	Purchase
L3090	NU EP	Foot, arch support, non-removable, attached to shoe, longitudinal/\|metatarsal, each	All	N	Purchase
L3100	NU EP	Hallus-valgus night dynamic splint	All	N	Purchase

L3140	NU EP	UB	***(Bebox foot orthosis club foot abduction orthosis) Foot, abduction rotation bar, including shoes	All	N	Manually Priced Purchase
L3140	NU	***(Don Joy knee orthosis) Foot, abduction rotation bar, including shoes	21 +	Y	Manually Priced
L3150	NU EP	Foot, abduction rotation bar, without shoes	All	N	Purchase
L3150	EP	***(Custom night "A" frame-KAFO, torsion control, bilateral night "A" frame) Foot, abduction rotation bar, without shoes	U21	N/A	Purchase
L3170	NU EP	Foot, plastic heel stabilizer	All	N	Purchase
L3202	EP	Orthopedic shoe, oxford with supinator or pronator, child	U21	N/A	Purchase
L3204	EP	Orthopedic shoe, high-top with supinator or pronator, infant	U21	N/A	Purchase
L3204	NU EP	***(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	***(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	***(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	***(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	***(Reverse last closed toe) Orthopedic shoe, high-top with supinator or pronator, infant	All	N	Manually Priced Purchase
L3204	NU	***(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	***(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	***(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	***(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	***(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	***(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	***(Reverse last closed toe) Orthopedic shoe, high-top with supinator or pronator, child	All	N	Manually Priced Purchase
L3206	NU	***(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	***(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	***(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	***(Straight last high-top shoe, each, size 8¹/4-12) Orthopedic shoe, high-top with supinator or pronator, junior	All	N	Manually Priced Purchase
L3207	NU EP	U1	***(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	***(Regular last high-top shoe, each, size 8¹/4-12) Orthopedic shoe, high-top with supinator or pronator, junior	All	N	Purchase
L3207	NU EP	U1	***(Reverse last closed toe) Orthopedic shoe, high-top with supinator or pronator, junior	All	N	Manually Priced Purchase
L3207	NU	***(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	***(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	***(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	Surgical boot, each, infant	U21	N/A	Purchase
L3209	EP	Surgical boot, each, child	U21	N/A	Purchase
L3215	NU EP	Orthopedic footwear, woman's shoes, oxford	All	Y	Manually Priced
L3216	NU EP	Orthopedic footwear, woman's shoes, depth inlay	All	Y	Purchase
L3217	NU EP	***(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	***(Straight last high-top shoe, each, size8¹/2-12) Orthopedic footwear, woman's shoes, high-top, depth inlay	All	N	Manually Priced Purchase
L3217	NU EP	U1	***(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	***(Regular last high-top shoe, each, size8¹/2-12) Orthopedic footwear, woman's shoes, high-top, depth inlay	All	N	Purchase
L3217	NU EP	U1	***(Reverse last closed toe) Orthopedic footwear, woman's shoes, high-top, depth inlay	All	N	Manually Priced Purchase
L3219	NU EP	Orthopedic footwear, man's shoes, oxford	All	Y	Manually Priced
L3221	NU EP	Orthopedic footwear, man's shoes, depth inlay	All	Y	Purchase
L3222	NU EP	***(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	***(Straight last high-top shoe, each, size8¹/2-12) Orthopedic footwear, man's shoes, high-top, depth inlay	All	N	Manually Priced Purchase

L3222	NU EP	U1	***(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	***(Regular last high-top shoe, each, size8¹/2-12) Orthopedic footwear, man's shoes, high-top, depth inlay	All	N	Purchase
L3222	NU EP	U1	***(Reverse last closed toe) Orthopedic footwear, man's shoes, high-top, depth inlay	All	N	Manually Priced Purchase
L3224	NU	Orthopedic footwear, woman's shoe, Oxford, used as an integral part of a brace (orthosis)	21 +	N	Purchase
L3225	NU	Orthopedic footwear, man's shoe, oxford, used as an integral part of a brace (orthosis)	21 +	N	Purchase
L3230	NU EP	Orthopedic footwear, custom shoes, depth inlay	All	Y	Purchase
L3250	NU EP	Orthopedic footwear, custom molded shoe, removable inner molded, prosthetic shoe, each	All	Y	Manually Priced
L3253	NU EP	Foot, molded shoe Plastazote (or similar), custom fitted, each	All	Y	Purchase
L3257	NU EP	Orthopedic footwear, additional charge for split size	All	Y	Purchase
L3260	NU EP	Surgical boot/shoe, each	All	N	Purchase
L3265	NU EP	Plastazote sandal, each	All	N	Purchase
L3310	NU EP	Lift, elevation, heel and sole, neoprene, per inch	All	N	Purchase
L3332	NU EP	Lift, elevation, inside shoe, tapered, up to one-half inch	All	N	Purchase
L3334	NU EP	Lift, elevation, heel, per inch	All	N	Purchase
L3350	NU EP	Heel wedge	All	N	Purchase
L3360	NU EP	Sole wedge, outside sole	All	N	Purchase
L3370	NU EP	Sole wedge, between sole	All	N	Purchase
L3400	NU EP	Metatarsal bar wedge, rocker	All	N	Purchase

L3420	NU EP	Full sole and heel wedge, between sole	All	N	Purchase
L3450	NU EP	Heel, SACH cushion type	All	N	Purchase
L3455	NU EP	Heel, new leather, standard	All	N	Purchase
L3465	NU EP	Heel, Thomas with wedge	All	N	Purchase
L3540	NU EP	Orthopedic shoe addition, sole full	All	N	Purchase
L3580	NU EP	Orthopedic shoe addition, convert instep to velcro closure	All	N	Purchase
L3590	NU EP	Orthopedic shoe addition, convert firm shoe counter to soft counter	All	N	Purchase
L3600	NU EP	Transfer for an orthosis from one shoe to another, caliper plate, existing	All	N	Purchase
L3620	NU EP	Transfer of an orthosis from one shoe to another, solid stirrup, existing	All	N	Purchase
L3630	NU EP	Transfer of an orthosis from one shoe to another, solid stirrup, new	All	N	Purchase
L3649	EP	Orthopedic shoe, modification, addition or transfer, NOS	U21	N/A	Manually Priced
L3649	NU EP	U1	***(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	***(Orthopedic footwear, wooden sole shoe, each) Orthopedic shoe, modification, addition or transfer, NOS	All	N	Manually Priced Purchase
L3650	NU EP	SO, figure of eight design abduction re-strainer prefabricated, includes fitting and adjustment	All	N	Purchase
L3660	NU EP	SO, figure of eight design, abduction restrainer, canvas and webbing, prefabricated, includes fitting and adjustment	All	N	Purchase
L3670	NU EP	SO, acromio/clavicular (canvas and webbing type) prefabricated, includes fitting and adjustment	All	N	Purchase

L3675	NU	SO, vest type abduction restrainer, canvas webbing type, or equal, prefabricated, includes fitting and adjustment	21 +	N	Purchase
L3700	NU EP	Elbow orthoses (EO), elastic with stays, prefabricated, includes fitting and adjustment	All	N	Purchase
L3710	NU EP	EO, elastic with metal joints, prefabricated, includes fitting and adjustment	All	N	Purchase
L3720	NU EP	EO, double upright with forearm/arm cuffs, free motion, custom fabricated	All	N	Purchase
L3730	NU EP	EO, double upright with forearm/arm cuffs, extension/flexion assist, custom fabricated	All	Y	Purchase
L3740	NU EP	EO, double upright with forearm/arm cuffs, adjustable position lock with active control, custom fabricated	All	Y	Purchase
L3800	NU EP	WHFO, short opponens, no attachments, custom fabricated	All	N	Purchase
L3805	NU EP	WHFO, long opponens, no attachment, custom fabricated	All	N	Purchase
L3807	NU EP	WHFO, without joint(s), prefabricated, includes fitting and adjustments, any type	All	N	Purchase
L3810	NU EP	WHFO, addition to short and long opponens, thumb abduction ("C") bar	All	N	Purchase
L3815	NU EP	WHFO, addition to short and long opponens, second M.P. abduction assist	All	N	Purchase
L3820	NU EP	WHFO, addition to short and long opponens, I.P. extension assist, with M.P. extension stop	All	N	Purchase
L3825	NU EP	WHFO, addition to short and long opponens, M.P. extension stop	All	N	Purchase
L3830	NU EP	WHFO, addition to short and long opponens, M.P. extension assist	All	N	Purchase
L3835	NU EP	WHFO, addition to short and long opponens, M.P. spring extension assist	All	N	Purchase
L3840	NU EP	WHFO, addition to short and long opponens, spring swivel thumb	All	N	Purchase

L3845	NU EP	WHFO, addition to short and long opponens, thumb I.P. extension assist, with M.P. stop	All	N	Purchase
L3850	NU EP	WHO, addition to short and long opponens, action wrist with dorsiflexion assist	All	N	Purchase
L3855	NU EP	WHFO, addition to short and long opponens, adjustable M.P. flexion control	All	N	Purchase
L3860	NU EP	WHFO, addition to short and long opponens, adjustable M.P. flexion control and LP.	All	N	Purchase
L3900	NU EP	WHFO, dynamic flexor hinge, reciprocal wrist extension/flexion, finger flexion/extension, wrist or finger driven, custom fabricated	All	Y	Purchase
L3901	NU EP	WHFO, dynamic flexor hinge, reciprocal wrist extension/flexion, finger flexion/extension, cable driven, custom fabricated	All	Y	Purchase
L3902	NU EP	WHFO, external powered, compressed gas, custom fabricated	All	Y	Purchase
L3904	NU EP	WHFO, external powered, electric, custom fabricated	All	Y	Purchase
L3906**	NU EP	WHFO, wrist gauntlet, molded to patient model, custom fabricated	All	N	Purchase
L3907**	NU EP	WHFO, wrist gauntlet with thumb spica, molded to patient model, custom fabricated	All	N	Purchase
L3908	NU EP	WHFO, wrist extension control cock-up, nonmolded, prefabricated, includes fitting and adjustment	All	N	Purchase
L3910	NU EP	WHFO, Swanson design, prefabricated, includes fitting and adjustment	All	N	Purchase
L3912	NU EP	HFO, flexion glove with elastic finger control, prefabricated, includes fitting and adjustment	All	N	Purchase
L3914	NU EP	WHO, wrist extension (cock-up) prefabricated, includes fitting and adjustment	All	N	Purchase
L3916	NU EP	WHFO, wrist extension (cock-up), with outrigger, prefabricated, includes fitting and adjustment	All	N	Purchase

L3918	NU EP	HFO, knuckle bender prefabricated, includes fitting and adjustment	All	N	Purchase
L3920	NU EP	HFO, knuckle bender, with outrigger prefabricated, includes fitting and adjustment	All	N	Purchase
L3922	NU EP	HFO, knuckle bender, two segment to flex joints prefabricated, includes fitting and adjustment	All	N	Purchase
L3924	NU EP	WHFO, Oppenheimer, prefabricated, includes fitting and adjustment	All	N	Purchase
L3926	NU EP	WHFO, Thomas suspension, prefabricated, includes fitting and adjustment	All	N	Purchase
L3928	NU EP	HFO, finger extension, with lock spring, prefabricated, includes fitting and adjustment	All	N	Purchase
L3930	NU EP	WHFO, finger extension, with wrist support, prefabricated, includes fitting and adjustment	All	N	Purchase
L3932	NU EP	FO, safety pin, spring wire, prefabricated, includes fitting and adjustment	All	N	Purchase
L3934	NU EP	FO, safety pin, modified, prefabricated, includes fitting and adjustment	All	N	Purchase
L3936	NU EP	WHFO, Palmer prefabricated, includes fitting and adjustment	All	N	Purchase
L3938	NU EP	WHFO, Dorsal wrist, prefabricated, includes fitting and adjustment	All	N	Purchase
L3940	NU EP	WHFO, Dorsal wrist, with outrigger attachment, prefabricated, includes fitting and adjustment	All	N	Purchase
L3942	NU EP	HFO, reverse knuckle bender, prefabricated, includes fitting and adjustment	All	N	Purchase
L3944	NU EP	HFO, reverse knuckle bender, with outrigger, prefabricated, includes fitting and adjustment	All	N	Purchase
L3946	NU EP	HFO, composite elastic, prefabricated, includes fitting and adjustment	All	N	Purchase
L3948	NU EP	FO, finger knuckle bender, prefabricated, includes fitting and adjustment	All	N	Purchase

L3950	NU EP	WHFO, combination Oppenheimer, with knuckle bender and two attachments, prefabricated, includes fitting and adjustment	All	N	Purchase
L3952	NU EP	WHFO, combination Oppenheimer, with reverse knuckle and two attachments, prefabricated, includes fitting and adjustment	All	N	Purchase
L3954	NU EP	HFO, spreading hand, prefabricated, includes fitting and adjustment	All	N	Purchase
L3956	NU	Addition of joint to upper extremity orthosis, any material; per joint	21 +	N	Purchase
L3960	NU EP	SEWHO, abduction, positioning, airplane design, prefabricated, includes fitting and adjustment	All	Y	Purchase
L3962	NU EP	SEWHO, abduction positioning, Erb's palsy design, prefabricated, includes fitting and adjustment	All	N	Purchase
L3963	NU EP	SEWHO, molded shoulder, arm, forearm, and wrist, with articulating elbow joint, custom fabricated	All	Y	Purchase
L3964	NU EP	SEO, mobile arm supports attached to wheelchair, balanced, adjustable, prefabricated, includes fitting and adjustment	All	N	Purchase
L3965	NU EP	SEO mobile arm support attached to wheelchair, balanced, adjustable Rancho type, prefabricated, includes fitting and adjustment	All	Y	Purchase
L3966	NU EP	SEO, mobile arm support attached to wheelchair, balanced, reclining, prefabricated, includes fitting and adjustment	All	Y	Purchase
L3968	NU EP	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	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	SEO, addition to mobile arm support elevating proximal arm	All	N	Purchase
L3972	NU EP	SEO , addition to mobile arm support, offset or lateral rocker arm with elastic balance control	All	N	Purchase
L3974	NU EP	SEO, addition to mobile arm support, supinator	All	N	Purchase
L3980	NU EP	Upper extremity fracture orthosis, humeral, prefabricated, includes fitting and adjustment	All	N	Purchase
L3982	NU EP	Upper extremity fracture orthosis, radius/ulnar prefabricated, includes fitting and adjustment	All	N	Purchase
L3984	NU EP	Upper extremity fracture orthosis, wrist, prefabricated, includes fitting and adjustment	All	N	Purchase
L3985	NU EP	Upper extremity fracture orthosis, forearm, hand with wrist hinge, custom fabricated	All	N	Purchase
L3986	NU EP	Upper extremity fracture orthosis, combination of humeral, radius/ulnar, wrist (example - Colles' fracture), custom fabricated	All	N	Purchase
L3995	NU EP	Addition to upper extremity orthosis sock, fracture or equal, each	All	N	Purchase
L3999	EP	Upper limb orthosis, NOS	U21	N/A	Manually Priced
L3999	NU EP	***(The manufacturer's invoice must be attached to all claims.) Upper limb orthosis, NOS	All	Y	Manually Priced Manually Priced
L4000	NU EP	Replace girdle for spinal orthosis (CTLSO or SO)	All	Y	Purchase
L4002	NU EP	Replace strap, any orthosis, includes all components, any length, any type	All	N	Manually Priced
L4010	NU EP	Replace trilateral socket brim	All	N	Purchase
L4020	NU EP	Replace quadrilateral socket brim, molded to patient model	All	N	Purchase
L4030	NU EP	Replace quadrilateral socket brim, custom fitted	All	N	Purchase
L4040	NU EP	Replace molded thigh lacer	All	N	Purchase

L4045	NU EP	Replace nonmolded thigh lacer	All	N	Purchase
L4050	NU EP	Replace molded calf lacer	All	N	Purchase
L4055	NU EP	Replace nonmolded calf lacer	All	N	Purchase
L4060	NU EP	Replace high roll cuff	All	N	Purchase
L4070	NU EP	Replace proximal and distal upright for KAFO	All	N	Purchase
L4080	NU EP	Replace metal bands KAFO, proximal thigh	All	N	Purchase
L4090	EP	***(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	Replace metal bands KAFO-AFO, calf or distal thigh	All	N	Purchase
L4100	NU EP	Replace leather cuff KAFO, proximal thigh	All	N	Purchase
L4110	NU EP	Replace leather cuff KAFO-AFO, calf or distal thigh	All	N	Purchase
L4130	NU EP	Replace pretibial shell	All	N	Purchase
L4205	NU EP	Repair of orthotic device, labor component, per 15 minutes	All	Y	Manually Priced Purchase
L4210	NU EP	Repair of orthotic device, repair or replace minor parts	All	Y	Manually Priced Purchase
L4350	NU EP	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	Walking boot, pneumatic with or without joints, with or without interface material, prefabricated, includes fitting and adjustment	All	N	Purchase
L4370	NU EP	Pneumatic full leg splint, prefabricated, includes fitting and adjustment	All	N	Purchase

L4380	NU EP	Pneumatic knee splint, prefabricated, includes fitting and adjustment	All	N	Purchase
L4392	Replacement soft interface material, static AFO	21 +	N	Purchase
L4394	NU	Replace soft interface material, foot drop splint	21 +	N	Purchase
L4396	NU	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	Foot drop splint, recumbent positioning device, prefabricated, includes fitting and adjustment	21 +	N	Purchase
L5999	NU EP	*(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	*(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	Repair of prosthetic device, hourly rate	All	Y	Manually Priced Purchase
L7520	NU EP	Repair prosthetic device, labor component, per 15 minutes	All	Y	Manually Priced Purchase
L8499	NU EP	*(Unlisted Prosthetic Devices or Orthotic Appliances; the manufacturer's invoice must be attached to all claims.)**Unlisted procedure for miscellaneous prosthetic services	All	Y	Manually Priced Purchase

242.190Prosthetic Devices, All Ages

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

Modifiers in this section are indicated by the headings M1 and M2. Prior authorization requirements are shown under the heading PA. If prior authorization is needed for individuals age 21 and older, that information is indicated with a "Y" in the column; if not, an "N" is shown. When codes are payable for all ages, "AN" is indicated in the column, "U21" is shown when the code is payable only for individuals under age 21 and "21+" is shown when the code is payable only for those individuals age 21 and older.

* Replacement only

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

NOTE: Procedure codes for prosthetic eyes and information regarding prosthetic eye care can be found in the Arkansas Medicaid Visual Care Program Manual.

Prosthetic Devices, All Ages (section 242.190)

Procedure Code	M1	M2	Description	All U21 21 +	PA 21 +	Payment Method
L1499	NU EP	***(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	***(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	***(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	***(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	/*(Orthotics and Prosthetics Repairs) Repair of orthotic device, labor component, per 15 minutes	All	Y	Manually Priced Purchase
L4210	NU EP	/*(Orthotics and Prosthetics Repairs) Repair of orthotic device, repair or replace minor parts	All	Y	Manually Priced Purchase
L5000	NU EP	Partial foot, shoe insert with longitudinal arch, toe filler	All	N	Purchase
L5010	NU EP	Partial foot, molded socket, ankle height, with toe filler	All	Y	Purchase

L5020	NU EP	Partial foot, molded socket, tibial tubercle height, with toe filler	All	Y	Purchase
L5050	NU EP	Ankle, Symes, molded socket, SACH foot	All	Y	Purchase
L5060	NU EP	Ankle, Symes, metal frame, molded leather socket, articulated ankle/foot	All	Y	Purchase
L5100	NU EP	Below knee, molded socket, shin, SACH foot	All	Y	Purchase
L5105	NU EP	Below knee, plastic socket, joints and thigh lacer, SACH foot	All	Y	Purchase
L5150	NU EP	Knee disarticulation (or through knee), molded socket, external knee joints, shin, SACH foot	All	Y	Purchase
L5160	NU EP	Knee disarticulation (or through knee), molded socket, bent knee configuration, external knee joints, shin, SACH foot	All	Y	Purchase
L5200	NU EP	Above knee, molded socket, single axis constant friction knee, shin, SACH foot	All	Y	Purchase
L5210	NU EP	Above knee, short prosthesis, no knee joint ("stubbies"), with foot blocks, no ankle joints, each	All	Y	Purchase
L5220	NU EP	Above knee, short prosthesis, no knee joint (stubbies), with articulated ankle/foot, dynamically aligned, each	All	Y	Purchase
L5230	NU EP	Above knee, for proximal femoral focal deficiency, constant friction knee, shin, SACH foot	All	Y	Purchase
L5250	NU EP	Hip disarticulation, Canadian type, molded socket, hip joint, single axis constant friction knee, shin, SACH foot	All	Y	Purchase
L5270	NU EP	Hip disarticulation, tilt table type, molded socket, locking hip joint, single axis constant friction knee, shin, SACH foot	All	Y	Purchase
L5280	NU EP	Hemipelvectomy, Canadian type, molded socket, hip joint, single axis constant friction knee, shin, SACH foot	All	Y	Purchase
L5301	NU EP	Below knee, molded socket, shin, SACH foot, endoskeletal system	All	Y	Purchase

L5311	NU EP	Knee disarticulation (or through knee), molded socket, external knee joints, shin, SACH foot, endoskeletal system	All	Y	Purchase
L5321	NU EP	Above knee, molded socket, open end, SACH foot, endoskeletal system, single axis knee	All	Y	Purchase
L5331	NU EP	Hip disarticulation, Canadian type, molded socket, endoskeletal system, hip joint, single axis knee, SACH foot	All	Y	Purchase
L5341	NU EP	Hemipelvectomy, Canadian type, molded socket, endoskeletal system, hip joint, single axis knee, SACH foot	All	Y	Purchase
L5400	NU EP	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	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	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	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	Immediate postsurgical or early fitting, application of nonweight bearing rigid dressing, below knee	All	N	Purchase
L5460	NU EP	Immediate post surgical or early fitting, application of nonweight bearing rigid dressing, above knee	All	N	Purchase
L5500	NU EP	Initial, below knee ("PTB" type socket, non-alignable system, pylon, no cover, SACH foot, plaster socket, direct formed	All	N	Purchase

L5505	NU EP	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	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	Preparatory, below knee "PTB" type socket, non-alignable pylon, no cover, SACH foot, thermoplastic or equal, direct formed	All	Y	Purchase
L5530	NU EP	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	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	Preparatory, below knee "PTB" type socket, non alignable, pylon, no cover, SACH foot, laminated socket, molded to model	All	Y	Purchase
L5560	NU EP	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	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	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	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	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	Preparatory, hip disarticulation-hemipelvectomy, pylon, no cover, SACH foot, thermoplastic or equal, molded to patient model	All	Y	Purchase
L5600	NU EP	Preparatory, hip disarticulation-hemipelvectomy, pylon, no cover, SACH foot, laminated socket, molded to patient model	All	Y	Purchase
L5610	NU EP	Addition to lower extremity, endoskeletal system, above knee, hydracadence system	All	Y	Purchase
L5611	NU EP	Addition to lower extremity, endoskeletal system, above knee-knee disarticulation, 4-bar linkage, with friction swing phase control	All	N	Purchase
L5613	NU EP	Addition to lower extremity, endoskeletal system, above knee-knee disarticulation, 4-bar linkage, with hydraulic swing phase control	All	Y	Purchase
L5614	NU	Addition to lower extremity, endoskeletal system, above knee -knee disarticulation, 4-bar linkage, with pneumatic swing phase control	21 +	Y	Purchase
L5616	NU EP	Addition to lower extremity, endoskeletal system above knee, universal multiplex system, friction swing phase control	All	Y	Purchase
L5617	NU	Addition to lower extremity, quick change self-aligning unit, above or below knee, each	21 +	Y	Purchase
L5618	NU EP	Addition to lower extremity, test socket, Symes	All	N	Purchase
L5620	NU EP	Addition to lower extremity, test socket, below knee	All	N	Purchase
L5622	NU EP	Addition to lower extremity, test socket, knee disarticulation	All	N	Purchase
L5624	NU EP	Addition to lower extremity, test socket, above knee	All	N	Purchase
L5626	NU EP	Addition to lower extremity, test socket, hip disarticulation	All	N	Purchase

L5628	NU EP	Addition to lower extremity, test socket, hemipelvectomy	All	N	Purchase
L5629	NU EP	Addition to lower extremity, below knee, acrylic socket	All	N	Purchase
L5630	NU EP	Addition to lower extremity, Symes type, expandable wall socket	All	N	Purchase
L5631	NU EP	Addition to lower extremity, above knee or knee disarticulation, acrylic socket	All	N	Purchase
L5632	NU EP	Addition to lower extremity, Symes type, "PTB" brim design socket	All	N	Purchase
L5634	NU EP	Addition to lower extremity, Symes type posterior opening (Canadian) socket	All	N	Purchase
L5636	NU EP	Additions to lower extremity, Symes type, medial opening socket	All	N	Purchase
L5637	NU EP	Addition to lower extremity, below knee, total contact	All	N	Purchase
L5638	NU EP	Addition to lower extremity, below knee, leather socket	All	N	Purchase
L5639	NU EP	Addition to lower extremity, below knee, wood socket	All	N	Purchase
L5640	NU EP	Addition to lower extremity, knee disarticulation, leather socket	All	N	Purchase
L5642	NU EP	Addition to lower extremity, above knee, leather socket	All	N	Purchase
L5643	NU EP	Addition to lower extremity, hip disarticulation, flexible inner socket, external frame	All	Y	Purchase
L5644	NU EP	Addition to lower extremity, above knee, wood socket	All	N	Purchase
L5645	NU EP	Addition to lower extremity, below knee, flexible inner socket, external frame	All	N	Purchase
L5646	NU EP	Addition to lower extremity, below knee, air, fluid, gel or equal, cushion socket	All	N	Purchase
L5647	NU EP	Addition to lower extremity, below knee suction socket	All	N	Purchase
L5648	NU EP	Addition to lower extremity, above knee, air, fluid, gel or equal, cushion socket	All	N	Purchase

L5649	NU EP	Addition to lower extremity, ischial containment/narrow M-L socket	All	Y	Purchase
L5650	NU EP	Addition to lower extremity, total contact, above knee or knee disarticulation socket	All	N	Purchase
L5651	NU EP	Addition to lower extremity, above knee, flexible inner socket, external frame	All	N	Purchase
L5652	NU EP	Addition to lower extremity, suction suspension, above knee or knee disarticulation, socket	All	N	Purchase
L5653	NU EP	Addition to lower extremity, knee disarticulation, expandable wall socket	All	N	Purchase
L5654	NU EP	Addition to lower extremity, socket insert, Symes, (Kemblo, Pelite, Aliplast, Plastazote or equal)	All	N	Purchase
L5655	NU EP	Addition to lower extremity, socket insert, below knee (Kemblo, Pelite, Aliplast, Plastazote or equal)	All	N	Purchase
L5656	NU EP	Addition to lower extremity, socket insert, knee disarticulation (Kemblo, Pelite, Aliplast, Plastazote or equal)	All	N	Purchase
L5658	NU EP	Addition to lower extremity, socket insert, above knee (Kemblo, Pelite, Aliplast, Plastazote or equal)	All	N	Purchase
L5661	NU EP	Addition to lower extremity, socket insert, multi durometer Symes	All	N	Purchase
L5665	EP	Addition to lower extremity, socket insert, multo-durometer, below knee	U21	N/A	Purchase
L5666	NU EP	Additions to lower extremity, below knee, cuff suspension	All	N	Purchase
L5668	NU EP	Addition to lower extremity, below knee, molded distal cushion	All	N	Purchase
L5670	NU EP	Addition to lower extremity, below knee, molded supracondyular suspension ("PTS" or similar)	All	N	Purchase
L5672	NU EP	Addition to lower extremity, below knee, removable medial brim suspension	All	N	Purchase
L5676	NU EP	Addition to lower extremity, below knee, knee joints, single axis, pair	All	N	Purchase
L5677	NU EP	Addition to lower extremity, below knee, knee joints, polycentric, pair	All	N	Purchase

L5678	NU EP	Addition to lower extremity, below knee, joint covers, pair	All	N	Purchase
L5679	NU EP	Addition to lower extremity, below knee/above knee, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, not for use with locking mechanism	All	N	Purchase
L5680	NU EP	Addition to lower extremity, below knee, thigh lacer, nonmolded	All	N	Purchase
L5682	NU EP	Addition to lower extremity, below knee, thigh lacer, gluteal/ischial, molded	All	N	Purchase
L5684	NU EP	Addition to lower extremity, below knee, fork strap	All	N	Purchase
L5685	NU EP	Addition to lower extremity prosthesis, below knee, suspension/sealing sleeve, with or without valve, any material, each	All	N	Manually Priced
L5686	NU EP	Addition to lower extremity, below knee, back check (extension control)	All	N	Purchase
L5688	NU EP	Addition to lower extremity, below knee, waist belt, webbing	All	N	Purchase
L5690	NU EP	Addition to lower extremity, below knee, waist belt, padded and lined	All	N	Purchase
L5692	NU EP	Addition to lower extremity, above knee, pelvic control belt, light	All	N	Purchase
L5694	NU EP	Addition to lower extremity, above knee, pelvic control belt, padded and lined	All	N	Purchase
L5695	NU EP	Addition to lower extremity, above knee, pelvic control, sleeve suspension, neoprene or equal, each	All	N	Purchase
L5696	NU EP	Addition to lower extremity, above knee or knee disarticulation, pelvic joint	All	N	Purchase
L5697	NU EP	Addition to lower extremity, above knee or knee disarticulation, pelvic band	All	N	Purchase
L5698	NU EP	Addition to lower extremity, above knee or knee disarticulation, silesian bandage	All	N	Purchase
L5699	NU EP	All lower extremity prosthesis, shoulder harness	All	N	Purchase

L5700	NU	Replacement, socket, below knee, molded to patient model	21 +	Y	Purchase
L5701	NU	Replacement, socket, above knee/knee disarticulation, including attachment plate, molded to patient model	21 +	Y	Purchase
L5702	NU	Replacement, socket, hip disarticulation, including hip joint, molded to patient model	21 +	Y	Purchase
L5704	NU	Custom shaped protective cover, below knee	All	N	Purchase
L5705	NU	Custom shaped protective cover, above knee	21 +	N	Purchase
L5706	NU	Custom shaped protective cover, knee disarticulation	21 +	N	Purchase
L5707	NU	Custom shaped protective cover, hip disarticulation	21 +	N	Purchase
L5710	NU EP	Addition, exoskeletal knee-shin system, single axis, manual lock	All	N	Purchase
L5711	NU EP	Addition exoskeletal knee-shin system, single axis, manual lock, ultra-light material	All	N	Purchase
L5712	NU EP	Addition exoskeletal knee-shin system, single axis, friction swing and stance phase control (safety knee)	All	N	Purchase
L5714	NU EP	Addition, exoskeletal knee-shin system, single axis, variable friction swing phase control	All	N	Purchase
L5716	NU EP	Addition, exoskeletal knee-shin system, polycentric, mechanical stance phase lock	All	N	Purchase
L5718	NU EP	Addition, exoskeletal knee-shin system, polycentric, friction swing and stance phase control	All	N	Purchase
L5722	NU EP	Addition, exoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase control	All	N	Purchase
L5724	NU EP	Addition, exoskeletal knee-shin system, single axis, fluid swing phase control	All	Y	Purchase
L5726	NU EP	Addition, exoskeletal knee-shin system, single axis, external joints, fluid swing phase control	All	Y	Purchase

L5728	NU EP	Addition, exoskeletal knee-shin system, single axis, fluid swing and stance phase control	All	Y	Purchase
L5780	NU EP	Addition, exoskeletal knee-shin system, single axis, pneumatic/hydra pneumatic swing phase control	All	N	Purchase
L5785	NU EP	Addition, exoskeletal system, below knee, ultra-light material (titanium, carbon fiber or equal)	All	N	Purchase
L5790	NU EP	Addition, exoskeletal system, above knee, ultra-light material (titanium, carbon fiber or equal)	All	N	Purchase
L5795	NU EP	Addition, exoskeletal system, hip disarticulation, ultra-light material (titanium, carbon fiber or equal)	All	N	Purchase
L5810	NU EP	Addition, endoskeletal knee-shin system, single axis, manual lock	All	N	Purchase
L5811	NU EP	Addition, endoskeletal knee-shin system, single axis, manual lock, ultra-light material	All	N	Purchase
L5812	NU EP	Addition, endoskeletal knee-shin system, single axis, friction swing and stance phase control (safety knee)	All	N	Purchase
L5816	NU EP	Addition, endoskeletal knee-shin system, polycentric, mechanical stance phase lock	All	N	Purchase
L5818	NU EP	Addition, endoskeletal knee-shin system, polycentric, friction swing, and stance phase control	All	N	Purchase
L5822	NU EP	Addition, endoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase control	All	Y	Purchase
L5824	NU EP	Addition, endoskeletal knee-shin system, single axis, fluid swing phase control	All	Y	Purchase
L5826	NU	Addition, endoskeletal knee-shin system, single axis, hydraulic swing phase control with miniature high activity frame	21 +	Y	Purchase
L5828	NU EP	Addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control	All	Y	Purchase
L5830	NU EP	Addition, endoskeletal knee-shin system, single axis, pneumatic/swing phase control	All	Y	Purchase

L5840	NU	Addition, endoskeletal knee-shin system, 4-bar linkage or multiaxial, pneumatic swing phase control	21 +	N	Purchase
L5845	NU	Addition, endoskeletal knee-shin system, stance flexion feature, adjustable	21 +	Y	Purchase
L5850	NU EP	Addition, endoskeletal system, above knee or hip disarticulation, knee extension assist	All	N	Purchase
L5855	NU EP	Addition, endoskeletal system, hip disarticulation, mechanical hip extension assist	All	N	Purchase
L5910	NU EP	Addition, endoskeletal system, below knee, alignable system	All	N	Purchase
L5920	NU EP	Addition, endoskeletal system, above knee or hip disarticulation, alignable system	All	N	Purchase
L5925	NU	Addition, endoskeletal system, above knee, knee disarticulation, manual lock	21 +	N	Purchase
L5930	NU	Addition, endoskeletal system, high activity knee control frame	21 +	Y	Purchase
L5940	NU EP	Addition, endoskeletal system, below knee, ultra-light material (titanium, carbon fiber or equal)	All	N	Purchase
L5950	NU EP	Addition, endoskeletal system, above knee, ultra-light material (titanium, carbon fiber or equal)	All	N	Purchase
L5960	NU EP	Addition, endoskeletal system, hip disarticulation, ultra-light material (titanium, carbon fiber or equal)	All	N	Purchase
L5962	NU	Addition, endoskeletal system, below knee, flexible protective outer surface covering system	21 +	N	Purchase
L5964	NU	Addition, endoskeletal system, above knee, flexible protective outer surface covering system	21 +	N	Purchase
L5966	NU	Addition, endoskeletal system, hip disarticulation, flexible protective outer surface covering system	21 +	N	Purchase
L5968	NU	Addition to lower limb prostheses, multiaxial ankle with swing phase active dorsiflexion feature	21 +	Y	Purchase

L5970	NU EP	All lower extremity prostheses, foot, external keel, SACH foot	All	N	Purchase
L5972	NU EP	All lower extremity prostheses, flexible keel foot (Safe, Sten, Bock Dynamic or equal)	All	N	Purchase
L5974	NU EP	All lower extremity prostheses, foot, single axis ankle/foot	All	N	Purchase
L5975	NU	All lower extremity prosthesis, combination single axis ankle and flexible keel foot	21 +	N	Purchase
L5976	NU EP	All lower extremity prostheses, energy storing foot (Seattle Carbon Copy II or equal)	All	N	Purchase
L5978	NU EP	All lower extremity prostheses, foot, multiaxial ankle/foot	All	N	Purchase
L5979	NU	All lower extremity prostheses, multi-axial ankle, dynamic response foot, one piece system	21 +	Y	Purchase
L5980	NU EP	All lower extremity prostheses, flex-foot system	All	Y	Purchase
L5981	NU	All lower extremity prostheses, flex-walk system or equal	All	Y	Purchase
L5982	NU EP	All exoskeletal lower extremity prostheses, axial rotation unit	All	N	Purchase
L5984	NU EP	All endoskeletal lower extremity prosthesis, axial rotation unit, with or without adjustability	All	N	Purchase
L5985	NU	All endoskeletal lower extremity prostheses, dynamic prosthetic pylon	21 +	N	Purchase
L5986	NU EP	All lower extremity prostheses, multi-axial rotation unit ("MCP" or equal)	All	N	Purchase
L5987	NU	All lower extremity prostheses, shank foot system with vertical loading pylon	21 +	Y	Purchase
L5988	NU	Addition to lower limb prosthesis, vertical shock reducing pylon feature	21 +	Y	Purchase
L5999	NU EP	***(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	Partial hand, Robin-Aids, thumb remaining (or equal)	All	N	Purchase

L6010	NU EP	Partial hand, Robin-Aids, little and/or ring finger remaining (or equal)	All	N	Purchase
L6020	NU EP	Partial hand, Robin-Aids, no finger remaining (or equal)	All	N	Purchase
L6050	NU EP	Wrist disarticulation, molded socket, flexible elbow hinges, triceps pad	All	Y	Purchase
L6055	NU EP	Wrist disarticulation, molded socket with expandable interface, flexible elbow hinges, triceps pad	All	Y	Purchase
L6100	NU EP	Below elbow, molded socket, flexible elbow hinge, triceps pad	All	Y	Purchase
L6110	NU EP	Below elbow, molded socket (Muenster or Northwestern suspension types)	All	Y	Purchase
L6120	NU EP	Below elbow, molded double wall split socket, step-up hinges, half cuff	All	Y	Purchase
L6130	NU EP	Below elbow, molded double wall split socket, stump activated locking hinge, half cuff	All	Y	Purchase
L6200	NU EP	Elbow disarticulation, molded socket, outside locking hinge, forearm	All	Y	Purchase
L6205	NU EP	Elbow disarticulation, molded socket with expandable interface, outside locking hinges, forearm	All	Y	Purchase
L6250	NU EP	Above elbow, molded double wall socket, internal locking elbow, forearm	All	Y	Purchase
L6300	NU EP	Shoulder disarticulation, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearm	All	Y	Purchase
L6310	NU EP	Shoulder disarticulation, passive restoration (complete prosthesis)	All	Y	Purchase
L6320	NU EP	Shoulder disarticulation, passive restoration (shoulder cap only)	All	Y	Purchase
L6350	NU	Interscapular thoracic, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearm	21 +	Y	Purchase
L6360	NU EP	Interscapular thoracic, passive restoration (complete prosthesis)	All	Y	Purchase
L6370	NU EP	Interscapular thoracic, passive restoration (shoulder cap only)	All	Y	Purchase

L6380	NU EP	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	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	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	Immediate postsurgical or early fitting, each additional cast change and realignment	All	N	Purchase
L6388	NU EP	Immediate postsurgical or early fitting, application of rigid dressing only	All	N	Purchase
L6400	NU EP	Below elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping	All	Y	Purchase
L6450	NU EP	Elbow disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue shaping	All	Y	Purchase
L6500	NU EP	Above elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping	All	Y	Purchase
L6550	NU EP	Shoulder disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue shaping	All	Y	Purchase
L6570	NU EP	Interscapular thoracic, molded socket, endoskeletal system including soft prosthetic tissue shaping	All	Y	Purchase

L6580	NU EP	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	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	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	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	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	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	Upper extremity additions, polycentric hinge, pair	All	N	Purchase
L6605	NU EP	Upper extremity additions, single pivot hinge, pair	All	N	Purchase
L6610	NU EP	Upper extremity additions, flexible metal hinge, pair	All	N	Purchase
L6615	NU EP	Upper extremity addition, disconnect locking wrist unit	All	N	Purchase

L6616	NU EP	Upper extremity addition, additional disconnect insert for locking wrist unit, each	All	N	Purchase
L6620	NU EP	Upper extremity addition, flexion/extension wrist unit, with or without friction	All	N	Purchase
L6623	NU EP	Upper extremity addition, spring assisted rotational wrist unit with latch release	All	N	Purchase
L6625	NU EP	Upper extremity addition, rotation wrist unit with cable lock	All	N	Purchase
L6628	NU EP	Upper extremity addition, quick disconnect hook adapter, Otto Bock or equal	All	N	Purchase
L6629	NU EP	Upper extremity addition, quick disconnect lamination collar with coupling piece, Otto Bock or equal	All	N	Purchase
L6630	NU EP	Upper extremity addition, stainless steel, any wrist	All	N	Purchase
L6632	NU EP	Upper extremity addition, latex suspension sleeve, each	All	N	Purchase
L6635	NU EP	Upper extremity additions, lift assist for elbow	All	N	Purchase
L6637	NU EP	Upper extremity addition, nudge control elbow lock	All	N	Purchase
L6640	NU EP	Upper extremity additions, shoulder abduction joint, pair	All	N	Purchase
L6641	NU EP	Upper extremity addition, excursion amplifier, pulley type	All	N	Purchase
L6642	NU EP	Upper extremity addition, excursion amplifier, lever type	All	N	Purchase
L6645	NU EP	Upper extremity addition, shoulder flexion-abduction joint, each	All	N	Purchase
L6650	NU EP	Upper extremity addition, shoulder universal joint, each	All	N	Purchase
L6655	NU EP	Upper extremity addition, standard control cable, extra	All	N	Purchase
L6660	NU EP	Upper extremity addition, heavy duty control cable	All	N	Purchase
L6665	NU EP	Upper extremity addition, Teflon, or equal, cable lining	All	N	Purchase
L6670	NU EP	Upper extremity addition, hook to hand cable adapter	All	N	Purchase

L6672	NU EP	Upper extremity addition, harness, chest or shoulder, saddle type	All	N	Purchase
L6675	NU EP	Upper extremity addition, harness, (e.g., figure of eight type), single cable design	All	N	Purchase
L6676	NU EP	Upper extremity additions, harness, (e.g., figure of eight type), dual cable design	All	N	Purchase
L6680	NU EP	Upper extremity addition, test socket, wrist disarticulation or below elbow	All	N	Purchase
L6682	NU EP	Upper extremity addition, test socket, elbow disarticulation or above elbow	All	N	Purchase
L6684	NU EP	Upper extremity addition, test socket, shoulder disarticulation or interscapular thoracic	All	N	Purchase
L6686	NU EP	Upper extremity addition, suction socket	All	N	Purchase
L6687	NU EP	Upper extremity addition, frame type socket, below elbow or wrist disarticulation	All	N	Purchase
L6688	NU EP	Upper extremity addition, frame type socket, above elbow or elbow disarticulation	All	N	Purchase
L6689	NU EP	Upper extremity addition, frame type socket, shoulder disarticulation	All	N	Purchase
L6690	NU EP	Upper extremity addition, frame type socket, interscapular-thoracic	All	N	Purchase
L6691	NU EP	Upper extremity addition, removable insert, each	All	N	Purchase
L6692	NU EP	Upper extremity addition, silicone gel insert or equal, each	All	N	Purchase
L6693	NU	Upper extremity addition, locking elbow, forearm counterbalance	21 +	Y	Purchase
L6700	NU EP	Terminal device, hook, Dorrance or equal, model #3	All	N	Purchase
L6705	NU EP	Terminal device, hook, Dorrance or equal, model #3	All	N	Purchase
L6710	NU EP	Terminal device, hook, Dorrance or equal, model #5x	All	N	Purchase
L6715	NU EP	Terminal device, hook, Dorrance or equal, Model # 5xa	All	N	Purchase
L6720	NU EP	Terminal device, hook, Dorrance or equal, model #6	All	N	Purchase

L6725	NU EP	Terminal device, hook, Dorrance or equal, model #7	All	N	Purchase
L6730	NU EP	Terminal device, hook, Dorrance or equal, model #7LO	All	N	Purchase
L6735	NU EP	Terminal device, hook, Dorrance or equal, model #8	All	N	Purchase
L6740	NU EP	Terminal device, hook, Dorrance or equal, model #8x	All	N	Purchase
L6745	NU EP	Terminal device, hook, Dorrance or equal, model #88x	All	N	Purchase
L6750	NU EP	Terminal device, hook, Dorrance or equal, model # 10P	All	N	Purchase
L6755	NU EP	Terminal device, hook, Dorrance or equal, model # 10x	All	N	Purchase
L6765	NU EP	Terminal device, hook, Dorrance or equal, model # 12P	All	N	Purchase
L6770	NU EP	Terminal device, hook, Dorrance or equal, model #99x	All	N	Purchase
L6775	NU EP	Terminal device, hook, Dorrance or equal, model #555	All	N	Purchase
L6780	NU EP	Terminal device, hook, Dorrance or equal, model # SS555	All	N	Purchase
L6790	NU EP	Terminal device, hook-Accu hook or equal	All	N	Purchase
L6795	NU EP	Terminal device, hook 2 load or equal	All	N	Purchase
L6800	NU EP	Terminal device, hook-APRL VC or equal	All	N	Purchase
L6805	NU EP	Terminal device, modifier wrist flexion unit	All	N	Purchase
L6806	NU EP	Terminal device, hook, TRS grip, Grip III, VC, or equal	All	Y	Purchase
L6807	NU EP	Terminal device, hook, Grip I, Grip II, VC, or equal	All	N	Purchase
L6808	NU EP	Terminal device, hook, TRS Adept, infant or child, VC, or equal	All	N	Purchase
L6809	NU EP	Terminal device, hook, TRS Super Sport, passive	All	N	Purchase
L6810	NU EP	Terminal device, pinchertool, Otto Bock or equal	All	N	Purchase

L6825	NU EP	Terminal device, hand, Dorrance, VO	All	N	Purchase
L6830	NU EP	Terminal device, hand, APRL, VC	All	N	Purchase
L6835	NU EP	Terminal device, hand, Sierra, VO	All	N	Purchase
L6840	NU EP	Terminal device, hand, Becker Imperial	All	N	Purchase
L6845	NU EP	Terminal device, hand, Becker Lock Grip	All	N	Purchase
L6850	NU EP	Terminal device, hand, Becker Plylite	All	N	Purchase
L6855	NU EP	Terminal device, hand, Robin-Aids, VO	All	N	Purchase
L6860	NU EP	Terminal device, hand, Robin-Aids, VO soft	All	N	Purchase
L6865	NU EP	Terminal device, hand, passive hand	All	N	Purchase
L6867	NU EP	Terminal device, hand, Detroit Infant Hand (mechanical)	All	N	Purchase
L6868	NU EP	Terminal device, hand, passive infant hand, Steeper, Hosmer or equal	All	N	Purchase
L6870	NU EP	Terminal device, hand, child mitt	All	N	Purchase
L6872	NU EP	Terminal device, hand, NYU child hand	All	N	Purchase
L6873	NU EP	Terminal device, hand, mechanical infant hand, Steeper or equal	All	N	Purchase
L6875	NU EP	Terminal device, hand, Bock, VC	All	N	Purchase
L6880	NU EP	Terminal device, hand, Bock, VO	All	N	Purchase
L6890	NU EP	Terminal device, gloves for above hands, production glove	All	N	Purchase
L6895	NU EP	Terminal device, glove for above hands, custom glove	All	N	Purchase
L6900	NU EP	Hand restoration (casts, shading and measurements included), partial hand, with glove, thumb or one finger remaining	All	N	Purchase

L6905	NU EP	Hand restoration (casts, shading and measurements included), partial hand, with glove, multiple fingers remaining	All	N	Purchase
L6910	NU EP	Hand restoration (casts, shading and measurements included), partial hand, with glove, no fingers remaining	All	N	Purchase
L6915	NU EP	Hand restoration (shading and measurements included), replacement glove for above	All	N	Purchase
L6920*	NU EP	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	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	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	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	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	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	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	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	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	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	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	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	Electronic hand, Otto Bock, Steeper or equal, switch controlled	All	Y	Purchase
L7015*	NU EP	Electronic hand, System Teknik, Variety Village or equal, switch controlled	All	Y	Purchase
L7020*	NU EP	Electronic greifer, Otto Bock or equal, switch controlled	All	Y	Purchase
L7025*	NU EP	Electronic hand, Otto Bock or equal, myoelectronically controlled	All	Y	Purchase
L7030*	NU EP	Electronic hand, System Teknik, Variety Village or equal, myoelectronically controlled	All	Y	Purchase
L7035*	NU EP	Electronic greifer, Otto Bock or equal, myoelectronically controlled	All	Y	Purchase
L7040*	NU EP	Prehensile actuator, Hosmer or equal, switch controlled	All	Y	Purchase
L7045*	NU EP	Electronic hook, child, Michigan or equal, switch controlled	All	Y	Purchase
L7170*	NU EP	Electronic elbow, Hosmer or equal, switch controlled	All	Y	Purchase
L7180*	NU EP	Electronic elbow, Utah or equal, myoelectronically controlled	All	Y	Purchase
L7185	EP	Electronic elbow, adolescent, Variety Village or equal, switch controlled	U21	N/A	Purchase
L7186	EP	Electronic elbow, child, Variety Village or equal, switch controlled	U21	N/A	Purchase
L7190	EP	Electronic elbow, adolescent, Variety Village or equal, myoelectronically controlled	U21	N/A	Purchase
L7191	EP	Electronic elbow, child, Variety Village or equal, myoelectronically controlled	U21	N/A	Purchase
L7260*	NU EP	Electronic wrist rotator, Otto Bock or equal	All	Y	Purchase

L7261*	NU EP	Electronic wrist rotator, for Utah arm	All	Y	Purchase
L7266*	NU EP	Servo control, Steeper or equal	All	N	Purchase
L7272*	NU EP	Analogue control, UNB or equal	All	Y	Purchase
L7274*	NU EP	Proportional control, 6-12 volt, Liberty, Utah or equal	All	Y	Purchase
L7360*	NU EP	Six volt battery, Otto Bock or equal, each	All	N	Purchase
L7362*	NU EP	Battery charger, six volt, Otto Bock or equal	All	N	Purchase
L7364*	NU EP	Twelve volt battery, Utah or equal, each	All	N	Purchase
L7366*	NU EP	Battery charger, twelve volt, Utah or equal	All	N	Purchase
L7499	NU EP	***(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	/*(Orthotics and Prosthetics Repairs) Repair of prosthetic device, repair or replace minor parts	All	Y	Manually Priced Purchase
L7510	NU EP	***(Twister cables - repair/replace) Repair of prosthetic device, repair or replace minor parts	All	N	Manually Priced Purchase
L7520	NU EP	/*(Orthotics and Prosthetics Repairs) Repair prosthetic device, labor component, per 15 minutes	All	Y	Manually Priced Purchase
L8000	NU EP	Breast prosthesis, mastectomy bra	All	N	Purchase
L8010	NU EP	Breast prosthesis, mastectomy sleeve	All	N	Purchase
L8015	NU	External breast prosthesis garment, with mastectomy form, post-mastectomy	21 +	N	Purchase
L8020	NU EP	Breast prosthesis, mastectomy form	All	N	Purchase
L8030	NU EP	Breast prosthesis, silicone or equal	All	N	Purchase

L8300	NU EP	Truss, single with standard pad	All	N	Purchase
L8310	NU EP	Truss, double with standard pads	All	N	Purchase
L8320	NU EP	Truss, addition to standard pad, water pad	All	N	Purchase
L8330	NU EP	Truss, addition to standard pad, scrotal pad	All	N	Purchase
L8400	NU EP	Prosthetic sheath, below knee, each	All	N	Purchase
L8410	NU EP	Prosthetic sheath, above knee, each	All	N	Purchase
L8415	NU EP	Prosthetic sheath, upper limb, each	All	N	Purchase
L8417	NU	Prosthetic sheath/sock, including a gel cushion layer, below knee or above knee, each	21 +	N	Purchase
L8420	NU EP	Prosthetic sock, multiple ply, below knee,each	All	N	Purchase
L8430	NU EP	Prosthetic sock, multiple ply, above knee,each	All	N	Purchase
L8435	NU EP	Prosthetic sock, multiple ply upper limb, each	All	N	Purchase
L8440	NU EP	Prosthetic shrinker, below knee, each	All	N	Purchase
L8460	NU EP	Prosthetic shrinker, above knee, each	All	N	Purchase
L8465	NU EP	Prosthetic shrinker, upper limb, each	All	N	Purchase
L8470	NU EP	Prosthetic sock, single ply, fitting below knee, each	All	N	Purchase
L8480	NU EP	Prosthetic sock, single ply fitting, above knee, each	All	N	Purchase
L8485	NU	Prosthetic sock, single ply, fitting, upper limb, each	21 +	N	Purchase
L8499	NU EP	***(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	Artificial larynx, any type	All	N	Purchase

L8501	NU EP	Tracheostomy speaking valve	All	N	Purchase
L8600	NU EP	Implantable breast prosthesis, silicone or equal	All	N	Manually Priced

242.191Specialized Wheelchairs and Wheelchair Seating Systems

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 older. When a second modifier is listed, that modifier must be used in conjunction with either EP orNU.

Other coding information found in the chart:

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

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

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

** Bill only for beneficiaries under age 21.

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

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

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

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

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

Specialized Wheelchairs and Wheelchair Seating Systems for Individuals Age Two Through Adult (section 242.191 )

Procedure Code	M1	M2	Description	PA	Payment Method
E0700	NU EP	U2 U2	***(Travel restraint auto safe harness, E-Z on vest, no known comparable product) Safety equipment, e.g., belt, harness or vest	K 1****	Purchase

E0705	NU EP	Transfer board or device, each	Y	Purchase
E0911	NU EP	Trapeze bar, heavy duty, for patient weight capacity greater than 250 pounds, attached to bed, with grab bar	N	Purchase
E0950	NU EP	U7 U7	Wheelchair accessory, tray, each	N	Purchase
E0950	NU EP	U2 U2	***(ABS tray, 4-SM 5-LG) W/C accessory, tray, each	K 1****	Purchase
E0950	NU EP	U5 U5	***(Clear upper Ex support system) W/C accessory, tray, each	K 1****	Purchase
E0950	NU EP	U4 U4	***(Tray, customized) W/C accessory, tray, each	N	Purchase
E0950	NU EP	***(Tray for W/C) W/C accessory, tray, each	N	Purchase
E0950	NU EP UE	U7 U7	/*(Removable Hinged Overlay for Tray) W/C accessory, tray, each	K 1****	Purchase
E0950	NU EP	U8 U8	***(Lap Tray for Switch Array) Wheelchair accessory, tray, each	Y	Purchase
E0950	NU EP	U6 U6	***(Lap Tray Switch Array) Wheelchair accessory, tray, each	K 1****	Purchase
E0950	NU EP	U3 U3	***(W/C Tray, Custom) W/C accessory, tray, each	K 1****	Purchase
E0951	NU EP	Heel loop/holder, with or without ankle strap, each	K 1****	Purchase
E0952	NU EP	Toe loop/holder, each	K 1****	Purchase
E0953	NU EP	***(8" x 2" for manual W/C, each, replacement) Pneumatic tire, each	N	Purchase
E0954	NU EP	Semi-pneumatic caster, each	K 1****	Purchase
E0955	NU EP	W/C accessory, headrest, cushioned, prefabricated, w/fixed mounting hardware, each	N	Purchase
E0956	NU EP	***(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	K 1****	Purchase
E0956	NU EP	U1 U1	***(Lateral trunk supports, swing away, ea.) W/C accessory, lateral trunk or hip support, prefabricated w/fixed mounting hardware, each	K 1****	Purchase

E0956	NU EP	U2 U2	***(Med. Chest Panel Support) W/C accessory, lateral trunk or hip support, prefabricated w/fixed mounting hardware, each	K 1****	Purchase
E0956	NU EP	U3 U3	***(Chest/Thoracic Supports) W/C accessory, lateral trunk or hip support, prefabricated w/fixed mounting hardware, each	K 1****	Purchase
E0957	NU EP	W/C accessory, medial thigh support, prefabricated, w/fixed mounting hardware, each	N	Purchase
E0958	NU EP	Manual W/C accessory, one-arm drive attachment, each	K 1****	Purchase
E0959	NU EP	U1 U1	Manual W/C accessory, adapter for amputee, each	N	Purchase
E0959	NU EP	***(Amputee adapters for conventional chair, ea.) Manual W/C accessory, adapter for amputee, each	K 1****	Purchase
E0959	NU EP	***(Amputee axle plate for high performance manual W/C, ea.) Manual W/C accessory, adapter for amputee, each	K 1****	Purchase
E0960	NU EP	W/C accessory, shoulder harness/straps or chest strap including any type mounting hardware	N	Purchase
E0961	NU EP	Manual W/C accessory, wheel lock brake extension (handle), each	K 1****	Purchase
E0966	NU EP	***(Headrest/Fixture, O.B., 46-LG 45-SM) Manual W/C accessory, headrest extension, each	K 1****	Purchase
E0967	NU EP	***(Hand rim, any type) Manual W/C accessory, hand rim w/projections, any type, replacement only, each	K 1****	Purchase
E0967	NU EP	U1 U1	***(Hand rim, any type) Manual W/C accessory, hand rim w/projections, any type, replacement only, each	K 1****	Purchase
E0967	NU EP	U2 U2	***(Hand rim, any type) Manual W/C accessory, hand rim w/projections, any type, replacement only, each	K 1****	Purchase
E0967	NU EP	U3 U3	***(Hand rim, any type) Manual W/C accessory, hand rim w/projections, any type, replacement only, each	K 1****	Purchase
E0967	NU EP	U4 U4	***(Hand rim, any type) Manual W/C accessory, hand rim w/projections, any type, replacement only, each	K 1****	Purchase

E0970	NU EP	No. 2 footplates, except for elevating legrest	K 1****	Purchase
E0971	NU EP	Anti-tipping device W/C	K 1****	Purchase
E0973	NU EP	W/C accessory, adjustable height, detachable armrest, complete assembly, each	K 1****	Purchase
E0973	NU EP	U1 U1	***(Height Adj. Arms, replacement) W/C accessory, adjustable height, detachable armrest, complete assembly, each	K 1****	Purchase
E0974	NU EP	Manual W/C accessory, anti-rollback device, each	K 1****	Purchase
E0978	NU EP	U2	W/C accessory, safety belt/pelvic strap, each	K 1****	Purchase
E0978	NU EP	U1	***(Belt, safety or chest, w/pad) W/C accessory, safety belt/ pelvic strap, each	K 1**** N	Purchase
E0980	NU EP	***(Chest panel, 21-SM 22-LG) Safety vest, W/C	K 1****	Purchase
E0980	NU EP	U1 U1	***(Shoulder retractors) Safety vest, W/C	K 1****	Purchase
E0981	NU EP	W/C accessory, seat upholstery, replacement only, each	N	Purchase
E0982	NU EP	U1 U1	***(Standard back upholstery replacement) W/C accessory, back upholstery, replacement only, each	K 1****	Purchase
E0990	EP	***(Elevating foot, leg rest) W/C accessory, elevating leg rest, complete assembly, each	K 1****	Purchase
E0990	NU EP	U1 U1	***(Elevating Leg Rest 90 Degree, 12" -16" Wdth) W/C accessory, elevating leg rest, complete assembly, each	K 1****	Purchase
E0992	NU EP	Manual w/c accessory, solid seat insert	K 1****	Purchase
E0992	NU EP	U3 U3	***(Foam & Plywood Seat, MPI Like) Manual w/c access, solid seat insert	K 1****	Purchase
E0992	NU EP	U2 U2	***(Foam and Plywood Flat Side) Manual w/c access, solid seat insert	K 1****	Purchase
E0992	NU EP	U4 U4	/*(Adjustable solid standard seat w/hardware) Manual w/c accessory, solid seat insert	K 1****	Purchase
E0992	NU EP	U1 U1	AManual w/c accessory, solid seat insert (Large adjustable solid seat w/hardware)	K 1****	Purchase

E0994	NU EP	Armrest, each	K 1****	Purchase
E1001	NU	Wheel, single	N	Manually Priced
E1002	NU EP	W/C accessory, power seating system, tilt only	Y	Purchase
E1002	NU EP	W/C accessory power seating system, tilt only	Y*	Purchase
E1004	NU EP	W/C accessory, power seat system, recline only, w/mechanical shear reduction	Y	Purchase
E1004	NU EP	W/C accessory, power seating system, recline only, with mechanical shear reduction	Y*	Purchase
E1006	NU EP	W/C accessory, power seating system, combination tilt and recline, w/o shear reduction	Y	Purchase
E1006	NU EP	U1 U1	/*(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	W/C accessory, addition to power seating system, power leg elevation system, including leg rest, each	Y	Purchase
E1019	NU EP	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	/*(Adjustable Contour Lateral Thigh Support) Residual limb support system for W/C	K 1****	Purchase
E1026	EP	***(Adjustable Contour Back, 10" -12" Frame) Lateral thoracic support, contoured, for pediatric W/C, each (includes hardware)	K 1****	Purchase
E1026	EP	U1	/*(Adjustable Contour Back, 14" -16" Frame) Lateral thoracic support, contoured, for pediatric W/C, each (includes hardware)	K 1****	Purchase
E1029	NU EP	/*(Ventilator Tray Wth Battery Tray) Wheelchair accessory, ventilator tray, fixed	Y	Purchase
E1030	NU EP	Wheelchair accessory, ventilator tray, gimbaled	Y	Purchase

E1050*	NU EP	Full reclining W/C, fixed full-length arms, swing-away, detachable elevating legrests	K 1****	Purchase
E1060*	NU EP	Full reclining W/C, detachable arms, desk or full-length, swing-away detachable, elevating legrests	Y*	Purchase
E1065*	NU EP	Power attachment (to convert any W/C to motorized W/C, e.g., Solo)	Y*	Purchase
E1070#	***(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	Hemi-W/C; detachable arms, desk or full-length, swing-away, detachable, elevating leg rests	K 1****	Purchase
E1086*	NU EP	U1 U1	Hemi W/C, detachable arms, desk or full-length, swing-away detachable footrests	Y*	Purchase
E1086*	NU EP	Hemi W/C; detachable arms, desk or full-length, swing-away, detachable footrests	K 1****	Purchase
E1088*	NU EP	High strength lightweight W/C; detachable arms, desk or full-length, swing-away, detachable, elevating legrests	Y*	Purchase
E1090	NU EP	High-strength lightweight W/C; detachable arms, desk or full-length, swing-away, detachable footrests	K 1****	Purchase
E1091**	EP	UB	Youth stroller	K 1****	Purchase
E1091	NU EP	Youth positioning stroller	N	Purchase
E1091	NU EP	U1 U1	Youth positioning stroller	N	Manually Priced
E1092*	NU EP	Wde, heavy-duty W/C; detachable arms, desk or full-length, swing-away, detachable, elevating legrests	Y*	Purchase
E1093*	NU EP	Wde, heavy-duty W/C; detachable arms, desk or full-length arms, swing-away, detachable footrests	Y*	Purchase
E1110*	NU EP	Semi-reclining W/C; detachable arms, desk or full-length, elevating legrest	Y*	Purchase
E1161	NU EP	Manual adult size W/C, includes tilt in space	Y*	Purchase
E1170*	NU EP	Amputee W/C; fixed full-length arms, swing-away, detachable, elevating legrests	K 1****	Purchase

E1172*	NU EP	Amputee W/C; detachable arms, desk or full-length, without footrests or legrests	Y*	Purchase
E1180*	NU EP	Amputee W/C; detachable arms, desk or full-length, swing-away, detachable footrests	Y*	Purchase
E1200*	NU EP	Amputee W/C; fixed full-length arms, swing-away, detachable footrests	K 1**** *	Purchase
E1211*	NU EP	Motorized W/C; detachable arms, desk or full-length, swing-away, detachable, elevating legrests	Y*	Purchase
E1213*	NU EP	Motorized W/C; detachable arms, desk or full-length, swing-away, detachable footrests	Y*	Purchase
E1220*	NU EP	W/C, specially sized or constructed (indicate brand name, model number, if any, and justification)	Y	Manually Priced
E1225	NU EP	***(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	K 1****	Purchase
E1226*	NU EP	Manual w/c accessory, fully reclining back, each	Y	Purchase
E1228	NU EP	U2 U2	/*(Positioning tall back) Special back height for W/C	K 1****	Purchase
E1228	NU EP	***(Folding Backrest, Tall, 19" - 20") Special back height for W/C	K 1****	Purchase
E1228	NU EP	***(Folding Straight Backrest, Low, (15" -16") Special back height for W/C	K 1****	Purchase
E1228	NU EP	***(Folding Straight Backrest, Tall, 19" -20") Special back height for W/C	K 1****	Purchase
E1228	NU EP	U1 U1	***(High back contour seat) Special back height for W/C	K 1****	Purchase
E1230*	NU EP	Power operated vehicle (three- or four-wheel nonhighway), specify brand name and model number	Y*	Purchase
E1232*	EP	W/C, pediatric size, tilt-in-space, folding, adjustable, with seating system	Y*	Purchase
E1233*	EP	W/C, pediatric size, tilt-in-space, rigid, adjustable, without seating system	Y*	Purchase
E1234*	EP	W/C, pediatric size, tilt-in-space, folding, adjustable, without seating system	Y*	Purchase

E1235*	NU EP	W/C, pediatric size, rigid, adjustable, with seating system	Y*	Purchase
E1235	NU EP	***(Snug Seat I Mobility System) W/C, pediatric size, rigid, adjustable, with seating system	Y*	Purchase
E1235¹'²	EP	U1 U1	***(Rigid W/C Frame) W/C, pediatric size, rigid, adjustable with seating system	Y	Purchase
E1236	EP	Wheelchair, pediatric size, folding, adjustable, with seating system	Y	Purchase
E1237*	NU EP	W/C, pediatric size, rigid, adjustable, without seating system	Y*	Purchase
E1238*	NU EP	W/C, pediatric size, folding, adjustable, without seating system	Y*	Purchase
E1240*	NU EP	Lightweight W/C; detachable arms, desk or full-length, swing-away, detachable, elevating legrest	Y*	Purchase
E1260*	NU EP	Lightweight W/C; detachable arms, desk or full-length, swing-away, detachable footrests	K 1****	Purchase
E1280*	NU EP	Heavy-duty W/C; detachable arms, desk or full-length, elevating legrests	Y*	Purchase
E1290*	NU EP	Heavy-duty W/C; detachable arms, swing-away, detachable footrests	Y*	Purchase
E1340	NU EP	U1 U1	***(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	*(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	K 1****	Manually Priced
E2201	NU EP	U3 U3	Manual w/c accessory, nonstandard seat frame width [GREATER THAN] than or equal to 20 inches and [LESS THAN]24 inches	K 1****	Manually Priced
E2201	NU EP	U1 U1	***(Frame Wdth 14"-15") Manual w/c accessory, nonstandard seat frame width[GREATER THAN]than or equal to 20 inches and [LESS THAN]24 inches	K 1****	Manually Priced (21+) Purchase

E2201	NU EP	U2 U2	***(Frame Width 19"-20") Manual w/c accessory, nonstandard seat frame width[GREATER THAN]than or equal to 20 inches and [LESS THAN]24 inches	K 1****	Manually Priced (21+) Purchase
E2201	NU EP	***(Seat Width 20") Manual w/c accessory, nonstandard seat frame width [GREATER THAN] than or equal to 20 inches and [LESS THAN] 24 inches	K 1****	Manually Priced Purchase
E2203	NU EP	U4 U4	Manual w/c accessory, nonstandard seat frame depth, 20 to less than 22 inches	N	Manually Priced Purchase
E2203	NU EP	U2 U2	***(Frame, Long; 16", 17"3, 18", 19"3, 20" Depth) Manual w/c accessory, nonstandard seat frame depth, 20 to less than 22 inches	K 1****	Manually Priced (21+) Purchase
E2203	NU EP	U3 U3	***(Seat Depth 19" - 20") Manual w/c accessory, nonstandard seat frame depth, 20 to less than 22 inches	K 1****	Manually Priced Purchase
E2203	NU EP	***(Seat Depth 15") Manual w/c accessory, nonstandard seat frame depth, 20 to less than 22 inches	K 1****	Manually Priced Purchase
E2203	NU EP	U1 U1	***(Seat Depth 17" -18") Manual w/c accessory, nonstandard seat frame depth, 20 to less than 22 inches	K 1****	Manually Priced Purchase
E2206	NU EP	Manual wheelchair accessory, wheel lock assembly, complete, each	N	Purchase
E2207	NU EP	Wheelchair accessory, crutch and cane holder, each	K 1****	Purchase
E2208	NU EP	Wheelchair accessory, cylinder tank carrier, each	N	Purchase
E2209	NU EP	Wheelchair accessory, arm trough, each	N	Purchase
E2210	NU EP	Wheelchair accessory, bearings, any type, replacement only, each	N	Purchase
E2211	NU EP	Manual wheelchair accessory, pneumatic propulsion tire, any size, each	N	Purchase
E2212	NU EP	Manual wheelchair accessory, tube for pneumatic propulsion tire, any size, each	N	Purchase
E2213	NU EP	Manual wheelchair accessory, insert for pneumatic propulsion tire (removable), any type, any size, each	N	Purchase

E2214	NU EP	Manual wheelchair accessory, pneumatic caster tire, any size, each	N	Purchase
E2215	NU EP	Manual wheelchair accessory, tube for pneumatic caster tire, any size, each	N	Purchase
E2220	NU EP	Manual wheelchair accessory, solid (rubber/plastic) propulsion tire, any size, each	N	Purchase
E2221	NU EP	Manual wheelchair accessory, solid (rubber/plastic) caster tire (removable), any size, each	N	Purchase
E2226	NU EP	Manual wheelchair accessory, caster fork, any size, replacement only, each	N	Purchase
E2291	EP	Back, planar, for pediatric-size wheelchair, including fixed attaching hardware	N	Manually Priced
E2292	EP	Seat, planar, for pediatric-size wheelchair, including fixed attaching hardware	N	Manually Priced
E2293	EP	Back, contoured, for pediatric-size wheelchair, including fixed attaching hardware	N	Manually Priced
E2294	EP	Seat, contoured, for pediatric-size wheelchair, including fixed attaching hardware	N	Manually Priced
E2310	NU EP	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	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	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	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	Power w/c accessory, specialty joystick handle for hand control interface, prefabricated	N	Purchase
E2324	NU EP	Power w/c accessory, chin cup for chin control interface	N	Purchase
E2325	NU EP	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	Power w/c accessory, breath tube kit for sip & puff interface	Y	Purchase
E2327	NU EP	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	Power w/c accessory, 22 NF non-sealed lead acid battery, each	N	Purchase
E2361	NU EP	Power w/c accessory, 22 NF sealed lead acid battery, each, (e.g., gel cell, absorbed glassmat)	N	Purchase
E2362	NU EP	Power wheelchair accessory, group 24 non-sealed lead acid battery, each	N	Purchase
E2363	EP	***(Group 24 Gel Batteries) Power W/C accessory, group 24 sealed lead acid battery, each, e.g., gel cell, absorbed glassmat	K 1****	Purchase
E2363	NU EP	Power w/c accessory, group 24 sealed lead acid battery, each (e.g., gel cell, absorbed glassmat)	N	Purchase
E2363	NU EP	U1 U1	Power w/c accessory, group 24 sealed lead acid battery, each (e.g., gel cell, absorbed glassmat)	N	Purchase
E2364	NU EP	Power wheelchair accessory, U-1 non-sealed lead acid battery, each	N	Purchase
E2365	NU EP	***(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	Power w/c accessory, U-1 sealed lead acid battery, each, gel cell	N	Purchase
E2365	NU EP	U1 U1	Power w/c accessory, U-1 sealed lead acid battery, each, gel cell	N	Purchase
E2366	NU EP	***(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	***(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	Power wheelchair component, motor, replacement only	N	Purchase
E2369	NU EP	Power wheelchair component, gear box, replacement only	N	Purchase
E2372	NU EP	Power wheelchair accessory, group 27 non-sealed lead acid battery, each	N	Purchase
E2601	NU EP UE	General use wheelchair seat cushion, width less than 22 in., any depth	N	Purchase
E2602	NU EP UE	General use wheelchair seat cushion, width 22 in. or greater, any depth	N	Purchase
E2611	NU EP UE	General use wheelchair back cushion, width less than 22 in., any height, including any type mounting hardware	N	Purchase
E2612	NU EP UE	General use wheelchair back cushion, width 22 in. or greater, any height, including any type mounting hardware	N	Purchase
E2618	NU EP	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	Replacement cover for wheelchair seat cushion or back cushion, each	N	Purchase
E2620	NU	Positioning wheelchair back cushion, planar back with lateral supports, width less than 22 in., any height, including any type mounting hardware	K 1****	Purchase

E2621	NU	Positioning wheelchair back cushion, planar back with lateral supports, width 22 in. or greater, any height, including any type mounting hardware	K 1****	Purchase
K0004	NU EP	High-strength lightweight wheelchair	W****	Purchase
K0005*	NU EP	***(High-performance manual W/C-adult) Ultralightweight W/C	Y*	Purchase
K0005*	NU EP	U1 U1	***(High-performance manual W/C with growth adjustability-child) Ultralightweight W/C	Y*	Purchase
K0010	NU EP	***(Motorized, standard frame, DA, swing away footrests) Standard weight frame motorized/power W/C	Y*	Purchase
K0010	NU EP	U1 U1	***(Motorized, standard frame, DA, swing away ELR) Standard weight frame motorized/power W/C	Y*	Purchase
K0011	NU EP	***(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	***(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	***(Motorized folding frame, DA, swing away footrests) Lightweight portable motorized/power W/C	Y*	Purchase
K0012	NU EP	U1 U1	***(Motorized folding frame, DA, swing away ELR) Lightweight portable motorized/power W/C	Y*	Purchase
K0014¹'²	NU EP	U1 U1	***(Center Drive power base) Other motorized/ power W/C base	Y	Purchase
K0017	NU EP	U1 U1	***(Dual post and adjustable height DA) Detachable, adjustable height armrest, base, each	K 1****	Purchase

K0017	NU EP	***(Receiver for height adj. arms, replacement) Detachable, adjustable height armrest, base, each	K 1****	Purchase
K0019	NU EP	Arm pad, each	N	Purchase
K0020	NU EP	Fixed, adjustable height armrest, pair	K 1****	Purchase
K0038	NU EP	***(Single leg strap, each) Leg strap, each	K 1****	Purchase
K0038	NU EP	U2 U2	***(Foot straps, pair) Leg strap, each	K 1****	Purchase
K0038**	EP	U1	***(Knee strap) Leg strap, each	N	Purchase
K0039	NU EP	Leg strap, H style, each	K 1****	Purchase
K0040	NU EP	Adjustable angle footplate, each	K 1****	Purchase
K0043	NU EP	***(SWFR, replacement) Footrest, lower extension tube, each	N	Purchase
K0044	NU EP	***(SWFR Hanger bracket, replacement) Footrest, upper hanger bracket, each	K 1****	Purchase
K0045	NU EP	***(Padded custom foot box) Footrest, complete assembly	K 1****	Purchase
K0047	NU EP	Elevating legrest, upper hanger bracket, each	K 1****	Purchase
K0056	NU EP	Seat height less than 17 inches or equal to or greater than 21 inches for a high-strength, lightweight, or ultralightweight W/C	K 1****	Manually Priced
K0056	NU EP	U1 U1	***(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	K 1****	Purchase
K0065	NU EP	Spoke protectors, each	K 1****	Purchase
K0070	NU EP	***(Wheel assembly, complete with pneumatic tires, 207227247267ea. replacement) Rear wheel assembly, complete with pneumatic tire, spokes or molded, each	K 1****	Purchase
K0071	NU EP	U1 U1	***(Wheel assembly with pneumatic tires, 22", pair, rear wheels) Front caster assembly, complete, with pneumatic tire, each	K 1****	Purchase

K0071	NU EP	***(Polyeurethane casters, 5", pair, front casters) Front caster assembly, complete, with pneumatic tire, each	K 1****	Purchase
K0072	NU EP	***(Polyeurethane casters, 5", pair, front casters) Front caster assembly, complete, with semipneumatic tire, each	K 1****	Purchase
K0073	NU EP	Caster pin lock, each	K 1****	Purchase
K0077	NU EP	Front caster assembly, complete, with solid tire, each	N	Purchase
K0091	NU EP	U1 U1	***(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	***(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	Rear wheel assembly for power wheelchair, complete, each	N	Purchase
K0093	NU EP	***(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	K 1****	Purchase
K0093	NU EP	U1 U1	***(Mag. Airless Insert, Drive Wheel) Rear wheel zero pressure tire tube (flat free insert) for power W/C, any size, each	K 1****	Purchase
K0094	NU EP	***(20" x 2 1/8" replacement) Wheel tire for power base, any size, each	N	Purchase
K0097	NU EP	Wheel, zero pressure tire tube (flat free insert) for power base, any size, each	K 1****	Purchase
K0099	NU EP	***(9 x 2 3/4" foam filled caster for power base W/C) Front caster for power W/C	K 1****	Purchase
K0108	NU EP	*(W/C miscellaneous equipment; applicable pages from the manufacturer's catalog must be attached to the claim form.)**Other accessories	K 1****	Manually Priced
K0195	NU EP	Elevating legrest, pair (for use with capped rental wheelchair base)	N	Rental Only
S1002	NU EP	***(Wheelchair, custom molded seating system only) Customized item, list in addition to code for basic item	K 1****	Manually Priced

S1002

NU EP

U1 U1

***(Foam-in-place seat, Pindot quick foam contour system) Customized item, list in addition to code for basic item

K 1****

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	Local Code	Description	PA	Payment Method
Bill on paper	NU EP	Z1613	One-piece footboard (each)	K 1****	Purchase
Bill on paper	NU EP	Z1785	W/C Mounting Kit, O.B.	K 1****	Purchase
Bill on paper	NU EP	Z1789	Custom Headrest	K 1****	Purchase
Bill on paper	NU EP	Z1793	Custom foot platform	K 1****	Purchase
Bill on paper	EP	Z1824**	PC Car Seat/Snug Seat	Y	Purchase
Bill on paper	NU EP	Z2137	Adjustable Rem. Abductor w/hardware (ea)	K 1****	Purchase
Bill on paper	NU EP	Z2138	Adjustable Flip Down Abductor w/hardware (ea)	K 1****	Purchase
Bill on paper	NU EP	Z2139	Lateral Hip/Thigh support w/hardware (ea)	K 1****	Purchase
Bill on paper	NU EP	Z2140	Adductor - no hardware	K 1****	Purchase
Bill on paper	NU EP	Z2141	Abductor - no hardware	K 1****	Purchase
Bill on paper	NU EP	Z2142	Hip guides - no hardware	N	Purchase
Bill on paper	NU EP	Z2143	Fluid supplement	N	Purchase
Bill on paper	NU EP	Z2145	Laterals - no hardware	K 1 ****	Purchase
Bill on paper	NU	Z2158	Air Exchange Seat Cover for Cushions (Replacement)	N	Purchase
Bill on paper	NU EP	Z2159	Fluid Flo-lite pad (Replacement)	N	Purchase

Bill on paper	NU EP	Z2175	Power W/C Sleeve Top or Bottom Stem Bearing (Replacement)	K 1****	Purchase
Bill on paper	NU EP	Z2178	SWFR Pivot Saddle (Replacement)	N	Purchase
Bill on paper	NU EP	Z2180	SWFR Latch Block (Replacement)	N	Purchase
Bill on paper	NU EP	Z2181	SWFR Composite Foot Plate (Replacement)	K 1****	Purchase
Bill on paper	NU EP	Z2183	Shoe Holders S/M/L/XL	K 1****	Purchase
Bill on paper	NU EP	Z2184	X-Tube Assembly Folding W/C (Replacement)	K 1****	Purchase
Bill on paper	NU EP	Z2185	Rigid Wheelchair Growth Kit	N	Purchase
Bill on paper	NU EP	Z2186	Rigid Side Guard	K 1****	Purchase
Bill on paper	NU EP	Z2187	Fabric Side Guard	K 1****	Purchase
Bill on paper	NU EP	Z2188	Sub Occipital Three Piece Head SetW/REM Hardware	K 1****	Purchase
Bill on paper	NU EP	Z2189	Forehead Strap System	K 1****	Purchase
Bill on paper	NU EP	Z2190	Regular Links	K 1****	Purchase
Bill on paper	NU EP	Z2192	Pneumatic or Semi Casters (Replacement) 8x1 1/4 (ea) or 8 x 1 3/4 (ea)	K 1****	Purchase
Bill on paper	NU EP	Z2196	Swing Away Adj. Stroller Handles	K 1****	Purchase
Bill on paper	NU EP	Z2200	Support Fixture for Head Rest	K 1****	Purchase
Bill on paper	NU EP	Z2202	Lg. Chest Panel Support	K 1****	Purchase
Bill on paper	NU EP	Z2203	Elbow Block w/Bracket	K 1****	Purchase
Bill on paper	NU EP	Z2554	Swing Away Retractable Joystick Mount	K 1****	Purchase
Bill on paper	NU EP	Z2582	Quick Release Axle	K 1****	Purchase

Bill on paper	NU EP	Z2585	Growing Seat Pan	K 1****	Purchase
Bill on paper	NU EP	Z2586	Growing Back Upholstery	K 1****	Purchase
Bill on paper	NU EP	Z2588	Deep Contour Back 20" Width	K 1****	Purchase
Bill on paper	NU EP	Z2589	Adjustable Contour Lateral Pelvic Support	K 1****	Purchase
Bill on paper	NU EP	Z2591¹	Heavy Duty Motor Pack 350 Pounds	N	Purchase
Bill on paper	NU EP	Z2592	Remote Joystick Module	K 1****	Purchase
Bill on paper	NU EP	Z2596	Adjustable Contour Seat Attaching Hardware	K 1****	Purchase
Bill on paper	NU EP	Z2599	Transit Option	K 1****	Purchase
Bill on paper	NU EP	Z2604	Adjustable Back Upholstery	K 1****	Purchase
Bill on paper	NU EP	Z2607	Lateral/Posterior Pelvic Support	K 1****	Purchase
Bill on paper	NU EP	Z2608	Shoulder Harness Guide Kit	K 1****	Purchase
Bill on paper	NU EP	Z2609	Universal Head Rest Kit	K 1****	Purchase
Bill on paper	NU EP	Z2615	Remote Joystick With 1/8" Jacks	K 1****	Purchase
Bill on paper	NU EP	Z2616	Swing Away Mount (Joystick)	K 1****	Purchase

242.192Specialized Rehabilitative Equipment, All Ages

** Indicates that providers may bill only for individuals under age 21.

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

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

Specialized Rehabilitative Equipment, All Ages (section 242.192 )

Procedure Code	M1	M2	Description	PA	Payment Method
E0149	NU EP	***(4 Wheel Reverse Walker) Walker, heavy duty, wheeled, rigid or folding, any type	N	Purchase
E0163	EP	***(Potty Chair - Sm) Commode chair, stationary, with fixed arms	Y	Purchase
E0166	EP	U1	***(Potty Chair - Lg) Commode chair, mobile, with detachable arms	Y	Purchase
E0168	NU	U1	***(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	***(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	***(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	***(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	***(Bolt-on Sm. Grab Bar) Bathroom wall rail, each	N	Purchase
E0241	NU EP	U1 U1	***(Bolt-on Lg. Grab Bar) Bathroom wall rail, each	N	Purchase
E0241	NU EP	U2 U2	***(Bolt-on Med. Grab Bar) Bathroom wall rail, each	N	Purchase
E0245	NU EP	U3 U3	***(30" Bath Chair) Tub stool or bench	N	Purchase
E0245	NU EP	U4 U4	***(38" Bath Chair) Tub stool or bench	N	Purchase
E0245	NU EP	U5 U5	***(47" Bath Chair) Tub stool or bench	N	Purchase
E0245	NU EP	U6 U6	***(56" Bath Chair) Tub stool or bench	N	Purchase
E0245	NU EP	U2 U2	***(Padded Tub Transfer Bench) Tub stool or bench	N	Purchase

E0245	NU EP	UB UB	***(Non-padded tub transfer bench) Tub stool or bench	N	Purchase
E0245	NU EP	***(Adj. Bath Chair w/Back) Tub stool or bench	N	Purchase
E0246	NU EP	***(Clamp-on Tub Grab Bar) Transfer tub rail attachment	N	Purchase
E0638	NU EP	Standing frame system, any size, with or without wheels	Y	Purchase
E0638	EP EP	U1 U2	Standing frame system, any size, with or without wheels	Y	Purchase
E0700	NU EP	***(Chin Guard for Safety Helmet, sm) Safety equipment, e.g., belt, harness or vest	N	Purchase
E0701	NU EP	***(Soft Shell Helmets) Helmet with face guard and soft interface material, prefabricated	N	Purchase
E0701	NU EP	U1	***(Hard Shell Helmets) Helmet with face guard and soft interface material, prefabricated	N	Purchase
E0701	NU EP	U2 U2	***(Face guard for safety helmet) Helmet with face guard and soft interface material, prefabricated	N	Purchase
E0950	NU EP	U1 U1	***(Tray for gait trainer) Wheelchair accessory, tray, each	N	Purchase
E1031**	EP	U5	***(Low Back Activity Chair) Rollabout chair, any and all types with casters five inches or greater	N	Purchase
E1031**	EP	/*(Transition Toddler Chair - Sm.) Rollabout chair, any and all types with casters five inches or greater	N	Purchase
E1031**	EP	/*(Transition Toddler Chair - Lg.) Rollabout chair, any and all types with casters five inches or greater	Y	Purchase
E1031**	EP	U1	***(Corner Chair w/Tray & Casters - Sm.) Rollabout chair, any and all types with casters five inches or greater	N	Purchase
E1031**	EP	U3	***(Corner Chair w/T ray & Casters - Lg.) Rollabout chair, any and all types with casters five inches or greater	N	Purchase
E1031**	EP	U4	***(Bolster Chair w/T ray, Chest Support & Casters - Sm.) Rollabout chair, any and all types with casters five inches or greater	N	Purchase
E1035**	EP	***(Carrie Seat - Pre School) Multi-positional patient transfer system, with integrated seat, operated by care giver	Y	Purchase

E1035**	EP	U1	***(Carrie Seat - Elementary) Multi-positional patient transfer system, with integrated seat, operated by care giver	Y	Purchase
E1035**	EP	U2	***(Carrie Seat - Jr.) Multi-positional patient transfer system, with integrated seat, operated by care giver	Y	Purchase
E1035	NU EP	U3 U3	***(Carrie Seat - Sm. Adult) Multi-positional patient transfer system, with integrated seat, operated by care giver	Y*	Purchase
E8000	EP	***(14") Gait trainer, pediatric size, posterior support, includes all accessories and components	Y	Purchase
E8000	EP	U1	***(19") Gait trainer, pediatric size, posterior support, includes all accessories and components	Y	Purchase
E8000	EP	U2	/*(Intermediate) Gait trainer, pediatric size, posterior support, includes all accessories and components	Y	Purchase
E8001	EP	***(14") Gait trainer, pediatric size, upright support, includes all accessories and components	Y	Purchase
E8001	EP	U1	***(19") Gait trainer, pediatric size, upright support, includes all accessories and components	Y	Purchase
E8001	EP	U2	/*(Intermediate) Gait trainer, pediatric size, upright support, includes all accessories and components	Y	Purchase
E8002	EP	***(14") Gait trainer, pediatric size, anterior support, includes all accessories and components	Y	Purchase
E8002	EP	U1	***(19") Gait trainer, pediatric size, anterior support, includes all accessories and components	Y	Purchase
E8002	EP	U2	/*(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)

National

Code

M 2

Local Code

Description

Payment Method

Bill on paper

NU EP

Z1996

Sm. 51" Supine Stander

Purchase

Bill on paper	NU EP	Z1997	Lg. 71" Supine Stander	Y*	Purchase
Bill on paper	EP	Z1998**	27" Prone Stander	Y	Purchase
Bill on paper	EP	Z1999**	35" Prone Stander	Y	Purchase
Bill on paper	EP	Z2000**	42" Prone Stander	Y*	Purchase
Bill on paper	NU EP	Z2001	50" Prone Stander	Y*	Purchase
Bill on paper	NU EP	Z2002	Adj. Abduction Wedge w/hip stabilizer	N	Purchase
Bill on paper	NU EP	Z2003	Tray for Stander-Prone	N	Purchase
Bill on paper	NU EP	Z2004	Tray for Stander-Supine	N	Purchase
Bill on paper	NU EP	Z2005	Foot Sandals for Standers	N	Purchase
Bill on paper	EP	Z2006**	Up Rite Stander - Sm.	Y	Purchase
Bill on paper	EP	Z2007**	Up Rite Stander- Med.	Y	Purchase
Bill on paper	NU EP	Z2008	Up Rite Stander- Lg.	Y	Purchase
Bill on paper	NU EP	Z2009	Caster Base for Up Rite Stander-Sm.	N	Purchase
Bill on paper	NU EP	Z2010	Caster Base for Up Rite Stander-Med.	N	Purchase
Bill on paper	NU EP	Z2011	Caster Base for Up Rite Stander-Lg.	N	Purchase
Bill on paper	EP	Z2012**	Tumble Form Tri Stander w/Tray -Sm.	Y*	Purchase
Bill on paper	EP	Z2013**	Tumble Form Tri Stander w/T ray -Lg.	Y*	Purchase
Bill on paper	EP	Z2015**	48" Side Lyer	N	Purchase

Bill on paper	EP	Z2016**	72" Side Lyer	N	Purchase
Bill on paper	EP	Z2017**	Tumble Form Feeder Seat - Sm.	N	Purchase
Bill on paper	NU EP	Z2018**	Tumble Form Feeder Seat- Med.	N	Purchase
Bill on paper	EP	Z2019**	Tumble Form Feeder Seat - Lg.	N	Purchase
Bill on paper	EP	Z2021**	Mobile Floor Sitter Med/Lg.	N	Purchase
Bill on paper	EP	Z2038**	Therapy Ball - Sm.	N	Purchase
Bill on paper	EP	Z2039**	Therapy Ball - Med.	N	Purchase
Bill on paper	EP	Z2040**	Therapy Ball - Lg.	N	Purchase
Bill on paper	EP	Z2043**	Seat & Back Pad for Toddler Chairs	Y	Purchase
Bill on paper	EP	Z2044**	Tray for Toddler Chair	Y	Purchase
Bill on paper	EP	Z2045**	14" T&S High Back w/Support Activity Chair	Y	Purchase
Bill on paper	EP	Z2046**	16" T&S High Back w/Support Activity Chair	Y	Purchase
Bill on paper	NU EP	Z2047	Orthopedic Car Seat	Y	Purchase
Bill on paper	NU EP	Z2072	Lg. Wrap Around Bath Support	N	Purchase
Bill on paper	NU EP	Z2073	Sm. Wrap Around Back Support	N	Purchase
Bill on paper	NU EP	Z2074	Lg. Toilet Support w/Hi Back	N	Purchase
Bill on paper	NU EP	Z2075	Sm. Toilet Support w/Hi Back	N	Purchase
Bill on paper	NU EP	Z2077	Flexible Shower Hose	N	Purchase
Bill on paper	NU EP	Z2089	Toilet Seat Reducer Ring (Padded)	N	Purchase

Bill on paper	NU EP	Z2093	Adult Gait Trainer	Y*	Purchase
Bill on paper	EP	Z2094**	Tyke Strider Walker w/2 Wheels	N	Purchase
Bill on paper	EP	Z2095**	Tweener Strider Walker w/2 Wheels	N	Purchase
Bill on paper	EP	Z2096**	Middle Strider Walker w/2 Wheels	N	Purchase
Bill on paper	NU EP	Z2097	Adult Strider Walker w/2 Wheels	N	Purchase
Bill on paper	NU EP	Z2099	4 Wheel Reverse Walker	N	Purchase
Bill on paper	NU EP	Z2100	4 Wheel Reverse Walker	N	Purchase
Bill on paper	NU EP	Z2101	4 Wheel Reverse Walker	N	Purchase
Bill on paper	NU EP	Z2102	4 Wheel Reverse Walker	N	Purchase
Bill on paper	NU EP	Z2104	4 Wheel Front Swivel Reverse Walker	N	Purchase
Bill on paper	NU EP	Z2105	4 Wheel Front Swivel Reverse Walker	N	Purchase
Bill on paper	NU EP	Z2106	4 Wheel Front Swivel Reverse Walker	N	Purchase
Bill on paper	NU EP	Z2107	4 Wheel Front Swivel Reverse Walker	N	Purchase
Bill on paper	NU EP	Z2239	Bath Chair Headrest	N	Purchase
Bill on paper	NU EP	Z2605	Diverter Valve for Handheld Shower	N	Purchase

242.193Augmentative Communication Device, All Ages

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

Procedure codes found in this section must be billed either electronically or on paper with modifier EPfor 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 EPorNU.

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

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

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

Augmentative Communication Device, All Ages (section 242.193)

Procedure Code	M1	M2	PA	Description	Payment Method
E2500	NU EP	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	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	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	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	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	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	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	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	Y	Accessory for speech generating device, mounting system	Manually Priced
E2599	NU EP	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	Y	*(Augmentative Communication Device Repair - parts only)**Repair/modification of augmentative communicative system or device (excludes adaptive hearing aid)	N/A
V5336	NU EP	Y	*(Augmentative Communication Device Repair - labor only)**Repair/modification of augmentative communicative system or device (excludes adaptive hearing aid)	N/A

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

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

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

242.200National Place of Service and Modifier Codes

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

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

Modifiers

EP-Service provided as part of EPSDT Program

KH-Durable Medical Equipment (DME) item, initial claim, first month's rental

NU-New Equipment

RR-Durable Medical Equipment (DME) Rental

U1-Medicaid Level of Care 1 (defined by state)

U2-Medicaid level of Care 2 (defined by state) U3-Medicaid level of care 3 (defined by state) U4-Medicaid level of care 4 (defined by state) U5-Medicaid level of care 5 (defined by state) UE-Used durable medical equipment (DME) 52-Reduced Services

242.300 Billing Instructions - Paper Only

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

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

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

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

242.310Completion of CMS-1500 Claim Form

Field Name and Number	Instructions for Completion
1. (type of coverage)	Not required.
1a. INSURED'S I.D. NUMBER (For Program in Item 1)	Beneficiary's or participant's 10-digit Medicaid or ARKids First-A or ARKids First-B identification number.
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)	Beneficiary's or participant's last name and first name.
3. PATIENT'S BIRTH DATE	Beneficiary's or participant's date of birth as given on the individual's Medicaid or ARKids First-A or ARKids First-B identification card. Format: MM/DD/YY.
SEX	Check M for male or F for female.
4. INSURED'S NAME (Last Name, First Name, Middle Initial)	Required if insurance affects this claim. Insured's last name, first name, and middle initial.
5. PATIENT'S ADDRESS (No., Street) CITY	Optional. Beneficiary's or participant's complete mailing address (street address or post office box). Name of the city in which the beneficiary or participant resides.

STATE	Two-letter postal code for the state in which the beneficiary or participant resides.
ZIP CODE	Five-digit zip code; nine digits for post office box.
TELEPHONE (Include Area Code)	The beneficiary's or participant's telephone number or the number of a reliable message/contact/ emergency telephone.
6. PATIENT RELATIONSHIP TO INSURED	If insurance affects this claim, check the box indicating the patient's relationship to the insured.
7. INSURED'S ADDRESS (No., Street) CITY STATE ZIP CODE TELEPHONE (Include Area Code)	Required if insured's address is different from the patient's address.
8. PATIENT STATUS	Not required.
9. OTHER INSURED'S NAME (Last name, First Name, Middle Initial)	If patient has other insurance coverage as indicated in Field 11 d, the other insured's last name, first name, and middle initial.
a. OTHER INSURED'S POLICY OR GROUP NUMBER	Policy and/or group number of the insured individual.
b. OTHER INSURED'S DATE OF BIRTH	Not required.
SEX	Not required.
c. EMPLOYER'S NAME OR SCHOOL NAME	Required when items 9 a-d are required. Name of the insured individual's employer and/or school.
d. INSURANCE PLAN NAME OR PROGRAM NAME	Name of the insurance company.
10. IS PATIENT'S CONDITION RELATED TO:
a. EMPLOYMENT? (Current or Previous)	Check YES or NO.
b. AUTO ACCIDENT?	Required when an auto accident is related to the services. Check YES or NO.
PLACE (State)	If 10b is YES, the two-letter postal abbreviation for the state in which the automobile accident took place.
c. OTHER ACCIDENT?	Required when an accident other than automobile is related to the services. Check YES or NO.
10d. RESERVED FOR LOCAL USE	Not used.

11. INSURED'S POLICY GROUP OR FECA NUMBER	Not required when Medicaid is the only payer.
a. INSURED'S DATE OF BIRTH	Not required.
SEX	Not required.
b. EMPLOYER'S NAME OR SCHOOL NAME	Not required.
c. INSURANCE PLAN NAME OR PROGRAM NAME	Not required.
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?	When private or other insurance may or will cover any of the services, check YES and complete items 9a through 9d.
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE	Not required.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE	Not required.
14. DATE OF CURRENT: ILLNESS (First symptom) OR	Required when services furnished are related to an accident, whether the accident is recent or in the past. Date of the accident.
INJURY (Accident) OR PREGNANCY (LMP)
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS, GIVE FIRST DATE	Not required.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION	Not required.
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE	Primary Care Physician (PCP) referral is not required for prosthetics. If services are the result of a Child Health Services (EPSDT) screening/ referral, enter the referral source, including name and title.
17a. (blank)	The 9-digit Arkansas Medicaid provider ID number of the referring physician.
17b. NPI	Not required.
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES	When the serving/billing provider's services charged on this claim are related to a beneficiary's or participant's inpatient hospitalization, enter the individual's admission and discharge dates. Format: MM/DD/YY.
19. RESERVED FOR LOCAL USE	Not used.
20. OUTSIDE LAB?	Not required.

$ CHARGES	Not required.
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY	Diagnosis code for the primary medical condition for which services are being billed. Up to three additional diagnosis codes can be listed in this field for information or documentation purposes. Use the U.S. Department of Health and Human Services diagnosis coding, current as of the claim date (not the service date), from ICD-9-CM.
22. MEDICAID RESUBMISSION CODE	Reserved for future use.
ORIGINAL REF. NO.	Reserved for future use.
23. PRIOR AUTHORIZATION NUMBER	The prior authorization or benefit extension control number if applicable.
24A. DATE(S) OF SERVICE	The "from" and "to" dates of service for each billed service. Format: MM/DD/YY.
1. On a single claim detail (one charge on one line), bill only for services provided within a single calendar month.
2. Providers may bill on the same claim detail for two or more sequential dates of service within the same calendar month when the provider furnished equal amounts of the service on each day of the date sequence.
B. PLACE OF SERVICE	Two-digit national standard place of service code. See Section 242.200 for codes.
C. EMG	Not required.
D. PROCEDURES, SERVICES, OR SUPPLIES
CPT/HCPCS	Enter the correct CPT or HCPCS procedure code from Sections 242.100 through 242.195.
MODIFIER	Modifier(s) if applicable.
E. DIAGNOSIS POINTER	Enter in each detail the single number-1, 2, 3, or 4- that corresponds to a diagnosis code in Item 21 (numbered 1,2,3, or 4) and that supports most definitively the medical necessity of the service(s) identified and charged in that detail. Enter only one number in E of each detail. Each DIAGNOSIS POINTER number must be only a 1, 2, 3, or 4, and it must be the only character in that field.
F. $ CHARGES	The full charge for the service(s) totaled in the detail. This charge must be the usual charge to any client, patient, or other recipient of the provider's services.
G. DAYS OR UNITS	The units (in whole numbers) of service(s) provided during the period indicated in Field 24A of the detail.
H. EPSDT/Family Plan	Enter E if the services resulted from a Child Health Services (EPSDT) screening/referral.

1. IDQUAL	Not required.
J. RENDERING PROVIDER ID #	The 9-digit Arkansas Medicaid provider ID number of the individual who furnished the services billed for in the detail.
NPI	Not required.
25. FEDERAL TAX I.D. NUMBER	Not required. This information is carried in the provider's Medicaid file. If it changes, please contact Provider Enrollment.
26. PATIENT'S ACCOUNT N 0.	Optional entry that may be used for accounting purposes; use up to 16 numeric or alphabetic characters. This number appears on the Remittance Advice as "MRN."
27. ACCEPT ASSIGNMENT?	Not required. Assignment is automatically accepted by the provider when billing Medicaid.
28. TOTAL CHARGE	Total of Column 24F-the sum all charges on the claim.
29. AMOUNT PAID	Enter the total of payments previously received on this claim. Do not include amounts previously paid by Medicaid. Do not* include in this total the automatically deducted Medicaid or ARKids First-B co-payments.
30. BALANCE DUE	From the total charge, subtract amounts received from other sources and enter the result.
31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS	The provider or designated authorized individual must sign and date the claim certifying that the services were personally rendered by the provider or under the provider's direction. "Provider's signature" is defined as the provider's actual signature, a rubber stamp of the provider's signature, an automated signature, a typewritten signature, or the signature of an individual authorized by the provider rendering the service. The name of a clinic or group is not acceptable.
32. SERVICE FACILITY LOCATION INFORMATION	If other than home or office, enter the name and street, city, state, and zip code of the facility where services were performed.
a. (blank)	Not required.
b. (blank)	Not required.
33. BILLING PROVIDER INFO &PH#	Billing provider's name and complete address. Telephone number is requested but not required.
a. (blank)	Not required.
b. (blank)	Enter the 9-digit Arkansas Medicaid provider ID number of the billing provider.

016.06.07 Ark. Code R. § 019

7/5/2007