016-06-07 Ark. Code R. § 63

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

Rule 016.06.07-063 - Prosthetics Provider Manual Update Transmittal #94

Section II Prosthetics

242.111Initial Rental of a DME Item for Individuals of All Ages 10-1-07

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
E0181			Pressure pad, alternating with pump, heavy duty	U21
E0200			Heat lamp, without stand (table model), includes bulb, or infrared element	U21
E0205			Heat lamp, with stand includes bulb, or infrared element	U21
E0217			Water circulating heat pad with pump	U21
E0225			Hydrocollator unit, includes pad	U21
E0236			Pump for water circulating pad	U21
E0239			Hydrocollator unit, portable	U21
E0250*			Hospital bed, fixed height, with any type side rails, with mattress	AA
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
E0445*			Oximeter for measuring blood oxygen levels non-invasively. *** (Pulse oximeter, including 4 disposable probes)	AA
E0480			Percussor, electric or pneumatic, home model	U21
E0565*			Compressor, air power source for equipment which is not self-contained or cylinder driven	U21
E05754			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
E06304			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	AA
E0745*			Neuromuscular stimulator, electronic shock unit	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	AA
E0920			Fracture frame, attached to bed, includes weights	U21
E0930			Fracture frame, freestanding, includes weights	U21
E09354			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
E11304	KH		Standard wheelchair, fixed full-length arms, fixed or swing-away, detachable footrests	21+
E1224*			Wheelchair with detachable arms, elevating legrests	AA
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 must be billed when equipment is used less than 30 days during the first month of rental.

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

242.150Nutritional Formulae for Child Health Services (EPSDT) 10-1-07

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 EP for beneficiaries under 21 years of age. Modifier "BO " is used to bill for oral usage. When a second or third modifier is listed, that modifier must be used in conjunction with EP .

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	Benefib	er and	FOS	Fortison	Osmolite
Carnation In	stant B	reakfa	st -	Intraolite	Osmolite 1.0 CAL
Lactose F	ree			Isocal	Osmolite HN
Ensure				Isocal HN	Portagen
Ensure Fibe	r with F	OS		IsoSource	Probalance
Ensure Hig	h Protei	n		IsoSource HN	Promote
Ensure HN				Jevity 1.0 CAL	Promote with Fiber
Ensure Pow	der			Nutrapack	Ultracal
Fibersource				Nutren 1.0
B4150	EP	U1	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	Boost Pudding Ensure Pudding
B4152 B4152	EP EP	BO		Enteral formula, nutritionally complete, calorically dense (equal to or greater than 1.5 Kcal/ml), with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit	Boost Plus Carnation Instant Breakfast Lactose Free Plus Comply Ensure Plus Novasource 2.0 Nutren 1.5 Nutren 2.0 Osmolite 1.5 Cal 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 Tolerex 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:
Advera				Impact with Fiber	Pulmocare
AminAid				IsoSource VHN	Resource Diabetic
Boost Diabeti	c			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 Polycose Liquid
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	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	BO		Enteral formula, for pediatrics, nutritionally complete soy base with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 calories = 1 unit	Enfamil Next Step Prosobee Lipil Enfamil Prosobee Lipil Isomil Isomil Advance Soy with Iron Prosobee
B4160 B4160	EP EP	BO		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	BO	Enteral formula, for pediatrics, nutritionally calorically dense (equal to or greater than 0.7 Kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit	Enfamil Premature Lipil 24 Cal Low Iron Enfamil Premature Lipil 24 Cal with Iron Similac Neosure Similac Neosure Advance Special Care Advance 20 Special Care Advance 20 with Iron Special Care Advance 24 Special Care Advance 24 with Iron
B4161 B4161	EP EP	BO		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 Advanced
Cyclinex-1				Maxamaid MSUD	Periflex Infant
Cyclinex-2				Maxamum MSUD	Periflex Junior
Hominex-1				MSUD Analog	Phenex-1
Hominex-2				MSUD 1 and 2	Phenex-2
I-Valex-1					Phenyl Free 1
I-Valex-2					Phenyl Free 2
Ketonex-1					Propimex-1
Ketonex-2					Propimex-2 XLys, XTrp Maxamaid Xphe Maxamaid XPhe, XTyr Maxamaid Xphe Maxamum XPhe, XTyr 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 a monthly basis. Units may not be rounded up. Providers must bill a date span according to the prescribed daily volume.

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. View or print the Utilization Review Section contact information.

242.160Durable Medical Equipment, All Ages 10-1-07

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

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

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

*** This procedure code may not be billed for used equipment.

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

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

Durable Medical Equipment, All Ages (section 242.160)

Procedure Code	M1	M2	M3	PA	Description	Payment Method
A4635	NU EP UE			N	Underarm pad, crutch, replacement, each	Purchase
A4636				N	Replacement, handgrip, cane, crutch, or walker, each	Purchase
A4637				N	Replacement, tip, cane, crutch, walker, each	Purchase
E0100				N	Cane, includes canes of all materials, adjustable or fixed, with tip	Purchase
E0105				N	Cane, quad or three-prong, includes canes of all materials, adjustable or fixed, with tips	Purchase
E0110				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	NU EP UE			N	Crutches, underarm, wood, adjustable or fixed, pair, with pads, tips and handgrips	Purchase
E0113	NU EP UE			N	Crutch, underarm, wood, adjustable or fixed, each, with pad, tip and handgrip	Purchase
E0114				N	Crutches, underarm, other than wood, adjustable or fixed, pair, with pads, tips and handgrips	Purchase
E0116				N	Crutch, underarm, other than wood, adjustable or fixed, each, with pad, tip and handgrip	Purchase
E0130				N	Walker, rigid (pickup), adjustable or fixed height	Purchase
E0135				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				N	Walker, rigid, wheeled, adjustable or fixed height	Purchase
E0143				N	Walker, folding, wheeled, adjustable or fixed height	Purchase
E0147				N	Walker, heavy duty, multiple braking system, variable wheel resistance	Purchase
E0153				N	Platform attachment, forearm crutch, each	Purchase
E0154				N	Platform attachment, walker, each	Purchase
E0155				N	Wheel attachment, rigid pick-up walker, per pair seat attachment, walker	Purchase
E0156	NU EP			N	Seat attachment, walker	Purchase
E0157				N	Crutch attachment, walker, each	Purchase
E0158	NU EP UE			N	Leg extensions for walker, per set of four (4)	Purchase
E0159	NU EP			N	Brake attachment for wheeled walker, replacement, each	Purchase
E0160				N	Sitz type bath or equipment, portable, used with or without commode	Purchase
E0161				N	Sitz type bath or equipment, portable, used with or without commode, with faucet attachment(s)	Purchase
E0163				N	Commode chair, stationary, with fixed arms	Purchase
E0167				N	Pail or pan for use with commode chair	Purchase
E0175				N	Foot rest, for use with commode chair, each	Purchase
E0181				N	Pressure pad, alternating with pump, heavy duty	Capped Rental
E0182	NU EP UE	U1		N	Pump for alternating pressure pad	Purchase
E0184				N	Dry pressure mattress	Purchase
E0185				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				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 *** (Tumble Form Therapy Roll 4")	Purchase
E0190	EP	U1		N	Positioning cushion/pillow/wedge, any shape or size *** (Tumble Form Therapy Roll 6")	Purchase
E0190	EP	U2		N	Positioning cushion/pillow/wedge, any shape or size *** (Tumble Form Therapy Wedge 4"	Purchase
E0190	EP	U3		N	Positioning cushion/pillow/wedge, any shape or size *** (Tumble Form Therapy Roll 8")	Purchase
E0190	EP	U4		N	Positioning cushion/pillow/wedge, any shape or size *** (Tumble Form Therapy Wedge 6")	Purchase
E0190	EP	U5		N	Positioning cushion/pillow/wedge, any shape or size *** (Floor Sitter Wedge 4")	Purchase
E0190	EP	U6		N	Positioning cushion/pillow/wedge, any shape or size *** (Tumble Form Therapy Roll 12")	Purchase
E0190	EP	U7		N	Positioning cushion/pillow/wedge, any shape or size *** (Deluxe Wedge with strap 4")	Purchase
E0190	EP	U8		N	Positioning cushion/pillow/wedge, any shape or size *** (Deluxe Wedge with strap 6")	Purchase
E0190	EP	U9		N	Positioning cushion/pillow/wedge, any shape or size *** (Tumble Form Therapy Wedge 10")	Purchase
E0190	EP	KA	U1	N	Positioning cushion/pillow/wedge, any shape or size *** (Tumble Form Therapy Roll 14")	Purchase
E0190	EP	KA	U2	N	Positioning cushion/pillow/wedge, any shape or size *** (Tumble Form Therapy Roll 16")	Purchase
E0190	EP	KA	U3	N	Positioning cushion/pillow/wedge, any shape or size *** (Tumble Form Therapy Wedge 8")	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	U1 U1 U2 U2 U3 U3		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	NU EP NU EP	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	NU EP UE			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	R R R R		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	NU EP UE			N	Mattress, foam rubber	Capped Rental
E0273	NU EP UE			N	Bed board	Purchase
E0275	NU EP UE			N	Bed pan, standard, metal or plastic	Purchase
E0276	NU EP UE			N	Bed pan, fracture, metal or plastic	Purchase
E0280	NU EP UE			N	Bed cradle, any type	Purchase
E0300	EP EP	R R		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	NU EP UE			N	Urinal; female, jug-type, any material	Purchase
E0445***	NU EP			Y*	***(Pulse oximeter, including 4 disposable probes) Oximeter for measuring blood oxygen levels noninvasively	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	Purchase
E0748	NU EP			N	Osteogenesis stimulator, electrical noninvasive, spinal applications	Purchase
E0760	NU EP			Y	Osteogenesis stimulator, low intensity ultrasound, noninvasive	Rental Only
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*	Continuous passive motion exercise device for use on knee only	Capped Rental
E0936	NU EP			Y*	Continuous passive motion exercise device for use other than knee	Manually Priced
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*** Z2211 (Bill on Paper)	NU EP NU EP			N Y	***(Peak flow meter used by asthmatic patients) Portable peak flow meter Power Kit/Batteries	Purchase Purchase

Procedure codes E0250* , E0255* and E0260* must be billed when hospital beds are purchased for Medicaid beneficiaries of all ages. Providers must only provide these purchase-only services to beneficiaries who are expected to require the bed for a long period of time.

Each procedure code for hospital beds listed above may only be billed once every 10 years.

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

242.180Orthotic Appliances, All Ages 10-1-07

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

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

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

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

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

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+	N	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 ¼ inch material of shore a 35 durometer of 3/16 inch material of shore a 40 durometer (or higher), prefabricated, each	21+	N	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 ¼ 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+	N	Purchase
A8000	EP NU		Helmet, protective, soft, prefabricated, includes all components and accessories	All	N	Purchase
A8001	EP NU		Helmet, protective, hard, prefabricated, includes all components and accessories	All	N	Purchase
A8002	EP NU		Helmet, protective, soft, custom fabricated, includes all components and accessories	All	N	Purchase
A8003	EP NU		Helmet, protective, hard, custom fabricated, includes all components and accessories	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		Sacroiliac orthosis, 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		Lumbar orthosis, flexible, provides lumbar support, posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include pendulous abdomen design, shoulder straps, stays, prefabricated, 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		Lumbar-sacral orthosis, flexible, provides lumbo-sacral support, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include stays, shoulder straps, pendulous abdomen design, prefabricated, 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 (Ilfled 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, gluteal/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, longitudinal/metatarsal 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 8½-12) 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 8½-12) 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 8½-12) 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 8½-12) 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 8½-12) 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 8½-12) 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 8½-12) 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 8½-12) 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 8½-12) 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 8½-12) 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, size 8½-12) 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, size 8½-12) 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, size 8½-12) 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, size 8½-12) 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 I.P.	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
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
L3915	NU EP		Wrist hand orthosis, includes one or more nontorsion joint(s), elastic bands, turnbuckles, may include soft interface, straps, prefabricated, included fitting and adjustment	All	N	Manually Priced
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

242.192Specialized Rehabilitative Equipment, All Ages 10-1-07

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

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

** Indicates that providers may bill only for 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	U1	***(Potty Chair - Sm) Commode chair, stationary, with fixed 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
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/Tray & Casters - Lg.) Rollabout chair, any and all types with casters five inches or greater	N	Purchase
E1031**	EP	U4	***(Bolster Chair w/Tray, 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 )

No National Code	M1	Local Code	Description	PA	Payment Method
Bill on paper	NU EP	Z1996	Sm. 51" Supine Stander	Y*	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/Tray - 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

016.06.07 Ark. Code R. § 063

1/9/2008