N.J. Admin. Code § 10:55-2.4
Current through Register Vol. 57, No. 1, January 6, 2025
| HCPCS | Description | Maximum |
|---|---|---|
| Code | Fee | |
| Allowance $ | ||
| (a) PROSTHETIC PROCEDURES--LOWER LIMB (L5000-L5999) | ||
| The procedures in this section are considered as "base" or "basic | ||
| procedures" and may be modified by listing items/procedures or special | ||
| material from the "additions" section and adding them to the base procedure. | ||
| 1. PARTIAL FOOT | ||
| L5000 | Partial foot, shoe insert with longitudinal arch, | 339.53 |
| toe filler | ||
| L5010 | Partial foot, molded socket, ankle height, with | 680.00 |
| toe filler | ||
| L5020 | Partial foot, molded socket, tibial tubercle | 1,040.00 |
| height, with toe filler | ||
| 2. ANKLE | ||
| L5050 | Ankle, Syme, molded socket, Sach foot | 1,360.00 |
| L5060 | Ankle, Syme, metal frame, molded leather socket, | 2,000.00 |
| articulated ankle/foot | ||
| 3. BELOW KNEE | ||
| L5100 | Below knee, molded socket, shin, Sach foot | 1,036.56 |
| L5105 | Below knee, plastic socket, joints and thigh | 2,000.00 |
| lacer, Sach foot | ||
| 4. KNEE DISARTICULATION | ||
| L5150 | Knee disarticulation (or through knee), molded | 2,500.00 |
| socket, external knee joints, shin, Sach foot | ||
| L5160 | Knee disarticulation (or through knee), molded | 2,683.30 |
| socket, bent knee configuration, external knee | ||
| joints, shin, Sach foot | ||
| 5. ABOVE KNEE | ||
| L5200 | Above knee, molded socket, single axis constant | 1,301.76 |
| friction knee, shin, Sach foot | ||
| L5210 | Above knee, short prosthesis, no knee joint | 1,360.00 |
| ("stubbies"), with foot blocks, no ankle joints, each | ||
| L5220 | Above knee, short prosthesis, no knee joint | 1,680.00 |
| ("stubbies"), with articulated ankle/foot, | ||
| dynamically aligned, each | ||
| L5230 | Above knee, for proximal femoral focal deficiency, | 1,607.20 |
| constant friction knee, shin, Sach foot | ||
| 6. HIP DISARTICULATION | ||
| L5250 | Hip disarticulation, Canadian type; molded socket, | 3,040.00 |
| hip joint, single axis constant friction knee, shin | ||
| Sach foot | ||
| L5270 | Hip disarticulation, tilt table type, molded | 3,040.00 |
| socket, locking hip joint, single axis constant | ||
| friction knee, shin, Sach foot | ||
| 7. HEMIPELVECTOMY | ||
| L5280 | Hemipelvectomy, Canadian type; molded socket, hip | 3,440.00 |
| joint, single axis constant friction knee, shin, Sach | ||
| foot | ||
| 8. ENDOSKELETAL: BELOW KNEE | ||
| L5301 | Below knee, molded socket, shin, each foot | 1,379.04 |
| endoskeletal system | ||
| 9. ENDOSKELETAL: KNEE DISARTICULATION | ||
| L5311 | Knee disarticulation (or through knee), molded | 2,129.46 |
| socket, external knee joints, shin, Sach foot, | ||
| endoskeletal system | ||
| 10. ENDOSKELETAL: ABOVE KNEE | ||
| L5321 | Above knee, molded socket, open end, Sach foot, | 2,085.72 |
| endoskeletal system, single axis knee | ||
| 11. ENDOSKELETAL: HIP DISARTICULATION | ||
| L5331 | Hip disarticulation, Canadian type, molded socket, | 2,951.37 |
| endoskeletal system, hip joint, single axis knee, | ||
| each foot | ||
| 12. ENDOSKELETAL: HEMIPELVECTOMY | ||
| L5341 | Hemipelvectomy, Canadian type, molded socket, | 3,231.24 |
| endoskeletal system, hip joint, single axis knee, | ||
| each foot | ||
| 13. IMMEDIATE POSTSURGICAL OR EARLY FITTING PROCEDURES | ||
| L5400 | Immediate postsurgical or early fitting, | 844.78 |
| application of initial rigid dressing, including | ||
| fitting, alignment, suspension, and one cast change, | ||
| below knee | ||
| L5410 | Immediate postsurgical or early fitting, | 328.42 |
| application of initial rigid dressing, including | ||
| fitting, alignment and suspension, below knee, each | ||
| additional cast change and realignment | ||
| L5420 | Immediate postsurgical or early fitting, | 1,070.47 |
| application of initial rigid dressing, including | ||
| fitting, alignment and suspension and one cast change | ||
| "AK" or knee disarticulation | ||
| L5430 | Immediate postsurgical or early fitting, | 461.40 |
| application of initial rigid dressing, including | ||
| fitting, alignment and suspension, "AK" or knee | ||
| disarticulation, each additional cast change and | ||
| realignment | ||
| L5450 | Immediate postsurgical or early fitting, | 200.00 |
| application of nonweight bearing rigid dressing, | ||
| below knee | ||
| L5460 | Immediate postsurgical or early fitting, | 240.00 |
| application of nonweight bearing rigid dressing, | ||
| above knee | ||
| 14. INITIAL PROSTHESIS | ||
| L5500 | Initial, below knee "PTB" type socket, "USMC" or | 726.60 |
| equal pylon, no cover, Sach foot, plaster socket, | ||
| direct formed | ||
| L5505 | Initial, above knee--knee disarticulation, ischial | 980.00 |
| level socket, "USMC" or equal pylon, no cover, Sach | ||
| foot plaster socket, direct formed | ||
| 15. PREPARATORY PROSTHESIS | ||
| L5510 | Preparatory, below knee "PTB" type socket, "USMC" | 726.60 |
| or equal pylon, no cover, Sach foot, plaster socket, | ||
| molded to model | ||
| L5520 | Preparatory, below knee "PTB" type socket, "USMC" | 960.00 |
| or equal pylon, no cover, Sach foot, thermoplastic or | ||
| equal, direct formed | ||
| L5530 | Preparatory, below knee "PTB" type socket, "USMC" | 1,120.00 |
| or equal pylon, no cover, Sach foot, thermoplastic or | ||
| equal, molded to model | ||
| L5535 | Preparatory, below knee "PTB" type socket, "USMC" | 1,000.00 |
| or equal pylon, no cover, Sach foot, prefabricated, | ||
| adjustable open end socket | ||
| L5540 | Preparatory, below knee "PTB" type socket, "USMC" | 1,146.60 |
| or equal pylon, no cover, Sach foot, laminated | ||
| socket, molded to model | ||
| L5560 | Preparatory, above knee--knee disarticulation, | 1,120.00 |
| ischial level socket, "USMC" or equal pylon, no | ||
| cover, Sach foot, plaster socket, molded to model | ||
| L5570 | Preparatory, above knee--knee disarticulation, | 1,200.00 |
| ischial level socket, "USMC" or equal pylon, no | ||
| cover, Sach foot, thermoplastic or equal, direct | ||
| formed | ||
| L5580 | Preparatory, above knee--knee disarticulation, | 1,320.00 |
| ischial level socket, "USMC" or equal pylon, no cover | ||
| Sach foot, thermoplastic or equal, molded to model | ||
| L5585 | Preparatory, above knee--knee disarticulation, | 1,248.88 |
| ischial level socket, "USMC" or equal pylon, no | ||
| cover, Sach foot, prefabricated adjustable open end | ||
| socket | ||
| L5590 | Preparatory, above knee--knee disarticulation, | 1,499.40 |
| ischial level socket, "USMC" or equal pylon, no | ||
| cover, Sach foot, laminated socket, molded to model | ||
| L5595 | Preparatory, hip disarticulation-hemipelvectomy, | 2,120.00 |
| pylon, no cover, Sach foot, thermoplastic or equal, | ||
| molded to patient model | ||
| 16. ADDITIONS TO LOWER EXTREMITY | ||
| L5600 | Preparatory, hip disarticulation-hemipelvectomy, | 2,240.00 |
| pylon, no cover, Sach foot, laminated socket, molded | ||
| to patient model | ||
| L5610 | Addition to lower extremity, above knee, | 1,454.31 |
| hydracadence system | ||
| L5611 | Addition to lower extremity, above knee--knee | 768.00 |
| disarticulation, 4-bar linkage, with friction swing | ||
| phase control | ||
| L5613 | Addition to lower extremity, above knee--knee | 1,240.00 |
| disarticulation, 4-bar linkage, with hydraulic swing | ||
| phase control | ||
| L5614 | Addition to lower extremity, above knee--knee | 2,307.16 |
| disarticulation, 4-bar linkage, with pneumatic swing | ||
| phase control | ||
| L5616 | Additions to lower extremity, above knee, | 720.00 |
| universal multiplex system, friction swing phase | ||
| control | ||
| L5617 | Addition to lower extremity, quick self-aligning | 320.52 |
| unit, above knee or below knee, each | ||
| 17. ADDITIONS: TEST SOCKETS | ||
| L5618 | Addition to lower extremity, test socket, Symes | 160.00 |
| L5620 | Addition to lower extremity, test socket, below | 208.63 |
| knee | ||
| L5622 | Addition to lower extremity, test socket, knee | 264.00 |
| disarticulation | ||
| L5624 | Addition to lower extremity, test socket, above | 240.00 |
| knee | ||
| L5626 | Addition to lower extremity, test socket, hip | 300.00 |
| disarticulation | ||
| L5628 | Addition to lower extremity, test socket, | 340.00 |
| hemipelvectomy | ||
| L5629 | Addition to lower extremity, below knee, acrylic | 289.07 |
| socket | ||
| 18. ADDITIONS: SOCKET VARIATIONS | ||
| L5630 | Addition to lower extremity, Symes type, | 280.00 |
| expandable wall socket | ||
| L5631 | Addition to lower extremity, above knee or knee | 320.00 |
| disarticulation, acrylic socket | ||
| L5632 | Addition to lower extremity, Symes type, "PTB" | 180.02 |
| brim design socket | ||
| L5634 | Addition to lower extremity, Symes type, posterior | 231.74 |
| opening (Canadian) socket | ||
| L5636 | Addition to lower extremity, Symes type, medial | 196.85 |
| opening socket | ||
| L5637 | Addition to lower extremity, below knee, total | 160.00 |
| contact | ||
| L5638 | Addition to lower extremity, below knee, leather | 320.00 |
| socket | ||
| L5639 | Addition to lower extremity, below knee, wood | 600.00 |
| socket | ||
| L5640 | Addition to lower extremity, knee disarticulation, | 400.00 |
| leather socket | ||
| L5642 | Addition to lower extremity, above knee, leather | 400.00 |
| socket | ||
| L5643 | Addition to lower extremity, hip disarticulation, | 691.20 |
| flexible inner socket, external frame | ||
| L5644 | Addition to lower extremity, above knee, wood | 400.00 |
| socket | ||
| L5645 | Addition to lower extremity, below knee, flexible | 325.44 |
| inner socket, external frame | ||
| L5646 | Addition to lower extremity, below knee, air | 260.00 |
| cushion socket | ||
| L5647 | Addition to lower extremity, below knee, suction | 223.74 |
| socket | ||
| L5648 | Addition to lower extremity, above knee, air | 300.00 |
| cushion socket | ||
| L5649 | Addition to lower extremity, ischial | 1,354.99 |
| containment/narrow M-L socket | ||
| L5650 | Addition to lower extremity, total contact, above | 354.91 |
| knee or knee disarticulation socket | ||
| L5651 | Addition to lower extremity, above knee, flexible | 528.84 |
| inner socket, external frame | ||
| L5652 | Addition to lower extremity, suction suspension, | 310.53 |
| above knee or knee disarticulation socket | ||
| L5653 | Addition to lower extremity, knee disarticulation, | 408.96 |
| expandable wall socket | ||
| 19. ADDITIONS SOCKET INSERT AND SUSPENSION | ||
| L5654 | Addition to lower extremity, socket insert, Symes | 231.71 |
| (Kemblo, Pelite, Aliplast, Plastazote or equal) | ||
| L5655 | Addition to lower extremity, socket insert, below | 184.80 |
| knee (Kemblo, Pelite, Aliplast, Plastazote or equal) | ||
| L5656 | Addition to lower extremity, socket insert, knee | 273.00 |
| disarticulation (Kemblo, Pelite, Aliplast, Plastazote | ||
| or equal) | ||
| L5658 | Addition to lower extremity, socket insert, above | 259.38 |
| knee (Kemblo, Pelite, Aliplast, Plastazote or equal) | ||
| L5661 | Addition to lower extremity, socket insert, | 438.84 |
| multi-durometer, Symes | ||
| L5665 | Addition to lower extremity, socket insert, | 223.74 |
| multidurometer, below knee | ||
| L5666 | Addition to lower extremity, below knee, cuff | 40.72 |
| suspension | ||
| L5668 | Addition to lower extremity, below knee, molded | 77.53 |
| distal cushion | ||
| L5670 | Addition to lower extremity, below knee, molded | 199.00 |
| supracondylar suspension ("PTS" or similar) | ||
| L5671 | Addition to lower extremity: below knee, molded | 315.64 |
| supracondylar suspension ("PTS" or similar) | ||
| L5672 | Addition to lower extremity, below knee, removable | 220.00 |
| medial brim suspension | ||
| L5673 | Addition to lower extremity, below knee/above | 506.15 |
| knee, custom fabricated from existing mold or | ||
| prefabricated, socket insert, silicone gel, | ||
| elastomeric or equal, for use with locking mechanisms | ||
| L5676 | Addition to lower extremity, below knee, knee | 178.96 |
| joints, single axis, pair | ||
| L5677 | Addition to lower extremity, below knee, knee | 203.40 |
| joints, polycentric, pair | ||
| L5678 | Addition to lower extremity, below knee joint | 20.00 |
| covers, pair | ||
| L5679 | Addition to lower extremity, below knee/above | 421.77 |
| knee, custom fabricated from existing mold or | ||
| prefabricated, socket insert, silicone gel, | ||
| elastomeric or equal, not for use with locking | ||
| mechanism | ||
| L5680 | Addition to lower extremity, below knee, thigh | 172.88 |
| lacer, nonmolded | ||
| L5681 | Addition to lower extremity, below knee/above | 828.47 |
| knee, custom fabricated socket insert for congenital | ||
| or atypical traumatic amputee, silicone gel | ||
| elastomeric or equal, for use with or without locking | ||
| mechanism, initial only (for other than initial, use | ||
| code L5673 or L5679) | ||
| L5682 | Addition to lower extremity, below knee, thigh | 420.00 |
| lacer, gluteal/ischial, molded | ||
| L5683 | Addition to lower extremity, below knee/above | 828.47 |
| knee, custom fabricated socket insert for other than | ||
| congenital or atypical traumatic amputee, silicone | ||
| gel elastomeric or equal, for use with or without | ||
| locking mechanism, initial only (for other than | ||
| initial, use code L5673 or L5679) | ||
| L5684 | Addition to lower extremity, below knee, fork | 32.56 |
| strap | ||
| L5685 | Addition to lower extremity prosthesis, below | 79.39 |
| knee, suspension/sealing sleeve, with or without | ||
| valve, any material, each | ||
| L5686 | Addition to lower extremity, below knee, back | 32.00 |
| check (extension control) | ||
| L5688 | Addition to lower extremity, below knee, waist | 40.72 |
| belt, webbing | ||
| L5690 | Addition to lower extremity, below knee, waist | 71.62 |
| belt, padded and lined | ||
| L5692 | Addition to lower extremity, above knee, pelvic | 69.20 |
| control belt, light | ||
| L5694 | Addition to lower extremity, above knee, pelvic | 125.53 |
| control belt, padded and lined | ||
| L5695 | Addition to lower extremity, below knee, pelvic | 100.00 |
| control, sleeve suspension, neoprene or equal, Sach | ||
| L5696 | Addition to lower extremity, above knee or knee | 140.00 |
| disarticulation, pelvic joint | ||
| L5697 | Addition to lower extremity, above knee or knee | 32.56 |
| disarticulation, pelvic band | ||
| L5698 | Addition to lower extremity, above knee or knee | 72.40 |
| disarticulation, silesian bandage | ||
| L5699 | All lower extremity prostheses, shoulder harness | 113.40 |
| 20. REPLACEMENTS/ADDITIONS: EXOSKELETAL KNEE-SHIN SYSTEM | ||
| L5700 | Replacement, socket, below knee, molded to patient | 1,549.30 |
| model | ||
| L5701 | Replacement, socket, above knee-knee | 1,922.04 |
| disarticulation, including attachment plate, molded | ||
| to patient model | ||
| L5702 | Replacement, socket, hip disarticulation, | 2,422.44 |
| including hip joint, molded to patient model | ||
| L5703 | Ankle, symes, molded to patient model, socket | 1,468.67 |
| without solid ankle cushion heel (Sach) foot, | ||
| replacement only | ||
| L5704 | Replacement, custom shaped protective cover, below | 315.89 |
| knee | ||
| L5705 | Replacement, custom shaped protective cover, above | 579.14 |
| knee | ||
| L5706 | Replacement, custom shaped protective cover, knee | 564.88 |
| disarticulation | ||
| L5707 | Replacement, custom shaped protective cover, hip | 758.92 |
| disarticulation | ||
| L5710 | Addition, exoskeletal knee-shin system, single | 174.96 |
| axis, manual lock | ||
| L5711 | Addition, exoskeletal knee-shin system, single | 284.80 |
| axis, manual lock, ultra-light material | ||
| L5712 | Addition, exoskeletal knee-shin system, single | 252.00 |
| axis, friction swing and stance phase control (safety | ||
| knee) | ||
| L5714 | Addition, exoskeletal knee-shin system, single | 280.00 |
| axis, variable friction swing phase control (safety | ||
| knee) | ||
| L5716 | Addition, exoskeletal knee-shin system, | 420.00 |
| polycentric, mechanical stance phase lock | ||
| L5718 | Addition, exoskeletal knee-shin system, | 420.00 |
| polycentric, friction swing and stance phase control | ||
| L5722 | Addition, exoskeletal knee-shin system, single | 633.19 |
| axis, pneumatic swing, friction stance phase control | ||
| L5724 | Addition, exoskeletal knee-shin system, single | 880.00 |
| axis, fluid swing phase control | ||
| L5726 | Addition, exoskeletal knee-shin system, single | 1,000.00 |
| axis, external joints fluid swing phase control | ||
| L5728 | Addition, exoskeletal knee-shin system, single | 1,540.00 |
| axis, fluid swing and stance phase control | ||
| L5780 | Addition, exoskeletal knee-shin system, single | 600.00 |
| axis, pneumatic/hydra pneumatic swing phase control | ||
| L5781 | Addition to lower limb prosthesis, vacuum pump, | 2,520.06 |
| residual limb volume management and moisture | ||
| evacuation system | ||
| L5782 | Addition to lower limb prosthesis, vacuum pump, | B.R. |
| residual limb volume management and moisture | ||
| evacuation system, heavy duty | ||
| 21. COMPONENT MODIFICATION | ||
| L5785 | Addition, exoskeletal system, below knee, | 203.40 |
| ultra-light material (titanium, carbon fiber or | ||
| equal) | ||
| L5790 | Addition, exoskeletal system, above knee, | 305.10 |
| ultra-light material (titanium, carbon fiber or | ||
| equal) | ||
| L5795 | Addition, exoskeletal system, hip disarticulation, | 406.80 |
| ultra-light material (titanium, carbon fiber or | ||
| equal) | ||
| 22. ENDOSKELETAL | ||
| L5810 | Addition, endoskeletal knee-shin system, single | 264.62 |
| axis, manual lock | ||
| L5811 | Addition, endoskeletal knee-shin system, single | 325.44 |
| axis, manual lock, ultra-light material | ||
| L5812 | Addition, endoskeletal knee-shin system, single | 284.80 |
| axis, friction swing and stance phase control (safety | ||
| knee) | ||
| L5814 | Addition, endoskeletal knee-shin system, | 400.00 |
| polycentric; hydraulic swing phase control, | ||
| mechanical stance phase lock | ||
| L5816 | Addition, endoskeletal knee-shin system, | 386.46 |
| polycentric, mechanical stance phase lock | ||
| L5818 | Addition, endoskeletal knee-shin system, | 552.00 |
| polycentric, friction swing and stance phase control | ||
| L5822 | Addition, endoskeletal knee-shin system, single | 1,120.00 |
| axis, pneumatic swing, friction stance phase control | ||
| L5824 | Addition, endoskeletal knee-shin system, single | 610.20 |
| axis, fluid swing phase control | ||
| L5826 | Addition, endoskeletal knee-shin system, single | B.R. |
| axis; hydraulic swing phase control, with miniature | ||
| high activity frame. | ||
| L5828 | Addition, endoskeletal knee-shin system, single | 1,440.00 |
| axis, fluid swing and stance phase control | ||
| L5830 | Addition, endoskeletal knee-shin system, single | 1,076.00 |
| axis, pneumatic/swing phase control | ||
| L5840 | Addition, endoskeletal knee-shin system, | 1,262.80 |
| multi-axial, pneumatic/swing phase control | ||
| L5845 | Addition, endoskeletal, knee-shin system, stance | 2,211.66 |
| flexion feature, adjustable | ||
| L5848 | Addition to endoskeletal, knee-shin system, | 677.28 |
| hydraulic stance extension, dampening feature, | ||
| adjustable | ||
| L5850 | Addition, endoskeletal system, above knee or hip | 64.80 |
| disarticulation, knee extension assist | ||
| L5855 | Addition, endoskeletal system, hip | 171.52 |
| disarticulation, mechanical hip extension assist | ||
| L5856 | Addition to lower extremity prosthesis, | 15,188.22 |
| endoskeletal knee-shin system, microprocessor control | ||
| feature, swing and stance phase includes electronic | ||
| sensor(s), any type | ||
| L5857 | Addition to lower extremity prosthesis, | 5,347.34 |
| endoskeletal knee-shin system, microprocessor control | ||
| feature, swing phase only, includes electronic | ||
| sensor(s), any type | ||
| L5858 | Addition to lower extremity prosthesis, | 11,519.80 |
| endoskeletal knee shin system, microprocessor control | ||
| feature, stance phase only, includes electronic | ||
| sensor(s), any type | ||
| L5910 | Addition, endoskeletal system, below knee, | 280.25 |
| alignable system | ||
| L5920 | Addition, endoskeletal system, above knee or hip | 252.00 |
| disarticulation, alignable system | ||
| L5925 | Addition, endoskeletal system, above knee, knee | 186.61 |
| disarticulation or hip disarticulation, manual lock | ||
| L5930 | Addition, endoskeletal system, high activity knee | 1,928.18 |
| control frame | ||
| L5940 | Addition, endoskeletal system, below knee, | 224.00 |
| ultra-light material (titanium, carbon fiber or | ||
| equal) | ||
| L5950 | Addition, endoskeletal system, above knee, | 500.00 |
| ultra-light material (titanium, carbon fiber or | ||
| equal) | ||
| L5960 | Addition, endoskeletal system, hip | 467.82 |
| disarticulation, ultra-light material (titanium, | ||
| carbon fiber or equal) | ||
| L5962 | Addition, endoskeletal system, below knee, | 326.45 |
| flexible protective outer surface covering system | ||
| L5964 | Addition, endoskeletal system, above knee, | 566.20 |
| flexible protective outer surface covering system | ||
| L5966 | Addition, endoskeletal system, hip | 729.36 |
| disarticulation, flexible protective outer surface | ||
| covering system | ||
| L5968 | All lower extremity prosthesis; ankle, multiaxial | 1,958.73 |
| shock absorbing system | ||
| L5970 | All lower extremity prostheses, foot, external | 78.40 |
| keel, Sach foot | ||
| L5971 | All lower extremity prosthesis, solid ankle | 128.23 |
| cushion heel (Sach) foot, replacement only | ||
| L5972 | All lower extremity prostheses, flexible keel foot | 122.40 |
| (Safe, Sten, Bock Dynamic or equal) | ||
| L5974 | All lower extremity prostheses, foot, single axis | 109.60 |
| ankle/foot | ||
| L5975 | All lower extremity prosthesis; combination single | 249.89 |
| axis ankle and flexible kneel foot | ||
| L5976 | All lower extremity prostheses, energy storing | 284.80 |
| foot (Seattle Carbon Copy II or equal) | ||
| L5978 | All lower extremity prostheses, foot, multi-axial | 135.20 |
| ankle/foot | ||
| L5979 | All lower extremity prostheses, multi-axial | 1,267.27 |
| ankle/foot, dynamic response | ||
| L5980 | All lower extremity prostheses, flex-foot system | 2,033.60 |
| L5981 | All lower extremity prostheses, flex-walk system | 1,723.48 |
| or equal | ||
| L5982 | All exoskeletal lower extremity prostheses, axial | 406.40 |
| rotation unit | ||
| L5984 | All endoskeletal lower extremity prostheses, axial | 304.80 |
| rotation unit | ||
| L5985 | All endoskeletal lower extremity prostheses, | 362.49 |
| dynamic prosthetic pylon | ||
| L5986 | All lower extremity prostheses, multi-axial | 304.80 |
| rotation unit ("MCP" or equal) | ||
| L5987 | All lower extremity prostheses, shank foot system | 4,152.19 |
| with vertical loading pylon | ||
| L5988 | All lower extremity prosthesis, combination | 1,076.78 |
| vertical shock and multiaxial rotation/torsional | ||
| force reducing pylon | ||
| L5990 | Addition to lower extremity prosthesis; user | 1,130.21 |
| adjustable heel height | ||
| L5999 | Unlisted procedures for lower extremity prosthesis | B.R. |
| (b) UPPER LIMB (L6000-L6699) | ||
| The procedures in L6000-L6699 are base procedures which may be modified | ||
| by listing procedures from the "additions" sections. The base procedures | ||
| include only standard friction wrist and control cable system, unless | ||
| otherwise specified. | ||
| 1. PARTIAL HAND | ||
| L6000 | Partial hand, Robin-aids, thumb remaining (or | 924.32 |
| equal) | ||
| L6010 | Partial hand, Robin-aids, little and/or ring | 1,000.00 |
| finger remaining (or equal) | ||
| L6020 | Partial hand, Robin-aids, no finger remaining (or | 953.27 |
| equal) | ||
| L6025 | Transcarpal/metacarpal or partial hand | 5040.17 |
| disarticulation prosthesis, external power, | ||
| self-suspended, inner socket with removable forearm | ||
| section, electrodes and cables, two batteries, | ||
| charger, myoelectric control of terminal device | ||
| 2. WRIST DISARTICULATION | ||
| L6050 | Wrist disarticulation, molded socket, flexible | 1,120.00 |
| elbow hinges, triceps pad | ||
| L6055 | Wrist disarticulation, molded socket with | 1,287.00 |
| expandable interface, flexible elbow hinges, triceps | ||
| pad | ||
| 3. BELOW ELBOW | ||
| L6100 | Below elbow, molded socket, flexible elbow hinge, | 1,120.00 |
| triceps pad | ||
| L6110 | Below elbow, molded socket (Muenster or | 1,420.00 |
| Northwestern suspension types) | ||
| L6120 | Below elbow, molded double wall split socket, | 1,520.00 |
| step-up hinges, half cuff | ||
| L6130 | Below elbow, molded double wall split socket, | 1,975.33 |
| stump activated locking hinge, half cuff | ||
| 4. ELBOW DISARTICULATION | ||
| L6200 | Elbow disarticulation, molded socket, outside | 1,504.00 |
| locking hinge, forearm | ||
| L6205 | Elbow disarticulation, molded socket with | 2,522.40 |
| expandable interface, outside locking hinges, forearm | ||
| 5. ABOVE ELBOW | ||
| L6250 | Above elbow, molded double wall socket, internal | 1,760.00 |
| locking elbow, forearm | ||
| 6. SHOULDER DISARTICULATION | ||
| L6300 | Shoulder disarticulation, molded socket, shoulder | 2,120.00 |
| bulkhead, humeral section, internal locking elbow | ||
| forearm | ||
| L6310 | Shoulder disarticulation, passive restoration | 1,840.00 |
| (complete prosthesis) | ||
| L6320 | Shoulder disarticulation, passive restoration | 1,200.00 |
| (shoulder cap only) | ||
| 7. INTERSCAPULAR THORACIC | ||
| L6350 | Interscapular thoracic, molded socket, shoulder | 2,380.00 |
| bulkhead, humeral section, internal locking elbow, | ||
| forearm | ||
| L6360 | Interscapular thoracic, passive restoration | 1,545.84 |
| (complete prosthesis) | ||
| L6370 | Interscapular thoracic, passive restoration | 1,400.00 |
| (shoulder cap only) | ||
| 8. IMMEDIATE AND EARLY POST SURGICAL PROCEDURES | ||
| L6380 | Immediate postsurgical or early fitting, | 691.56 |
| application of initial rigid dressing, including | ||
| fitting alignment and suspension of components, and | ||
| one cast change, wrist disarticulation or below elbow | ||
| L6382 | Immediate postsurgical or early fitting, | 813.60 |
| application of initial rigid dressing, including | ||
| fitting alignment and suspension of components, and | ||
| one cast change, elbow disarticulation or above elbow | ||
| L6384 | Immediate postsurgical or early fitting, | 976.00 |
| application of initial rigid dressing, including | ||
| fitting alignment and suspension of components, and | ||
| one cast change, shoulder disarticulation or | ||
| interscapular thoracic | ||
| L6386 | Immediate postsurgical or early fitting, each | 223.74 |
| additional cast change and realignment | ||
| L6388 | Immediate postsurgical or early fitting, | 203.40 |
| application of rigid dressing only | ||
| 9. ENDOSKELETAL: BELOW ELBOW | ||
| L6400 | Below elbow, molded socket, endoskeletal system, | 1,204.00 |
| including soft prosthetic tissue shaping | ||
| 10. ENDOSKELETAL: ELBOW DISARTICULATION | ||
| L6450 | Elbow disarticulation, molded socket, endoskeletal | 1,301.60 |
| system, including soft prosthetic tissue shaping | ||
| 11. ENDOSKELETAL: ABOVE ELBOW | ||
| L6500 | Above elbow, molded socket, endoskeletal system, | 1,512.00 |
| including soft prosthetic tissue shaping | ||
| 12. ENDOSKELETAL: SHOULDER DISARTICULATION | ||
| L6550 | Shoulder disarticulation, molded socket, | 1,760.00 |
| endoskeletal system, including soft prosthetic tissue | ||
| shaping | ||
| 13. ENDOSKELETAL: INTERSCAPULAR THORACIC | ||
| L6570 | Interscapular thoracic, molded socket, | 2,160.00 |
| endoskeletal system, including soft prosthetic tissue | ||
| shaping | ||
| L6580 | Preparatory, wrist disarticulation or below elbow, | 813.60 |
| single wall plastic socket, friction wrist, flexible | ||
| elbow hinges, figure of eight harness, humeral cuff, | ||
| Bowen cable control, "USMC" or equal pylon, no cover, | ||
| molded to patient model | ||
| L6582 | Preparatory, wrist disarticulation or below elbow, | 691.56 |
| single wall socket, friction wrist, flexible elbow | ||
| hinges, figure of eight harness, humeral cuff, Bowen | ||
| cable control, "USMC" or equal pylon, no cover, | ||
| direct formed | ||
| L6584 | Preparatory, elbow disarticulation or above elbow, | 1,159.38 |
| single wall plastic socket, friction wrist, locking | ||
| elbow, figure of eight harness, fair lead cable | ||
| control, "USMC" or equal pylon, no cover, molded to | ||
| patient model | ||
| L6586 | Preparatory, elbow disarticulation or below elbow, | 996.66 |
| single wall socket, friction wrist, locking elbow, | ||
| figure of eight harness, humeral cuff, fair lead | ||
| cable control, "USMC" or equal pylon, no cover, | ||
| direct formed | ||
| L6588 | Preparatory, shoulder disarticulation or | 1,732.80 |
| interscapular thoracic, single wall plastic socket, | ||
| shoulder joint, locking elbow, friction wrist, chest | ||
| strap, fair lead cable control, "USMC" or equal | ||
| pylon, no cover, molded to patient model | ||
| L6590 | Preparatory, shoulder disarticulation or | 1,586.40 |
| interscapular thoracic, single wall socket, shoulder | ||
| joint, locking elbow, friction wrist, chest strap, | ||
| fair lead cable control, "USMC" or equal pylon, no | ||
| cover, direct formed | ||
| 14. ADDITIONS: UPPER LIMB | ||
| The following procedures/modifications/components may be added to other | ||
| base procedures. The items in this section should reflect the additional | ||
| complexity of each modification procedure, in addition to base procedure, at | ||
| the time of the original order. | ||
| L6600 | Upper extremity additions, polycentric hinge, pair | 52.00 |
| L6605 | Upper extremity additions, single pivot hinge, | 116.00 |
| pair | ||
| L6610 | Upper extremity additions, flexible metal hinge, | 46.00 |
| pair | ||
| L6611 | Addition to upper extremity prosthesis, external | 255.21 |
| powered, additional switch, any type | ||
| L6615 | Upper extremity addition, disconnect locking wrist | 60.00 |
| unit | ||
| L6616 | Upper extremity addition, additional disconnect | 59.89 |
| insert for locking wrist unit, each | ||
| L6620 | Upper extremity addition, flexion-friction wrist | 211.56 |
| unit | ||
| L6621 | Flexion/extension wrist with or without friction, | 2,334.37 |
| for use with external powered terminal device | ||
| L6623 | Upper extremity addition, spring assisted | 386.40 |
| rotational wrist unit with latch release | ||
| L6624 | Flexion/extension and rotation wrist unit | 2,334.37 |
| L6625 | Upper extremity addition, rotation wrist unit with | 160.00 |
| cable lock | ||
| L6628 | Upper extremity addition, quick disconnect hook | 284.76 |
| adapter, Otto Bock or equal | ||
| L6629 | Upper extremity addition, quick disconnect | 73.22 |
| lamination collar with coupling piece, Otto Bock or | ||
| equal | ||
| L6630 | Upper extremity addition, stainless steel, any | 68.00 |
| wrist | ||
| L6632 | Upper extremity addition, latex suspension sleeve, | 32.54 |
| each | ||
| L6635 | Upper extremity addition, lift assist for elbow | 152.48 |
| L6637 | Upper extremity addition, nudge control elbow lock | 251.68 |
| L6638 | Upper extremity addition to prosthesis, electric | 1,575.48 |
| locking feature, only for use with manually powered | ||
| elbow | ||
| L6640 | Upper extremity additions, shoulder abduction | 130.40 |
| joint, pair | ||
| L6641 | Upper extremity addition, excursion amplifier, | 97.60 |
| pulley type | ||
| L6642 | Upper extremity addition, excursion amplifier, | 138.40 |
| lever type | ||
| L6645 | Upper extremity addition, shoulder | 65.00 |
| flexion-abduction joint, each | ||
| L6646 | Upper extremity addition, shoulder joint, | 1,986.49 |
| multipositional locking, flexion, adjustable | ||
| abduction friction control, for use with body powered | ||
| or external powered system | ||
| L6647 | Upper extremity addition, shoulder lock mechanism, | 327.03 |
| body powered actuator | ||
| L6648 | Upper extremity addition, shoulder lock mechanism, | 2,048.78 |
| external powered actuator | ||
| L6650 | Upper extremity addition, shoulder universal | 200.00 |
| joint, each | ||
| L6655 | Upper extremity addition, standard control cable, | 35.00 |
| extra | ||
| L6660 | Upper extremity addition, heavy duty control cable | 56.00 |
| L6665 | Upper extremity addition, Teflon, or equal, cable | 24.00 |
| lining | ||
| L6670 | Upper extremity addition, hook to hand, cable | 43.40 |
| adapter | ||
| L6672 | Upper extremity addition, harness, chest or | 108.00 |
| shoulder, saddle type | ||
| L6675 | Upper extremity addition, harness, figure of ("8") | 80.42 |
| eight type, for single control | ||
| L6676 | Upper extremity addition, harness, figure of ("8") | 86.32 |
| eight type, for dual control | ||
| L6677 | Harness, triple control, simultaneous operation of | 183.87 |
| terminal device and elbow | ||
| L6680 | Upper extremity addition, test socket, wrist | 160.00 |
| disarticulation or below elbow | ||
| L6682 | Upper extremity addition, test socket, elbow | 180.00 |
| disarticulation or above elbow | ||
| L6684 | Upper extremity addition, test socket, shoulder | 148.00 |
| disarticulation or interscapular thoracic | ||
| L6686 | Upper extremity addition, suction socket | 406.80 |
| L6687 | Upper extremity addition, frame type socket, below | 244.08 |
| elbow or wrist disarticulation | ||
| L6688 | Upper extremity addition, frame type socket, above | 284.76 |
| elbow or elbow disarticulation | ||
| L6689 | Upper extremity addition, frame type socket, | 325.60 |
| shoulder disarticulation | ||
| L6690 | Upper extremity addition, frame type socket, | 366.40 |
| interscapular-thoracic | ||
| L6691 | Upper extremity addition, removable insert, each | 244.08 |
| L6692 | Upper extremity addition, silicone gel insert or | 240.00 |
| equal, each | ||
| L6693 | Upper extremity additions; external locking elbow, | 1,530.26 |
| forearm counter balance | ||
| L6694 | Addition to upper extremity prosthesis, below | 421.90 |
| elbow/above elbow, custom fabricated from existing | ||
| mold or prefabricated, socket insert, silicone gel, | ||
| elastomeric or equal, for use with locking mechanism | ||
| L6695 | Addition to upper extremity prosthesis, below | |
| elbow/above elbow, custom fabricated from existing | 351.58 | |
| mold or prefabricated, socket insert, silicone gel, | ||
| elastomeric or equal, not for use with locking | ||
| mechanism | ||
| L6696 | Addition to upper extremity prosthesis, below | 815.32 |
| elbow/above elbow, custom fabricated socket insert | ||
| for congenital or atypical traumatic amputee, | ||
| silicone gel, elastomeric or equal, for use with or | ||
| without locking mechanism, initial only (for other | ||
| than initial, use code L6694 or L6695) | ||
| L6697 | Addition to upper extremity prosthesis, below | 815.32 |
| elbow/above elbow, custom fabricated socket insert | ||
| for other than congenital or atypical traumatic | ||
| amputee, silicone gel, elastomeric or equal, for use | ||
| with or without locking mechanism, initial only (for | ||
| other than initial, use code L6694 or L6695) | ||
| L6698 | Addition to upper extremity prosthesis, below | 314.06 |
| elbow/above elbow, lock mechanism, excludes socket | ||
| insert | ||
| (c) TERMINAL DEVICES (L6700-L6899) | ||
| 1. HOOKS | ||
| L6703 | Terminal device, passive hand/mitt, any material, | 273.68 |
| any size | ||
| L6704 | Terminal device, sport/recreational/work | 370.47 |
| attachment, any material, any size | ||
| L6706 | Terminal device, hook, mechanical, voluntary | 220.31 |
| opening, any material, any size, lined or unlined | ||
| L6707 | Terminal device, hook, mechanical, voluntary | 865.54 |
| closing, any material, any size, lined or unlined | ||
| L6708 | Terminal device, hand, mechanical, voluntary | 580.03 |
| opening, any material, any size | ||
| L6709 | Terminal device, hand, mechanical, voluntary | 776.50 |
| closing, any material, any size | ||
| L6711 | Terminal device, hook, mechanical, voluntary | 416.72 |
| opening, any material, any size, lined or unlined, | ||
| pediatric | ||
| L6712 | Terminal device, hook, mechanical, voluntary | 767.27 |
| closing, any material, any size, lined or unlined, | ||
| pediatric | ||
| L6713 | Terminal device, hand, mechanical, voluntary | 968.38 |
| opening, any material, any size, pediatric | ||
| L6714 | Terminal device, hand, mechanical, voluntary | 820.20 |
| closing, any material, any size, pediatric | ||
| L6721 | Terminal device, hook or hand, heavy duty, size, | 1,457.83 |
| mechanical, voluntary opening, any material, any | ||
| lined or unlined | ||
| L6722 | Terminal device, hook or hand, heavy duty, | 1,256.77 |
| mechanical, voluntary closing, any material, any | ||
| size, lined or unlined | ||
| L6810 | Terminal device, pincher tool, Otto Bock or equal | 104.24 |
| 2. HANDS | ||
| L6881 | Automatic grasp feature, addition to upper limb | 2,546.90 |
| electric prosthetic terminal device | ||
| L6882 | Microprocessor control feature, addition to upper | 1,931.94 |
| limb prosthetic terminal device (MCM:2133) | ||
| L6883 | Replacement socket, below elbow/wrist | 1,335.93 |
| disarticulation, molded to patient model, for use | ||
| with or without external power | ||
| L6884 | Replacement socket, above elbow/elbow with or | 1,469.13 |
| disarticulation, molded to patient model, for use | ||
| without external power | ||
| L6885 | Replacement socket, shoulder | 2,011.10 |
| disarticulation/interscapular thoracic, molded to | ||
| patient model, for use with or without external power | ||
| 3. GLOVES FOR ABOVE HANDS | ||
| L6890 | Terminal device, glove for above hands, | 84.00 |
| production, glove | ||
| L6895 | Terminal device, glove for above hands, custom | 296.00 |
| glove | ||
| (d) HAND RESTORATION (L6900-L6999) | ||
| L6900 | Hand restoration (casts, shading and measurements | 1,000.00 |
| included), partial hand, with glove, thumb or one | ||
| finger remaining | ||
| L6905 | Hand restoration (casts, shading and measurements | 1,000.00 |
| included), partial hand, with glove, multiple fingers | ||
| remaining) | ||
| L6910 | Hand restoration (casts, shading and measurements | 1,000.00 |
| included), partial hand, with glove, no fingers | ||
| remaining | ||
| L6915 | Hand restoration (shading and measurements | 320.00 |
| included), replacement glove for above | ||
| 1. EXTERNAL POWER--BASE DEVICES | ||
| L6920 | Wrist disarticulation, external power, | 3,789.90 |
| self-suspended inner socket, removable forearm shell, | ||
| Otto Bock or equal, switch, cables, two batteries and | ||
| one charger, switch control of terminal device | ||
| L6925 | Wrist disarticulation, external power, | 4,350.58 |
| self-suspended inner socket, removable forearm shell, | ||
| Otto Bock or equal, electrodes, cables, two batteries | ||
| and one charger, myoelectronic control of terminal | ||
| device | ||
| L6930 | Below elbow, external power, self-suspended inner | 3,807.50 |
| socket, removable forearm shell, Otto Bock or equal, | ||
| switch, cables, two batteries and one charger, switch | ||
| control of terminal device | ||
| L6935 | Below elbow, external power, self-suspended inner | 4,384.65 |
| socket, removable forearm shell, Otto Bock or equal, | ||
| electrodes, cables, two batteries and one charger, | ||
| myoelectronic control of terminal device | ||
| L6940 | Elbow disarticulation, external power, molded | 5,210.69 |
| inner socket, removable humeral shell, outside | ||
| locking hinges, forearm, Otto Bock or equal, switch, | ||
| cables, two batteries and one charger, switch control | ||
| of terminal device | ||
| L6945 | Elbow disarticulation, external power, molded | 5,780.01 |
| inner socket, removable humeral shell, outside | ||
| locking hinges, forearm, Otto Bock or equal, | ||
| electrodes, cables, two batteries and one charger, | ||
| myoelectronic control of terminal device | ||
| L6950 | Above elbow, external power, molded inner socket, | 5,761.18 |
| removable humeral shell, internal locking elbow | ||
| forearm, Otto Bock or equal, switch, cables, two | ||
| batteries and one charger, switch control of terminal | ||
| device | ||
| L6955 | Above elbow, external power, molded inner socket, | 6,850.89 |
| removable humeral shell, internal locking elbow, | ||
| forearm, Otto Bock or equal, electrodes, cables, two | ||
| batteries and one charger, myoelectronic control of | ||
| terminal device | ||
| L6960 | Shoulder disarticulation, external power, molded | 6,950.69 |
| inner socket, removable shoulder shell, shoulder | ||
| bulkhead, humeral section, mechanical elbow forearm, | ||
| Otto Bock or equal, switch, cables, two batteries and | ||
| one charger, switch control of terminal device | ||
| L6965 | Shoulder disarticulation, external power, molded | 7,934.50 |
| inner socket, removable shoulder shell, shoulder | ||
| bulkhead, humeral section, mechanical elbow, forearm, | ||
| Otto Bock or equal, electrodes, cables, two batteries | ||
| and one charger myoelectronic control of terminal | ||
| device | ||
| L6970 | Interscapular-thoracic, external power, molded | 8,475.55 |
| inner socket, removable shoulder shell, shoulder | ||
| bulkhead, humeral section, mechanical elbow, forearm, | ||
| Otto Bock or equal, switch, cables, two batteries and | ||
| one charger, switch control of terminal device | ||
| L6975 | Interscapular-thoracic, external power, molded | 9,418.54 |
| inner socket, removable shoulder shell, shoulder | ||
| bulkhead, humeral section, mechanical elbow, forearm, | ||
| Otto Bock or equal, electrodes, cables, two batteries | ||
| and one charger, myoelectronic control of terminal | ||
| device | ||
| (e) EXTERNAL POWER--TERMINAL DEVICES (L7000-L7499) | ||
| L7008 | Electric hand, switch or myoelectric controlled; | 3,880.11 |
| pediatric | ||
| L7009 | Electric hook, switch or myoelectric controlled; | 2,348.40 |
| adult | ||
| L7040 | Prehensile actuator, Hosmer or equal, switch | 1,616.36 |
| controlled | ||
| L7045 | Electronic hook, child, Michigan or equal, switch | 854.01 |
| controlled | ||
| 1. EXTERNAL POWER--ELBOW | ||
| L7170 | Electronic elbow, Hosmer or equal, switch | 3,238.90 |
| controlled | ||
| L7180 | Electronic elbow, Utah or equal, myoelectronically | 19,382.46 |
| controlled | ||
| L7181 | Electronic elbow, microprocessor simultaneous | B.R. |
| control of elbow and terminal device | ||
| L7185 | Electronic elbow, adolescent, Variety Village or | 3,625.58 |
| equal, switch controlled | ||
| L7186 | Electronic elbow, child, Variety Village or equal, | 4,800.00 |
| switch controlled | ||
| L7190 | Electronic elbow, adolescent, Variety Village or | 5,177.71 |
| equal, myoelectronically controlled | ||
| L7191 | Electronic elbow, child, Variety Village or equal, | 5,072.00 |
| myoelectronically controlled | ||
| L7260 | Electronic wrist rotator, Otto Bock or equal | 1,342.44 |
| L7261 | Electronic wrist rotator, for Utah arm | 2,000.62 |
| L7266 | Servo control, Steeper or equal | 554.90 |
| L7272 | Analogue control, UNB or equal | 1,216.24 |
| L7274 | Proportional control, 12 volt, Utah or equal | 3,666.11 |
| 2. EXTERNAL POWER--BATTERY COMPONENTS | ||
| L7360 | Six volt battery, Otto Bock or equal, each | 167.90 |
| L7362 | Battery charger, six volt, Otto Bock or equal | 150.23 |
| L7364 | Twelve volt battery, Utah or equal, each | 296.74 |
| L7366 | Battery charger, twelve volt, Utah or equal | 398.67 |
| L7367 | Lithium ion battery, replacement | 245.20 |
| L7368 | Lithium ion battery charger | 317.88 |
| L7400 | Addition to upper extremity prosthesis; below | 189.97 |
| elbow/wrist disarticulation, ultralight material | ||
| (titanium, carbon fiber or equal) | ||
| L7401 | Above elbow disarticulation, ultralight material | 212.67 |
| (titanium, carbon fiber or equal) | ||
| L7402 | Shoulder disarticulation/interscapular thoracic, | 212.67 |
| ultralight material (titanium, carbon fiber or equal) | ||
| L7403 | Below elbow/wrist disarticulation, acrylic | 228.26 |
| material | ||
| L7404 | Above elbow disarticulation, acrylic material | 344.51 |
| L7405 | Shoulder disarticulation/interscapular thoracic, | 450.58 |
| acrylic material | ||
| L7499 | Unlisted procedures for upper extremity prosthesis | B.R. |
| (f) REPAIRS (L7500-L7599 AND X3680-3690) | ||
| L7500 | Repair of prosthetic device, hourly rate | 40.72 |
| L7510 | Repair prosthetic device, repair or replace minor | B.R. |
| parts | ||
| X3680 | Travel time per round trip, per day | 40.72 |
| (g) GENERAL (L8000-L8399) | ||
| 1. BREAST PROSTHESES | ||
| L8000 | Breast prosthesis, mastectomy bra | B.R. |
| L8001 | Breast prosthesis, mastectomy bra, with integrated | B.R. |
| breast prosthesis form, unilateral (MCM: 2130.A) | ||
| L8002 | Breast prosthesis, mastectomy bra, with integrated | 102.72 |
| breast prosthesis form, bilateral (MM:2130.A) | ||
| L8010 | Breast prosthesis, mastectomy sleeve | 40.56 |
| L8015 | External breast prosthesis garment, with | 30.58 |
| mastectomy form, post mastectomy | ||
| L8020 | Breast prosthesis, mastectomy form | 132.00 |
| L8030 | Breast prosthesis, silicone or equal | B.R. |
| L8035 | Custom breast prosthesis, post mastectomy, molded | 1,974.74 |
| to patient model | ||
| L8039 | Breast prosthesis; not otherwise specified | B.R. |
| 2. TRUSSES | ||
| L8300 | Truss, single with standard pad | 51.28 |
| L8310 | Truss, double with standard pads | 101.68 |
| L8320 | Truss, addition to standard pad, water pad | 24.00 |
| L8330 | Truss, addition to standard pad, scrotal pad | 33.65 |
| (h) PROSTHETIC SOCKS (L8400-L8499) | ||
| L8400 | Prosthetic sheath, below knee, each | 12.00 |
| L8410 | Prosthetic sheath, above knee, each | 12.00 |
| L8415 | Prosthetic sheath, upper limb, each | 11.20 |
| L8417 | Prosthetic sheath/sock, including a gel cushion | 59.09 |
| layer, below knee or above knee, each | ||
| L8420 | Prosthetic sock, wool, below knee, each | 14.94 |
| L8430 | Prosthetic sock, wool, above knee, each | 18.40 |
| L8435 | Prosthetic sock, wool, upper limb, each | 8.14 |
| L8440 | Prosthetic shrinker, below knee, each | 33.60 |
| L8460 | Prosthetic shrinker, above knee, each | 41.60 |
| L8465 | Prosthetic shrinker, upper limb, each | 33.60 |
| L8470 | Stump sock, single ply, fitting, below knee, each | 2.52 |
| L8480 | Stump sock, single ply, fitting, above knee, each | 2.52 |
| L8485 | Stump sock, single ply, fitting, upper limb, each | 6.21 |
| L8499 | Unlisted procedure for miscellaneous prosthetic | B.R. |
| services | ||
| (i) HEAD (SKULL, FACIAL BONES AND TEMPEROMANDIBULAR JOINT) | ||
| L8619 | Cochlear implant external speech processor, | |
| replacement | B.R. | |
| (j) MISCELLANEOUS | ||
| L7600 | Prosthetic donning sleeve, any material, each | B.R. |
| L8470 | Orthotic and prosthetic supply, accessory and/or | |
| service component of another HCPCS "L" Code | B.R | |
N.J. Admin. Code § 10:55-2.4
See: 30 N.J.R. 512(a), 30 N.J.R. 2919(a).
In (a), added new Codes; and a new (i).
Amended by R.1999 d.40, effective 2/1/1999.
See: 30 N.J.R. 3897(a), 31 N.J.R. 439(a).
In (a), inserted L5826; and in (g), inserted L8039 and L8239.
Amended by R.1999 d.391, effective 11/15/1999.
See: 31 N.J.R. 2291(b), 31 N.J.R. 3635(a).
In (a), inserted L5968, L5975 and L5988; in (b), inserted L6693; and in (g), changed fee allowances in L8000 and L8030, and inserted L8015 and L8035.
Amended by R.2000 d.463, effective 11/20/2000.
See: 32 N.J.R. 2974(a), 32 N.J.R. 4108(a).
In (a), deleted a reference to X3540; and added (j).
Amended by R.2004 d.406, effective 11/1/2004.
See: 35 N.J.R. 4417(a), 36 N.J.R. 4963(a).
Rewrote the section.
Amended by R.2005 d.312, effective 9/19/2005.
See: 37 N.J.R. 933(a), 37 N.J.R. 3697(a).
Rewrote (a)-(e) and (g).
Amended by R.2009 d.93, effective 3/16/2009.
See: 40 N.J.R. 3912(a), 41 N.J.R. 1245(a).
In the introductory language of (f), inserted "AND X3680-3690"; and in the "Description" column of entry "X3680" in the table in (f), substituted "round trip, per day" for "hour (specify time involved)".
Amended by R.2011 d.080, effective 3/7/2011.
See: 42 N.J.R. 2179(a), 43 N.J.R. 622(a).
Rewrote (a)8 through (a)12, (a)18 through (a)20, (a)22, (b)14, (c)1, (c)2, (e) through (h), and (j).