Prosthetics Section II - Arkansas
|Section ii - Prosthetics | |
|CONTENTS | |
200.000 GENERAL INFORMATION
201.000 Arkansas Medicaid Participation Requirements for Prosthetics Providers
201.100 Providers in Arkansas and Bordering States
201.110 Routine Services Provider
201.200 Providers in Non-Bordering States
201.210 Limited Services Provider
202.000 The Prosthetics Provider Role in the Child Health Services (EPSDT) Program
203.000 Documentation Requirements
203.100 Documentation in Beneficiary’s Case Files
203.200 Reserved
203.300 Reserved
204.000 Electronic Signatures
210.000 PROGRAM COVERAGE
211.000 Scope
211.100 Condition for Provision of Services
211.200 Physician’s Role in the Prosthetics Program
211.300 Prosthetics Service Provision
211.400 Prescription and Referral Renewal
211.500 Service Initiation Delays
211.600 Termination of Services
211.700 Exclusions
211.800 Electronic Filing of Extension of Benefits
212.000 Services Provided
212.100 Diapers and Underpads for Individuals Age 3 and Older
212.200 Durable Medical Equipment (DME), All Ages
212.201 (DME) Apnea Monitors for Infants Under Age 1
212.202 (DME) Speech Generating Device (SGD), All Ages
212.203 Cochlear Implants for Beneficiaries Under Age 21
212.204 (DME) Electronic Blood Pressure Monitor and Cuff for Beneficiaries of All Ages
212.205 (DME) Enteral Nutrition Infusion Pump and Enteral Feeding Pump Supply Kit for Beneficiaries Under Age 21
212.206 (DME) Home Blood Glucose Monitor, Pregnant Women Only, All Ages
212.207 (DME) Insulin Pump and Supplies, All Ages
212.208 Reserved
212.209 (DME) Low-Profile Skin Level Gastrostomy Tube (Low-Profile Button) and Supplies for Beneficiaries of All Ages
212.210 DME Low-Profile Percutaneous Cecostomy Tube (Low-Profile Button) for Beneficiaries of All Ages
212.211 Reserved
212.212 (DME) Specialized Rehabilitative Equipment, All Ages
212.213 (DME) Specialized Wheelchairs and Wheelchair Seating Systems for Individuals Age Two Through Adult
212.214 Reserved
212.300 Medical Supplies, All Ages
212.400 Nutritional Formulae for Individuals Under Age 21
212.500 Food Thickeners, All Ages
212.600 Orthotic Appliances and Prosthetic Devices, All Ages
212.700 Oxygen and Oxygen Supplies, All Ages
220.000 PRIOR AUTHORIZATION
221.000 Prosthetics Services Prior Authorization
221.100 Request for Prior Authorization
221.200 Filing for Prior Authorization
221.300 Approvals of Prior Authorization
221.400 Denial of Prior Authorization Request
221.500 Reconsideration of Denials
221.600 Fair Hearing Request
230.000 REIMBURSEMENT
231.000 Prosthetics Service Method of Reimbursement
231.010 Fee Schedule
232.000 Specialized Wheelchair, Seating and Rehabilitative Equipment Reimbursement for Repairs
233.000 Orthotic and Prosthetic Reimbursement for Repairs
234.000 Durable Medical Equipment (DME) Reimbursement for Repairs
235.000 Speech Generating Device Reimbursement for Repairs
236.000 Reimbursement for Repair of the Enteral Nutrition Pump
237.000 Rate Appeal Process
240.000 billing procedures
241.000 Introduction to Billing
242.000 CMS-1500 Billing Procedures
242.100 HCPCS Procedure Codes
242.105 Payment Methodology
242.110 Respiratory and Diabetic Equipment, All Ages
242.111 Initial Rental of a DME Item for Individuals of All Ages
242.112 Home Blood Glucose Monitor and Supplies – Pregnant Women Only, All Ages
242.120 Medical Supplies for Beneficiaries of All Ages
242.121 Food Thickeners, All Ages
242.122 Jobst Stocking for Beneficiaries of All Ages
242.123 Negative Pressure Wound Therapy Pump Accessories and Supplies for Beneficiaries Ages 2 Years and Older
242.130 Diapers and Underpads for Beneficiaries Ages 3 Years and Older
242.140 Electronic Blood Pressure Monitor and Cuff, All Ages
242.150 Nutritional Formulae for Child Health Services (EPSDT) Beneficiaries Under Twenty-one (21) Years of Age
242.151 Pedia-Pop
242.152 Enteral Nutrition Infusion Pump and Enteral Feeding Pump Supply Kit
242.153 Low-Profile Skin Level Gastrostomy Tube (Low-Profile Button) and Low-Profile Percutaneous Cecostomy Tube and Supplies for Beneficiaries of All Ages
242.154 Nasogastric Tubing for Individuals Under Age 21
242.155 Billing and Reimbursement Protocol for FM (Frequency Modulation) System and Replacement Cochlear Implant Parts
242.160 Durable Medical Equipment, All Ages
242.161 Reserved
242.170 Apnea Monitors for Beneficiaries Under 1 Year of Age
242.180 Orthotic Appliances for Beneficiaries of All Ages
242.190 Prosthetic Devices for Beneficiaries of All Ages
242.191 Specialized Wheelchairs and Wheelchair Seating Systems for Individuals Age Two Through Adult
242.192 Specialized Rehabilitative Equipment for Beneficiaries of All Ages
242.193 Speech Generating Device for Beneficiaries of All Ages
242.194 Replacement, Growth and Modification of Specialized Wheelchairs and Wheelchair Seating Systems
242.195 Repairs of Specialized Wheelchairs and Wheelchair Systems
242.200 National Place of Service and Modifier Codes
242.300 Billing Instructions - Paper Only
242.310 Completion of CMS-1500 Claim Form
242.400 Special Billing Procedures
242.401 National Drug Codes (NDCs)
242.402 Billing of Multi-Use and Single-Use Vials
242.410 Completion of Form - Medicare/Medicaid Deductible And Coinsurance
242.420 Freight Charges, All Ages
|200.000 GENERAL INFORMATION | |
|201.000 Arkansas Medicaid Participation Requirements for Prosthetics Providers |11-1-09 |
Prosthetics providers must meet the Provider Participation and enrollment requirements contained within Section 140.000 of this manual as well as the following criteria to be eligible to participate in the Arkansas Medicaid Program:
Durable Medical Equipment, Prosthetics, Orthotics and Medical Suppliers must be enrolled in the Title XVII (Medicare) Program as a durable medical equipment/oxygen, orthotic appliances or prosthetic device provider. A copy of the verification letter that reflects the provider’s Medicare supplier number must be submitted with the provider application and Medicaid contract. A separate letter and Medicare supplier number must be submitted for each Medicaid service location.
Providers must provide Arkansas Medicaid proof of DME Medicare accreditation and surety bond dated on or after October 1, 2009. New Providers will be required to submit Medicare accreditation and surety bond upon enrollment.
NOTE: The orthotics/prosthetics provider should maintain accreditation by the American Board for Certification in Orthotics and Prosthetics. The provider should ensure that staff providing patient care (including but not limited to direct care, evaluations, diagnoses, fabrication fittings and follow up care) are accredited by the American Board for Certification in Orthotics and Prosthetics and meet all national licensing and certification requirements and all licensing and certifications required by the State of Arkansas.
|201.100 Providers in Arkansas and Bordering States |10-13-03 |
Providers in Arkansas and the six bordering states (Louisiana, Mississippi, Missouri, Oklahoma, Tennessee and Texas) may be enrolled as routine services providers if they meet all Arkansas Medicaid participation requirements outlined above.
|201.110 Routine Services Provider |12-15-14 |
A. Routine services providers may be enrolled in the program as providers of routine services.
B. Reimbursement may be available for durable medical equipment/oxygen, orthotic appliances and prosthetic devices covered in the Arkansas Medicaid Program.
C. Claims must be filed according to the specifications in this manual. This includes assignment of ICD and HCPCS codes for all services rendered.
|201.200 Providers in Non-Bordering States |3-1-11 |
Providers in non-bordering states may enroll only as limited services providers.
|201.210 Limited Services Provider |3-1-11 |
A. Limited services providers may enroll in the Arkansas Medicaid program to provide prior authorized or emergency services only.
B. Emergency services are defined as inpatient or outpatient hospital services that a prudent layperson with an average knowledge of health and medicine would reasonably believe are necessary to prevent death or serious impairment of health and which, because of the danger to life or health, require use of the most accessible hospital available and equipped to furnish those services.
Source: 42 U.S. Code of Federal Regulations §422.2 and §424.101.
C. Prior authorized services are those that are medically necessary and not available in Arkansas. Each request for these services must be made in writing, forwarded to the Division of Medical Services, Utilization Review Section and approved before the service is provided. See Section 220.000 of this manual for instructions for obtaining prior authorization. To enroll, a non-bordering state provider must download an Arkansas Medicaid application and contract from the Arkansas Medicaid website and submit the application, contract and claim to Arkansas Medicaid Provider Enrollment. A provider number will be assigned upon receipt and approval of the provider application and Medicaid contract. View or print the Utilization Review Section contact information. View or print the provider enrollment and contract package (Application Packet). View or print Medicaid Provider Enrollment Unit contact information.
D. Limited services provider claims will be manually reviewed prior to processing to ensure that only emergency or prior authorized services are approved for payment. These claims should be mailed to the Arkansas Division of Medical Services Program Communications Unit. View or print the Arkansas Division of Medical Services Program Communications Unit contact information.
Providers such as pharmacies, home health agencies or hospitals which have agreements with Medicaid to provide services to Medicaid beneficiaries must complete a separate Medicaid contract and provider application to provide durable medical equipment/oxygen, orthotic appliances and prosthetic devices. A separate provider number will be assigned.
|202.000 The Prosthetics Provider Role in the Child Health Services (EPSDT) Program |10-13-03 |
The Child Health Services (EPSDT) program is a federally mandated child health component of Medicaid. It is designed to bring comprehensive health care to individuals eligible for medical assistance from birth up to their 21st birthday. The purpose of this program is to detect and treat health problems in the early stages and to provide preventive health care, including necessary immunizations. Child Health Services (EPSDT) combines case management and support services with screening, diagnostic and treatment services delivered on a periodic basis.
If a condition is diagnosed through a Child Health Services (EPSDT) screen that requires treatment services not normally covered under the Arkansas Medicaid Program, those treatment services will also be considered for reimbursement if the service is medically necessary and permitted under federal Medicaid regulations.
Prosthetics providers who are Child Health Services (EPSDT) providers are encouraged to refer to the Child Heath Services (EPSDT) provider manual for additional information.
|203.000 Documentation Requirements |11-1-09 |
Prosthetics providers must keep and properly maintain written records. Along with the required enrollment documentation, which is located in Section 141.000, the following records must be included in the beneficiary’s case file maintained by the provider.
|203.100 Documentation in Beneficiary’s Case Files |9-1-18 |
The provider must develop and maintain sufficient written documentation to support each service for which billing is made. All entries in a beneficiary’s file must be signed and dated by the individual who provided the service, along with the individual’s title. The documentation must be kept in the beneficiary’s case file.
Documentation should consist of, at a minimum, material that includes:
A. An audit trail between the prosthetics provider, the beneficiary, the beneficiary’s primary care physician and advanced practice registered nurse and the Division of Medical Services.
B. When applicable, documentation including the request for and approval of prior authorization and/or the request for and approval of extension of benefits for services provided.
C. Prescriptions for prosthetics services, signed and dated by the beneficiary’s primary care physician or advanced practice registered nurse within the scope of practice.
D. The prosthetics provider’s signed and dated:
1. Certification that used equipment is reconditioned, is in good working order and has no defects in workmanship or material
2. The beneficiary’s consent to receive services
3. Notification of termination of prosthetics services
4. Documentation to reflect that necessary training and orientation has been provided to the beneficiary and any other applicable persons
5. Any additional or special documentation, requested in writing, that is needed to provide fair and impartial review of individual cases, requested in writing.
|203.200 Reserved |11-1-09 |
|203.300 Reserved |11-1-09 |
|204.000 Electronic Signatures |10-8-10 |
Medicaid will accept electronic signatures provided the electronic signatures comply with Arkansas Code § 25-31-103 et seq.
|210.000 PROGRAM COVERAGE | |
|211.000 Scope |1-1-21 |
There are several broad areas of service provision in the Prosthetics manual. Services provided include durable medical equipment, which also encompasses specialized wheelchairs, wheelchair seating systems, specialized rehabilitation equipment and the speech generating device. Other programs covered in the Prosthetics manual include medical supplies, nutritional formulas, diapers and underpads, prosthetic devices and orthotic appliances.
|211.100 Condition for Provision of Services |9-1-18 |
The following conditions must be met for the provision of services:
A. The beneficiary must reside in the state of Arkansas.
B. The individual must be an Arkansas Medicaid beneficiary.
C. Services must be medically necessary and prescribed by the beneficiary’s primary care physician (PCP) or Advanced Practice Registered Nurses (APRN) unless the beneficiary is exempt from PCP requirements. A PCP referral is required. See Section I.
D. A beneficiary is accepted for services on the basis of a reasonable expectation that his or her medical needs can be adequately met by the provider.
E. When applicable, Form DMS-679, titled Medical Equipment Request for Prior Authorization and Prescription, must be utilized when requesting prior authorization for wheelchairs, wheelchair seating systems, wheelchair repairs, for eligible Medicaid beneficiaries. View or print form DMS-679 and instructions for completion.
F. When applicable, form DMS-679A, titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components, must be utilized when requesting prior authorization for some medical supplies (i.e.: compression burn garments), orthotics appliances, prosthetic devices and durable medical equipment, excluding wheelchairs, wheelchair seating systems or wheelchair repairs, when these items are prescribed for eligible Medicaid beneficiaries. View or print form DMS-679A and instructions for completion.
G. When applicable, form DMS-602, titled Request for Extension of Benefits for Medical Supplies for Medicaid Beneficiaries Under Age 21, must be utilized when requesting extension of benefits for medical supplies for beneficiaries under age 21. View or print form DMS-602 and instructions for completion.
H. When applicable, form DMS-699, titled Request for Extension of Benefits, must be utilized when requesting extension of benefits for diapers and underpads for eligible beneficiaries ages three and older. View or print form DMS-699.
I. The beneficiary must reside in his or her own dwelling, an apartment, relative’s or friend’s home, boarding home, residential care facility or any other type of supervised living situation that is not required to provide prosthetics services as part of the facility’s participation agreement as a service provider.
A beneficiary’s place of residence for services may not include a hospital, skilled nursing facility, intermediate care facility or any other supervised living situation that is required to provide prosthetics services under a provider agreement or contract as required by federal, state or local regulation.
|211.200 Physician’s Role in the Prosthetics Program |9-1-18 |
At least once every 6 months, the primary care physician or advanced practice registered nurse within the scope of practice must certify the medical necessity for services and prescribe them by signing and dating a prescription. When applicable, the primary care physician or advanced practice registered nurse within the scope of practice must complete a prior authorization form; either a Medical Equipment Request for Prior Authorization and Prescription Form (form DMS-679) when prescribing services for wheelchairs and wheelchair seating systems, or wheelchair repairs or a form DMS-679A, titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components, when prescribing orthotic appliances, prosthetic devices or durable medical equipment. View or print form DMS-679 and instructions for completion. View or print form DMS-679A and instructions for completion.
|211.300 Prosthetics Service Provision |9-1-18 |
At least once every 6 months, the prosthetics provider must receive a prescription for prosthetics services from either the beneficiary’s primary care physician or advanced practice registered nurse within the scope of practice and, when applicable:
A. Prepare a Medical Equipment Request for Prior Authorization and Prescription Form (form DMS-679) for wheelchairs, wheelchair seating systems or wheelchair repairs for beneficiaries 21 years of age or older and for specified services for beneficiaries under age 21. View or print form DMS-679 and instructions for completion.
B. Prepare a Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components for some medical supplies (i.e.: compression burn garments), orthotic appliances, prosthetic devices and durable medical equipment for beneficiaries 21 years of age or older and for specified services for beneficiaries under age 21. View or print form DMS-679A and instructions for completion.
C. Send the prepared request for prior authorization to either the beneficiary’s primary care physician or advanced practice registered nurse within the scope of practice for prescriptions
D. Send the completed Medical Equipment Request for Prior Authorization and Prescription Form (form DMS-679) to the Arkansas Foundation for Medical Care for prior authorization. View or print the AFMC contact information.
E. Send the Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components to the Arkansas Foundation for Medical Care, Inc. (AFMC) for prior authorization. View or print the AFMC contact information.
As necessary, the provider must:
A. Deliver and set up the prescribed equipment in the beneficiary’s home,
B. Teach the beneficiary, families and caregivers the correct use and maintenance of equipment,
C. Repair equipment within 3 working days of notification,
D. Retrieve from the beneficiary’s home equipment no longer prescribed for the beneficiary and
E. Provide necessary documentation.
|211.400 Prescription and Referral Renewal |9-1-18 |
At least once every 6 months, but within 30 working days before the end of currently prescribed or prior authorized prosthetics services, the prosthetics provider must obtain a new prescription from either the beneficiary’s primary care physician or advanced practice registered nurse within the scope of practice and, if applicable, send a new prior authorization form to the applicable entity. The primary care physician or advanced practice registered nurse within the scope of practice must initially review either form DMS-679 or form DMS-679A, and, based upon the physician’s certification of medical necessity, prescribe services. Form DMS-679 or form DMS-679A must then be reviewed by the applicable entity and services must be prior authorized. If services are prescribed, and when applicable, prior authorized, services may be furnished for a maximum of 6 months from the date of the prescription.
|211.500 Service Initiation Delays |9-1-18 |
If all prescribed prosthetics services are not begun by the prosthetics provider within 30 working days of the prescription date, the prosthetics provider must notify the beneficiary and either the beneficiary’s primary care physician or advanced practice registered nurse within the scope of practice in writing and explain the delay. The provider must retain documentation justifying the service delay.
|211.600 Termination of Services |9-1-18 |
If prosthetics services are terminated, the provider must notify either the beneficiary’s primary care physician or advanced practice registered nurse within the scope of practice and the beneficiary (if not deceased) in writing, within 10 working days of the termination, documenting the effective date of and reasons for the termination.
|211.700 Exclusions |8-1-05 |
Services that are not covered under the Arkansas Medicaid Prosthetics Program include but are not limited to:
A. Over-the-counter items provided through the Arkansas Medicaid Pharmacy Program (except as specified).
B. Over-the-counter drugs (except as specified).
C. Products that bear the Federal legend “Caution: Federal Law Prohibits Dispensing Without A Prescription” (except as specified).
D. Specialized wheelchair equipment that has been previously purchased by any payer. Specialized wheelchair equipment may not be reordered unless the patient’s condition changes and necessitates a change in prescription. This change in condition must be thoroughly documented.
E. Wheelchairs for individuals under 21 years of age within two years of the purchase of a specialized wheelchair.
F. Wheelchairs for individuals age 21 and over within five years of the purchase or rental of a wheelchair.
G. Foodstuffs.
H. Hyperalimentation.
I. Services that duplicate any other service provided to the patient or that replace existing patient supports.
|211.800 Electronic Filing of Extension of Benefits |1-1-21 |
Form DMS-699, titled Request for Extension of Benefits, serves as both a request form and a notification of approval or denial of extension of benefits when requesting diapers and underpads for beneficiaries age 3 and older. If the benefit extension is approved, the form returned to the provider will contain a Benefit Extension Control Number. The approval notification will also list the procedure codes approved for benefit extension, the approved dates or date-of-service range and the number of units of service (or dollars, when applicable) authorized.
Upon notification of a benefit extension approval, providers may file the benefit extension claims electronically, entering the assigned Benefit Extension Control Number in the Prior Authorization (PA) number field. Subsequent benefit extension requests to the Utilization Review Section will be necessary only when the Benefit Extension Control Number expires or when a beneficiary’s need for services unexpectedly exceeds the amount or number of services granted under the benefit extension.
Form DMS-679A, titled Prescription and Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components serves as a request form when requesting extension of benefits for the speech generating device. The QIO will notify providers of approval or denial by letter.
|212.000 Services Provided | |
|212.100 Diapers and Underpads for Individuals Age 3 and Older |6-1-09 |
Diapers and underpads are covered by the Arkansas Medicaid Program but are benefit limited and must be medically necessary.
A. Medical Necessity
Diaper services must be medically necessary and the medical condition that prohibits the ability to potty train must be documented. Only patients with a medical condition that results in incontinence of the bladder and/or bowel may receive diapers through the Home Health and Prosthetics Programs. This coverage does not apply to infants who would be in diapers regardless of their medical condition. Medicaid does not cover underpads or diapers for beneficiaries under the age of 3 years.
B. Benefit Limit
The benefit limit for diapers and underpads is $130.00 per month, per beneficiary, for diapers of any size and underpads. The benefit limit applies to any diaper or underpad, or any combination, whether provided through the Prosthetics Program, the Home Health Program or both. The limit on diapers and underpads is separate from the limit established for home health and durable medical equipment (DME) medical supplies.
The benefit may be extended with proper documentation.
C. Extension of Benefits for Diapers and Underpads
To obtain an extension of benefits for diapers and underpads, the following information must be submitted to the Prosthetics Services Reviewer, DMS Utilization Review. View or print the DMS Utilization Review contact information.
1. A completed Medicaid Form DMS-699, titled Request for Extension of Benefits for the requested time period prior to the delivery of the product. View or print form DMS-699.
2. Documentation supported by the medical record substantiating the medical necessity of an extension of benefits, including the prescription(s) for all prescribed incontinence products.
|212.200 Durable Medical Equipment (DME), All Ages |8-1-05 |
Durable medical equipment (DME) is equipment that can withstand repeated use and is used to serve a medical purpose.
Depending on the item involved, DME may be purchased for or by a beneficiary or may be rented. The equipment may be new or, in special circumstances, used equipment.
|212.201 (DME) Apnea Monitors for Infants Under Age 1 |3-1-10 |
Arkansas Medicaid covers apnea monitors only for infants less than one (1) year of age. Use of the apnea monitor must be medically necessary and prescribed by a physician.
A primary care physician (PCP) is not required until an infant's Medicaid eligibility has been determined. No PCP referral for medical services is required for retroactive eligibility periods.
For the initial certification, the prescribing physician must sign form DMS-679A titled Prescription and Prior Authorization Request for Medical Equipment Excluding Wheelchairs and Wheelchair Components. The physician’s signature must be an original, not a stamp. When an apnea monitor is prescribed during a hospital discharge, the physician ordering the apnea monitor must be in consultation with a neonatologist or pulmonologist.
As necessary, the primary care physician's (PCP’s) name and provider number must also be indicated on DMS-679A titled Prescription and Prior Authorization Request for Medical Equipment Excluding Wheelchairs and Wheelchair Components. The PCP's signature is not required on the initial certification but he or she must sign all re-certifications.
A prior authorization request for an apnea monitor must be submitted to AFMC on form DMS-679A titled Prescription and Prior Authorization Request for Medical Equipment Excluding Wheelchairs and Wheelchair Components. View or print form DMS-679 and instructions for completion. View or print AFMC contact information.
Compliance, and the download monitor report, must accompany the request for continued use of the apnea monitor following the initial sixty-day time period.
Prior authorization is not required for the initial sixty-day period of use of the monitor. If the apnea monitor is needed longer than an initial sixty-day period, prior authorization is required.
A new prescription, documentation of compliance during the initial sixty-day period and proof of medical necessity for the continuation of monitoring are required.
The following criteria, established by the American Academy of Pediatrics, are to be used to evaluate the need for an apnea monitor after the initial sixty-day period:
A. Evidence exists that preterm infants are at greater risk of extreme apnea episodes until approximately 43 weeks post conceptual age. Monitoring may be indicated until 43 weeks post conceptual age unless extreme episodes persist beyond that time. Home monitoring may be indicated for other selected groups of infants, as well.
B. Home cardiorespiratory monitoring may be warranted for premature infants who are at high risk of recurrent episodes of apnea, bradycardia, and hypoxemia after hospital discharge.
The use of home cardiorespiratory monitoring in this population should be limited to approximately 43 weeks post conceptual age or after the cessation of extreme episodes, whichever comes last.
C. Home cardiorespiratory monitoring may be warranted for infants who are technology dependent (tracheostomy, supplemental oxygen, continuous positive airway pressure, etc.), have unstable airways, have rare medical conditions affecting regulation of breathing or have symptomatic chronic lung disease.
In many of these cases, the use of pulse oximetry monitoring is superior and preferred over simple cardiorespiratory monitoring.
D. Other infants who may benefit from home cardiorespiratory home monitoring include:
1. Infants who have experienced an apparent life-threatening event (ALTE)
An ALTE is defined as “an episode that is frightening to the observer and is characterized by some combination of apnea (central or occasionally obstructive), color change (usually cyanotic or pallid but occasionally erythematous or plethoric), marked change in muscle tone (usually marked limpness), choking or gagging.”
2. Infants with tracheotomies or anatomic abnormalities that may compromise their airway
3. Infants with metabolic or neurological abnormalities affecting respiratory control
4. Infants with chronic lung disease of prematurity (bronchopulmonary dysplasia, BPD), especially those requiring some form of respiratory support
E. Parents or caregivers must be counseled regarding the purpose of the home cardiorespiratory monitoring and realistic expectations of what it can and cannot contribute to an infant’s well being.
1. When monitoring is used in the home, parents and other caregivers must be trained in observation techniques, operation of the monitor, and infant cardiopulmonary resuscitation prior to the use of the monitor.
2. Medical and technical support staff should always be available for direct or telephone consultation.
F. Duration and discontinuation of home cardiorespiratory monitoring
1. When home monitoring is prescribed for apnea/bradycardia in preterm infants, the physician should establish a plan for review of clinical and event (download) data at 43 weeks post conceptual age. If monitoring is to be continued beyond that time, documentation should be provided as to why it should be continued as well as a plan for reevaluation.
2. Infants whose mothers have unsure dates (uncertain post-conceptual age) may be monitored until the infants are at least 43 weeks post conceptual age.
3. When home monitoring is prescribed for indications other than apnea/bradycardia in preterm infants, continuation of monitoring will be reviewed on a case-by-case basis.
4. Discontinuation of home monitoring should be a clinical decision based on a combination of clinical data and cardiorespiratory monitor event data.
5. Decisions regarding discontinuation of home monitoring should NOT be based on single-night pneumograms, which have no proven predictive value in this setting.
|212.202 (DME) Speech Generating Device (SGD), All Ages |1-1-21 |
The speech generating device (SGD) is covered for beneficiaries of all ages. Coverage for beneficiaries under 21 years of age must result from an EPSDT screen. There is a $7,500.00 lifetime benefit for speech generating devices. When a beneficiary who is under age 21 has met the lifetime benefit and it is determined that additional equipment is medically necessary, the provider may request an extension of benefits by submitting form DMS-679A. View or print form DMS-679A.
The SGD is also covered for Medicaid beneficiaries 21 years old and older. Prior authorization is required on the device and on repairs of the device. For beneficiaries who are age 21 and above, there is a $7,500.00 lifetime benefit without benefit extensions.
The Arkansas Medicaid Program will not cover SGDs that are prescribed solely for social or educational development.
Training in the use of the device is not included and is not a covered cost.
Prior authorization must be requested for repairs of equipment or associated items after the expiration of the initial maintenance agreement.
The following information must be submitted when requesting prior authorization for SGDs for Medicaid beneficiaries.
Submit form DMS-679A, titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components. View or print form DMS-679A and instructions for completion. The form should be accompanied by:
A. A current speech generating device evaluation completed by a multidisciplinary team consisting of, at least, a speech/language pathologist and an occupational therapist. The team may consist of a physical therapist, regular and special educators, caregivers and parents. The speech-language pathologist must lead the team and sign the SGD evaluation report. (For the qualifications of the team members, see the Hospital/Critical Access Hospital/End Stage Renal Disease provider manual.)
1. The team must use an interdisciplinary approach in the evaluation, incorporating the goals, objectives, skills and knowledge of various disciplines. The team must use at least three SGD systems, with written documentation of each usage included in the SGD assessment.
2. The evaluation report must indicate the medical reason for the SGD. The report must give specific recommendations of the system and justification of why one system is more appropriate than another system.
3. The evaluation report must be submitted to the prosthetics provider who will request prior authorization for the SGD.
B. Written denial from the insurance company if the individual has other insurance.
This information must be submitted to the QIO. View or print QIO contact information.
Benefit Limit
There is a $7500 lifetime benefit for speech generating devices. When the beneficiary under age 21 has met the limit and it is determined that additional equipment is necessary, the provider may request an extension of benefits.
In order to obtain an extension of the $7,500.00 lifetime benefit for beneficiaries under 21 years of age, a medical necessity determination for additional equipment is required. The provider must submit a form DMS-679A, a completed Medicaid claim and medical records substantiating medical necessity that the beneficiary cannot function using his or her existing equipment and whether the equipment can be repaired or needs repair. The information must be sent to the QIO. View or print form DMS-679A titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components. View or print the QIO contact information.
The provider will be notified in writing of the approval or denial of the request for extended benefits.
|212.203 Cochlear Implants for Beneficiaries Under Age 21 |4-15-11 |
Cochlear implants are covered through the Arkansas Medicaid Physician or Prosthetics Programs for eligible Medicaid beneficiaries under the age of 21 years through the Child Health Services (EPSDT) program when prescribed by a physician.
The replacements of lost, stolen or damaged external components (not covered under the manufacturer’s warranty) are covered when prior authorized by Arkansas Medicaid.
Reimbursements for manufacturer’s upgrades will not be made. An upgrade of a speech processor to achieve aesthetic improvement, such as smaller profile components, or a switch from a body-worn, external sound processor to a behind-the-ear (BTE) model or technological advances in hardware are not considered medically necessary and will not be approved.
A. Speech Processor
Arkansas Medicaid will not cover new generation speech processors if the existing one is still functional. Consideration of the replacement of the external speech processors will be made only in the following instances:
1. The beneficiary loses the speech processor.
2. The speech processor is stolen.
3. The speech processor is irreparably damaged.
Additional medical documentation supporting medical necessity for replacement of external components should be attached to any requests for prior authorization.
B. Personal FM (Frequency Modulation) Systems
Arkansas Medicaid will reimburse for a personal FM system for use by a cochlear implant beneficiary when prior authorized and not available from any other source (i.e., educational services). The federal Individuals with Disabilities Education Act (IDEA) requires public school systems to provide FM systems for educational purposes for students starting at age three (3). Arkansas Medicaid does not cover FM systems for children who are eligible for this service through IDEA.
A request for prior authorization may be submitted for medically necessary FM systems (procedure code V5273 for use with cochlear implant) that are not covered through IDEA; each request must be submitted with documentation of medical necessity. These requests will be reviewed on an individual basis.
C. Replacement, Repair, Supplies
The repair or replacement of the cochlear implant external speech processor and other supplies (including batteries, cords, battery charger and headsets) will be covered in accordance with the Arkansas Medicaid policy for the Physician and Prosthetics Programs. The covered services must be billed by an Arkansas Medicaid Physician or Prosthetics provider. The supplier is required to request prior authorization for repairs or replacements of external implant parts.
D. Prior Authorization
A request for prior authorization of a medically necessary FM system (V5273 for use with cochlear implant) and replacement cochlear implant parts requires a paper submission to the Arkansas Foundation for Medical Care (AFMC) using form DMS-679A. All documentation supporting medical necessity should be attached to the form. The provider will be notified in writing of the approval or denial of the request for prior authorization. View or print form DMS-679A and instructions for completion.
Prior authorization does not guarantee payment for services or the amount of payment for services. Eligibility for, and payment of, services are subject to all terms, conditions and limitations of the Arkansas Medicaid Program. Documentation must support medical necessity. The provider must retain all documentation supporting medical necessity in the beneficiary’s medical record.
The following procedure codes must be prior authorized. Providers should use the following procedure codes when requesting prior authorization for replacement parts for cochlear implant devices. Applicable manufacturer warranty options must be exhausted before coverage is considered. Most warranties include one replacement for a stolen, lost or damaged piece of equipment free-of-charge by the manufacturer.
The table below contains new and existing HCPCS procedure codes for FM systems for use with cochlear implant and replacement cochlear implant parts.
NOTE: Coverage and billing requirements for the physician provider for cochlear device implantation are unchanged.
|Procedure Code |M1 |Age Restriction |PA |Payment Method |
|L8627* |EP |0-20 |Y |Manually Priced |
|L8628* |EP |0-20 |Y |Manually Priced |
|L8629* |EP |0-20 |Y |Manually Priced |
*Denotes paper claim
See Section 242.155 for information on billing and reimbursement for FM system and replacement cochlear implant parts.
|212.204 (DME) Electronic Blood Pressure Monitor and Cuff for Beneficiaries of All Ages |4-1-09 |
Arkansas Medicaid covers the automatic electronic blood pressure monitor for beneficiaries of all ages as a rental-only item. A provider must substantiate that an accurate blood pressure reading cannot be obtained by using a regular blood pressure monitor. Providers must also supply one disposable blood pressure cuff each month.
Prior authorization is required for the use of this item. Providers may request prior authorization by submitting form DMS-679A, Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components to AFMC. View or print form DMS-679A and instructions for completion. View or print AFMC contact information.
|212.205 (DME) Enteral Nutrition Infusion Pump and Enteral Feeding Pump Supply Kit for Beneficiaries Under Age 21 |4-1-09 |
The request for an enteral nutrition pump is covered on a case-by-case basis for beneficiaries under age 21 who require supplemental feeding because of medical necessity. Sufficient medical documentation must be provided to establish that the enteral nutrition infusion pump is medically necessary (e.g., supplemental feeding must be given over an extended period of time due to reflux, cystic fibrosis, etc.). The PCP or appropriate physician specialist must prescribe the pump, citing the medical reason that bolus feeds are inappropriate.
Reimbursement for use in the home may be made for the pump supply kit when the feeding method involves an enteral nutrition infusion pump. The pump supply kit and the infusion pump require prior authorization from AFMC using form DMS-679A titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components. View or print AFMC contact information. View or print form DMS-679A and instructions for completion.
The enteral feeding pump supply kit, necessary for the administration of the nutrients when the feeding method involves an enteral nutrition infusion pump, is reimbursed on a per-unit basis with 1 day equaling 1 unit of service. A maximum of 1 unit per day is allowed. The pump supply kit includes pump sets, containers and syringes necessary for administration of the nutrients.
Reimbursement for the enteral nutrition infusion pump is based on a rent-to-purchase methodology. Each unit reimbursed by Medicaid will apply towards the purchase price established by Medicaid. Reimbursement will only be approved for new equipment. Used equipment will not be prior authorized. View or print form DMS-679A and instructions for completion.
Requests for prior authorization for enteral pump repairs must be mailed to AFMC. Form DMS-679A titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components, must be used to request prior authorization. View or print form DMS-679A and instructions for completion.
|212.206 (DME) Home Blood Glucose Monitor, Pregnant Women Only, |8-1-05 |
|All Ages | |
Arkansas Medicaid covers the home blood glucose monitor for pregnant women of all ages. Prior authorization is not required for use of this device.
A. Patient Eligibility
1. Pregestational diabetes. Women on an oral hypoglycemic or insulin when the pregnancy is diagnosed.
2. Women that are being followed by a physician for elevated fasting hyperglycemia, but not on an oral hypoglycemic or insulin when the pregnancy is diagnosed.
3. Women demonstrating glucose intolerance during the pregnancy as demonstrated by an elevated three-hour glucose tolerance test.
B. Criteria for glucose intolerance
1. Demonstration of an elevated one-hour glucose tolerance test of greater than 140 mg/deciliter on a non-fasting value.
2. Elevation of two or more values on a three-hour glucose tolerance test above the accepted cut-off points of:
a. Fasting, less than 105
b. One-hour, less than 190
c. Two-hour, less than 165
d. Three-hour, less than 145
|212.207 (DME) Insulin Pump and Supplies, All Ages |4-1-09 |
Insulin pumps and supplies are covered by Arkansas Medicaid for beneficiaries of all ages.
Prior authorization is required for the insulin pump. A prescription and proof of medical necessity are required. The patient must be educated on the use of the pump, but the education is not a covered service.
Insulin is also not covered because it is covered in the prescription drug program.
The following criteria will be utilized in evaluating the need for the insulin pump:
A. Insulin-dependent diabetes that is difficult to control.
B. Fluctuation in blood sugars causing both high and low blood sugars in a patient on at least 3, if not 4, injections per day.
C. Beneficiary’s motivation level in controlling diabetes and willingness to do frequent blood glucose monitoring.
D. Beneficiary’s ability to learn how to use the pump effectively. This will have to be evaluated and documented by a professional with experience in the use of the pump.
E. Determination of the beneficiary’s suitability to use the pump should be made by a diabetes specialist or endocrinologist.
F. Beneficiaries not included in one of these categories will be considered on an individual basis.
Prior authorization requests for the insulin pump and supplies must be submitted on form DMS-679A titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components, to AFMC. View or print form DMS-679A and instructions for completion. View or print AFMC contact information.
|212.208 Reserved |8-1-05 |
|212.209 (DME) Low-Profile Skin Level Gastrostomy Tube (Low-Profile Button) and Supplies for Beneficiaries of All Ages |12-1-20 |
The Arkansas Medicaid Program reimburses for the Low-Profile Skin Level Gastrostomy Tube (Low-Profile Button) and supplies for Medicaid-eligible beneficiaries of all ages. Prior authorization (PA) from DHS or its designated vendor is required.
When requesting prior authorization, form DMS-679A titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components, must be completed and sent, along with sufficient medical documentation. View or print contact information for how to submit the request.
The Low-Profile Kit is benefit-limited to two (2) per state fiscal year (SFY). The accessories, extension sets, and adapters are covered under the $250 medical supply benefit limit.
Benefit extensions will be considered on a case-by-case basis if proven to be medically necessary.
|212.210 DME Low-Profile Percutaneous Cecostomy Tube (Low-Profile Button) for Beneficiaries of All Ages |12-1-20 |
The Low-Profile Button for a Percutaneous Cecostomy Tube requires use of the following diagnosis codes. (View ICD codes.)
The Low-Profile Button for a Percutaneous Cecostomy Tube requires use of the following CPT codes:
|44300 |49442 |49450 |
|212.211 Reserved |8-1-05 |
|212.212 (DME) Specialized Rehabilitative Equipment, All Ages |4-1-09 |
Arkansas Medicaid covers specialized rehabilitative equipment for Medicaid-eligible beneficiaries of all ages.
Some items of specialized equipment require prior authorization from AFMC. View or print form DMS-679A and instructions for completion. View or print AFMC contact information.
|212.213 (DME) Specialized Wheelchairs and Wheelchair Seating Systems |4-6-15 |
|for Individuals Age Two Through Adult | |
Arkansas Medicaid covers specialized wheelchairs and wheelchair seating systems for individuals age two through adulthood.
Some items of specialized equipment require prior authorization from the Arkansas Foundation for Medical Care (AFMC). View or print form DMS-679 and instructions for completion. View or print the AFMC contact information.
|212.214 Reserved |8-1-05 |
|212.300 Medical Supplies, All Ages |7-1-17 |
The Arkansas Medicaid Program reimburses home health providers and prosthetics providers for covered medical supplies up to a maximum of $250.00 per month, per beneficiary. The $250.00 may be provided by the Home Health program, the Prosthetics program or a combination of the two.
A beneficiary may not receive more than a total of $250.00 of supplies per month unless an extension has been granted. Extensions will be considered for beneficiaries under age 21 in the Child Health Services (EPSDT) program if documentation verifies medical necessity.
A provider must request an extension of the benefit limit for a Medicaid beneficiary under age 21 by completing the Request for Extension of Benefits for Medical Supplies for Medicaid Recipients Under Age 21 (form DMS-602.) View or print form DMS-602 and instructions for completion.
The Arkansas Medicaid program covers medical supplies using a specific HCPCS procedure code for each specific item. Only supply items that are listed and have a corresponding payable HCPCS procedure code are covered.
Supplies are healthcare-related items that are consumable or disposable, or cannot withstand repeated use by more than one individual, and that are required to address an individual medical disability, illness or injury.
Equipment and appliances are items that are primarily and customarily used to serve a medical purpose; generally are not useful to an individual in the absence of a disability, illness or injury; can withstand repeated use; and can be reusable or removable. Medical coverage of equipment and appliances is not restricted to items covered as durable medical equipment in the Medicare program.
Arkansas has a list of preapproved medical equipment, supplies and appliances for administrative ease, but the state is prohibited from having absolute exclusions of coverage on medical equipment, supplies or appliances. Items not available on the preapproval list may be requested on a case-by-case basis. When denying a request, the state must inform the beneficiary of the right to a fair hearing.
|212.400 Nutritional Formulae for Individuals Under Age 21 |8-1-05 |
Nutritional formulae may be covered by the Arkansas Medicaid Program when prescribed by a physician and documented as medically necessary for beneficiaries under age 21 participating in the Child Health Services (EPSDT) Program. The Women, Infants and Children Program (WIC) must be accessed first for individuals who are age 0 through age 5.
Nutritional formula may not be billed for the same beneficiary by more than one provider or in more than one program (e.g., Prosthetics and Hyperalimentation) for the same date of service.
Covered formulae represent the nutritional supplements most requested for medical purposes. However, if none of the formulae are appropriate and another formula is prescribed by a physician as a result of Child Health Services (EPSDT) screening, the prescribed formula will be reviewed for medical necessity.
Formulae are covered as nutritional supplements rather than as the sole source of nutrition. Beneficiaries who require enteral nutrition as the sole source of nutrition, with the formulae being administered through a nasogastric, jejunostomy or gastrostomy tube, should be referred to a hyperalimentation provider enrolled in the Medicaid Program.
One unit of service equals 100 calories with an allowable maximum of 30 units per day. This is a separate benefit limit from the limit established for medical supplies. Supplies provided in conjunction with the nutritional formulae through the Prosthetics Program must be billed under the medical supply codes, if those supplies are covered by the program.
There are certain nutritional formulae available to eligible beneficiaries through the WIC Program and the Food Stamp Program. These two programs should be accessed by beneficiaries prior to requesting Medicaid reimbursement for nutritional formulae. The coverage of these formulae through the Medicaid Program is limited to beneficiaries requiring nutrition therapy due to medical necessity and only when prescribed by a physician.
|212.500 Food Thickeners, All Ages |8-1-05 |
Arkansas Medicaid covers food thickeners for Medicaid-eligible individuals who have impaired swallowing and a risk of food aspiration.
Food thickeners are not subject to the $250 benefit limit for other medical supplies.
|212.600 Orthotic Appliances and Prosthetic Devices, All Ages |5-22-19 |
A. The Arkansas Medicaid Program covers orthotic appliances and prosthetic devices for beneficiaries under age 21 in the Child Health Services (EPSDT) Program. Providers of orthotic appliances and prosthetic devices may be reimbursed by the Arkansas Medicaid Program when the items are prescribed by a physician and documented as medically necessary for beneficiaries under age 21 participating in the Child Health Services (EPSDT) Program.
1. No prior authorization is required to obtain these services for beneficiaries under age 21.
2. No benefit limits apply to orthotic appliances and prosthetic devices for beneficiaries under age 21.
B. Arkansas Medicaid covers orthotic appliances for beneficiaries age 21 and over. The following provisions must be met before services may be provided.
1. Prior authorization is required for orthotic appliances valued at or above the Medicaid maximum allowable reimbursement rate of $500.00 per item for use by beneficiaries age 21 and over. Prior authorization may be requested by submitting form DMS-679A titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components to AFMC. View or print form DMS-679A and instructions for completion. View or print AFMC contact information.
2. For beneficiaries age 21 and over, a benefit limit of $3,000 per state fiscal year (SFY; July 1 through June 30) has been established for reimbursement for orthotic appliances. No extension of benefits will be granted.
The following restrictions apply to the coverage of orthotic appliances for beneficiaries age 21 and over:
a. Orthotic appliances may not be replaced for 12 months from the date of purchase. If a beneficiary’s condition warrants a modification or replacement and the $3,000.00 SFY benefit limit has not been met, the provider may submit documentation to AFMC, to substantiate medical necessity. If approved, AFMC will issue a prior authorization number. Section 221.000 of this provider manual may be referenced for information regarding prior authorization procedures.
b. Custom-molded orthotic appliances are not covered for a diagnosis of carpal tunnel syndrome prior to surgery.
C. Arkansas Medicaid covers prosthetic devices for beneficiaries age 21 and over; however, the following provisions must be met before services may be provided.
1. Prior authorization will be required for prosthetic device items valued at or in excess of the $1,000.00 per item Medicaid maximum allowable reimbursement rate for use by beneficiaries age 21 and over. Prior authorization may be requested by submitting form DMS-679A titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components to AFMC. View or print form DMS-679A and instructions for completion.
2. For beneficiaries age 21 and over, a benefit limit of $60,000 per SFY has been established for reimbursement for prosthetic devices. No extension of benefits will be granted.
3. The following restrictions apply to coverage of prosthetic devices for beneficiaries age 21 and over:
a. Prosthetic devices may be replaced only after five years have elapsed from their date of purchase. If the beneficiary’s condition warrants a modification or replacement, and the $60,000 per SFY benefit limit has not been met, the provider may submit documentation to AFMC to substantiate medical necessity. If approved, AFMC will issue a prior authorization number. Section 220.000 of this provider manual may be referenced for information regarding prior authorization procedures.
b. Myoelectric prosthetic devices may be purchased only when needed to replace myoelectric devices received by beneficiaries who were under age 21 when they received the original device.
D. The forms, listed below, are available for evaluating the need of beneficiaries age 21 and over for orthotic appliances and prosthetic devices, and prescribing the needed appliances and equipment. The Medicaid Program does not require providers to use the forms, but the information the forms are designed to collect is required by Medicaid to process requests for prior authorization of orthotic appliances and prosthetic devices for beneficiaries aged 21 and over.
The appropriate forms (or the required information in a different format) must accompany the form DMS-679A. View or print DMS-679A titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components and instructions for completion.
The forms and their titles are as follows:
1. DMS-647 Gait Analysis: Full Body. View or print form DMS-647.
2. DMS-648 Upper-Limb Prosthetic Evaluation. View or print form DMS-648.
3. DMS-649 Upper-Limb Prosthetic Prescription. View or print form DMS-649.
4. DMS-650 Lower-Limb Prosthetic Evaluation. View or print form DMS-650.
5. DMS-651 Lower-Limb Prosthetic Prescription. View or print form DMS-651.
|212.700 Oxygen and Oxygen Supplies, All Ages |4-1-09 |
A prescription for oxygen must be accompanied by a current arterial blood gas (ABG) laboratory report from a certified laboratory or the beneficiary’s attending physician. A current laboratory report is defined as one performed within a maximum of 30 days prior to the prescription for oxygen.
A prescription for oxygen must specify the oxygen flow rate, frequency and duration of use, estimate of the period of need for oxygen and method of delivery of oxygen to the beneficiary (e.g., two liters per minute, 10 minutes per hour, by nasal cannula for a period of two months). A prescription containing only “oxygen PRN” is not sufficient.
The following medical criteria will be utilized in evaluating coverage of oxygen:
A. Chronic Respiratory Disease
1. Continuous oxygen therapy
Resting Pa02 less than 55 mm Hg
2. Nocturnal oxygen therapy
Resting Pa02 less than 60 mm Hg
3. Exercise oxygen therapy
Pa02 with exercise less than 55 mm Hg
B. Congestive Heart Failure
Symptomatic at rest, with Pa02 less than 60 mm Hg
C. Carcinoma of the Lung
Resting Pa02 less than 60 mm Hg
D. Others
Reviewed on an individual basis
E. Children
O2 saturation below 94% by pulse oximeter with elevated PCO2 by capillary blood gas or end-tidal CO2 on two separate occasions.
The prior authorization request for all oxygen and respiratory equipment must be submitted on form DMS-679A titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components to AFMC for beneficiaries of all ages. View or print form DMS-679A and instructions for completion.
|220.000 PRIOR AUTHORIZATION | |
|221.000 Prosthetics Services Prior Authorization |4-1-09 |
Reimbursement for specified prosthetics services must be prior authorized. Prior authorization is required on items indicated (e.g., oxygen) or if the reimbursement for an item or items is $1000.00 or more (e.g., wheelchair and/or components).
|221.100 Request for Prior Authorization |9-1-18 |
The request for prior authorization must originate with the prosthetics provider. The provider is responsible for obtaining the required medical information and prescription needed for completion of the prior authorization request form.
A. The Medical Equipment Request for Prior Authorization and Prescription Form (Form DMS-679) will be used when requesting prior authorization for wheelchairs, wheelchair seating systems and wheelchair repairs. The primary care physician or advanced practice registered nurse within the scope of practice must sign the DMS-679. The primary care physician’s or advanced practice registered nurse’s signature must be an original, not a stamp.
Form DMS-679 must contain a diagnosis of the disease(s) necessitating use of prosthetics services. View or print form DMS-679 and instructions for completion.
B. The Arkansas Foundation for Medical Care, Inc., (AFMC) reviews requests for prior authorization for some medical supplies (i.e., compression burn garments), orthotic appliances, prosthetic devices and durable medical equipment, excluding wheelchairs, wheelchair seating systems and wheelchair repairs. Form DMS-679A, titled Prescription and Prior Authorization Request for Medicaid Equipment Excluding Wheelchairs & Wheelchair Components must be completed for use with those items of durable medical equipment, excluding wheelchairs, wheelchair seating systems and wheelchair repairs.
|221.200 Filing for Prior Authorization |4-6-15 |
Requests for prior authorization will be handled by the Arkansas Foundation for Medical Care (AFMC).
A. To request prior authorization for wheelchair and wheelchair seating systems, providers must use form DMS-679 and send the information to AFMC. The original and the first copy of the Medical Equipment Request for Prior Authorization and Prescription Form (form DMS-679) must be forwarded to AFMC. The third copy of the form must be retained in the provider’s records. View or print the AFMC contact information.
B. Requests for prior authorization of some medical supplies (i.e.: compression burn garments), orthotic appliances, prosthetic devices and all durable medical equipment, excluding wheelchairs and wheelchair seating systems, must be submitted to AFMC on the Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components Form (DMS-679A). View or print form DMS-679A.
|221.300 Approvals of Prior Authorization |4-6-15 |
A. The Arkansas Foundation for Medical Care (AFMC) reviews requests for prior authorization for wheelchair and wheelchair seating systems. If necessary, AFMC may request additional information.
1. When a request is approved for wheelchairs, wheelchair seating systems or wheelchair repair, a prior authorization control number will be assigned by AFMC. Determination of “purchase,” “rental only,” or “capped rental” will be made and an expiration date for “rental only” and “capped rental” items will be assigned. This information will be indicated on the copy of the form DMS-679 that is returned to the provider from AFMC within 30 working days of receipt of the prior authorization request.
2. Prior authorization may only be approved for a maximum of six (6) months (180 days) for beneficiaries of all ages. Within 30 working days before the end of currently prior authorized prosthetics services, the prosthetics provider must obtain a new prescription. If applicable, the provider must prepare and send a new Medical Equipment Request for Prior Authorization and Prescription Form (Form DMS-679), signed by the physician, to AFMC.
3. The effective date of the prior authorization will be the date on which the beneficiary’s physician prescribed prosthetics services or the day following the last day of the previously prior authorized time period, whichever comes last.
B. Consideration of prior authorization requests by AFMC requires correct completion of all fields on the request form. The prior authorization request form must contain current medical documentation necessitating use of the required prosthetics. If necessary, AFMC may request additional information.
1. When a PA request is approved, a prior authorization control number will be assigned by AFMC. View or print AFMC contact information. Prior authorization approvals will be authorized for a maximum of six (6) months (180 days) for beneficiaries of all ages. The effective date of the prior authorization will be the date on which the beneficiary’s physician prescribed prosthetics services or the day following the last day of the previously prior authorized time period, whichever comes last.
2. Within 30 working days before the end of currently authorized prosthetics services, the provider must obtain a new prescription. If applicable, the provider must prepare and submit a new Prescription and Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components (form DMS-679A) signed by the prescribing physician.
C. Providers should note the following authorization process exception.
1. Prior authorization numbers for “capped rental” items will be effective for the entire “capped rental” time period of 15 months. Therefore, only one prior authorization number is needed.
a. Providers may use the one prior authorization number for billing of “capped rental” items for all 15 months.
b. Previous prior authorization for an item will count toward the total 15-month period.
c. Providers must resubmit a request for prior authorization after the first 180 days.
d. Necessary information will be indicated on the copy of the notification letter sent to the provider within 30 working days of receipt of the prior authorization request.
|221.400 Denial of Prior Authorization Request |12-1-06 |
For denied cases, both Utilization Review and AFMC will mail a letter containing case specific rationale that explains why the request was not approved to the requesting provider and to the Medicaid beneficiary within 30 working days of receipt of the prior authorization request.
The provider may request reconsideration of the denial within thirty-five calendar days of the denial date. Requests must be made in writing and include additional documentation to substantiate the medical necessity of the requested services. Requests received after thirty-five calendar days of the denial date will not be accepted for reconsideration.
|221.500 Reconsideration of Denials |12-1-06 |
If the denial decision is reversed during the reconsideration review, an approval is forwarded to the provider specifying the approved units and services. If the denial decision is upheld, the provider and the Medicaid beneficiary will be notified in writing of the review determination.
Reconsideration is available only once per prior authorization request. However, if the denial is upheld during the reconsideration process, the provider may submit a new prior authorization request, for different dates of service, providing new supporting documentation is available. A subsequent prior authorization request will not be reviewed if it contains the same documentation submitted with the previous authorization and reconsideration requests.
|221.600 Fair Hearing Request |12-1-06 |
The Medicaid beneficiary may request a fair hearing of a denied review determination made by either Utilization Review, Department of Health and Human Services (DHHS) or the Arkansas Foundation for Medical Care (AFMC). The fair hearing request must be in writing and sent to the Appeals and Hearings Section of DHHS within thirty-five calendar days of the date on the denial letter. View or print the Department of Health and Human Services Appeals and Hearings Section contact information. Providers may refer to Section 190.000 for information regarding provider appeals through the Medicaid Fairness Act.
|230.000 REIMBURSEMENT | |
|231.000 Prosthetics Service Method of Reimbursement |10-13-03 |
Reimbursement for prosthetics services is based on the lesser of the amount billed or the Title XIX (Medicaid) maximum allowable.
Providers are cautioned that an approved prior authorization does not guarantee payment. Reimbursement is contingent upon eligibility of both the beneficiary and provider at the time service is provided and upon accurate completeness of the claim filed for the service. The provider is responsible for verifying the beneficiary’s eligibility by checking the beneficiary’s eligibility through the system.
|231.010 Fee Schedule |12-1-12 |
Arkansas Medicaid provides fee schedules on the Arkansas Medicaid website. The fee schedule link is located at under the provider manual section. The fees represent the fee-for-service reimbursement methodology.
Fee schedules do not address coverage limitations or special instructions applied by Arkansas Medicaid before final payment is determined.
Procedure codes and/or fee schedules do not guarantee payment, coverage or amount allowed. Information may be changed or updated at any time to correct a discrepancy and/or error. Arkansas Medicaid always reimburses the lesser of the amount billed or the Medicaid maximum.
|232.000 Specialized Wheelchair, Seating and Rehabilitative Equipment Reimbursement for Repairs |8-1-05 |
Reimbursement for repairs of specialized wheelchairs will be the manufacturer’s list price for parts listed less 40% manual equipment (dealer discount), 30% power equipment (dealer discount), plus 35% (profit margin), plus labor billed by the unit (15 min. = 1 unit). A maximum of twenty (20) units (20 units = 5 hours of labor) per date of service is allowable. Any applicable pages from the manufacturer’s catalog and the manufacturer’s invoice for parts must be attached to the claim form.
Reimbursement for specialized wheelchair equipment, seating and rehab items requiring manual pricing is calculated using the manufacturer’s current published suggested retail price less 15%. Any applicable pages from the manufacturer’s catalog that reflect a description and the manufacturer’s current published suggested retail price must be attached to the claim.
Kaye Products will be reimbursed at a set rate; therefore, the Kaye Products (procedure codes E1031, modifiers EP, U1; E1031, modifiers EP, U3; and E1031, modifiers EP, U4) may be billed electronically.
|233.000 Orthotic and Prosthetic Reimbursement for Repairs |11-1-17 |
Providers must bill for the repair of orthotic appliances and prosthetic devices utilizing the procedure codes listed in the table below. One unit of service equals 15 minutes. A maximum of 20 units of service is allowed per date of service. Any applicable pages from the manufacturer’s catalog and the manufacturer’s invoice for parts must be attached to all repair claims.
|National Procedure |Required Modifier| |
|Code | |Description |
|L4205 |— |Repair of orthotic appliances and prosthetic devices (non-EPSDT) |
|L4210 |— | |
|L7510 |— | |
|L7520 |— | |
|L4205 |EP |Repair of orthotic appliances and prosthetic devices (EPSDT) |
|L4210 |EP | |
|L7510 |EP, UB | |
|L7520 |— | |
Reimbursement for orthotic appliances and prosthetic devices requiring manual pricing will be calculated using the manufacturer’s invoice price plus 10%. The manufacturer invoice must be attached to all repair claims.
|234.000 Durable Medical Equipment (DME) Reimbursement for Repairs |8-1-05 |
Reimbursement for repairs of durable medical equipment (DME) will be manufacturer’s invoice price for parts plus 10% and labor billed per unit (15 minutes = 1 unit of service). A maximum of twenty (20) units (20 units = 5 hours of labor) per date of service is allowable. The manufacturer’s invoice must be attached to the repair claim for all parts.
Reimbursement for unlisted DME requiring manual pricing will be calculated using the manufacturer’s invoice price plus 10%. The manufacturer’s invoice must be attached to all repair claims.
|235.000 Speech Generating Device Reimbursement for Repairs |1-1-21 |
Reimbursement for repairs of speech generating device components will be manufacturer’s invoice price for parts plus 10%. Labor will be reimbursed per unit of service (1 unit = 15 minutes limited to a maximum of 20 units per date of service allowed).
|236.000 Reimbursement for Repair of the Enteral Nutrition Pump |4-1-09 |
Reimbursement for repairs to the enteral nutrition infusion pump requires prior authorization. Repairs will be approved only on equipment purchased by Medicaid. Therefore, no repairs will be reimbursable prior to the equipment becoming the property of the Medicaid beneficiary.
Requests for prior authorization for enteral pump repairs must be mailed to AFMC. (View or print AFMC contact information) on form DMS-679A titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components. (View or print form DMS-679A and instructions for completion.)
The repair invoice and the serial number of the equipment must accompany the prior authorization request form. Total repair costs to an infusion pump may not exceed $290.93. Medicaid will not reimburse for additional repairs to an infusion pump after the provider has billed repair invoices totaling $290.93. If the equipment is still not in proper working order after the provider has billed the Medicaid maximum allowed for repairs, the provider must supply the beneficiary with a new infusion pump and may bill either procedure code B9000 or B9002 after receiving prior authorization for the new piece of equipment.
|237.000 Rate Appeal Process |8-1-05 |
A provider may request reconsideration of a program decision by writing to the Assistant Director, Division of Medial Services. The request must be received within 20 calendar days following the application of policy and/or procedure or the notification of the provider of its rate. Upon receipt of the request for review, the Assistant Director will determine the need for a program/provider conference and will contact the provider to arrange a conference if needed. Regardless of the program decision, the provider will be afforded the opportunity for a conference, if he or she so wishes, for a full explanation of the factors involved and the program decision. Following review of the matter, the Assistant Director will notify the provider of the action to be taken by the Division within 20 calendar days of receipt of the request for review or the date of the program/provider conference.
When the provider disagrees with the decision of the Assistant Director, Division of Medical Services, the provider may appeal the question to a standing rate review panel established by the Director of the Division of Medical Services. The rate review panel will include one member of the Division of Medical Services, a representative of the provider association and a member of the Department of Human Services (DHS) management staff, who will serve as chairperson.
The request for review by the rate review panel must be postmarked within 15 calendar days following the notification of the initial decision by the Assistant Director, Division of Medical Services. The rate review panel will meet to consider the question(s) within 15 calendar days after receipt of a request for such appeal. The panel will hear the question(s) and a recommendation will be submitted to the Director of the Division of Medical Services.
|240.000 billing procedures | |
|241.000 Introduction to Billing |7-1-20 |
Prosthetics providers use the CMS-1500 form to bill the Arkansas Medicaid Program on paper for services provided to eligible Medicaid beneficiaries. Each claim may contain charges for only one (1) beneficiary.
Section III of this manual contains information about available options for electronic claim submission.
|242.000 CMS-1500 Billing Procedures | |
|242.100 HCPCS Procedure Codes |11-1-17 |
|242.105 Payment Methodology |8-1-05 |
Arkansas Medicaid has several methods of payment for all items covered by the Program. The following is a breakdown of the methods.
A. Purchase items are equipment that is purchased for or purchased by an eligible Medicaid beneficiary. The equipment may be new or used.
B. Rental-only items are those items paid by Arkansas Medicaid to providers for an unspecified time period on an as-needed basis. The equipment may be new or used.
C. A capped rental item is equipment whose purchase price exceeds $150.00. The items may be new or used. The items are reimbursed utilizing a daily rental rate. Medicaid pays the daily rental rate not to exceed a fifteen- (15-) month rental maximum (455 days). A period of continuous use allows for periods of interruption up to 60 consecutive days. If the interruption is 60 or fewer consecutive days, a new 15-month rental period will not begin. If the interruption is more than 60 days, a new 15-month rental period will begin.
D. After the total cost of a capped rental item has been reimbursed by Medicaid, the item remains the property of the DME provider. For items that have reached a 15-month rental cap, claims will be paid for maintenance and servicing fees after six months have passed from the end of the final paid rental month or from the end of the period the item is no longer covered under the supplier’s or manufacturer’s warranty, whichever is later.
E. Providers may be reimbursed for capped rental and rental-only items if the equipment is used fewer than 30 consecutive days from the first day of rental. This ensure the provider of adequate reimbursement for equipment used fewer than 30 days.
F. A rent-to-purchase item is an item for which Arkansas Medicaid reimburses a provider for the Medicaid-established purchase price of the item. After reimbursement has reached the maximum allowed, the equipment will become the property of the Medicaid beneficiary. Reimbursement is only approved for new equipment.
G. Initial rental transactions are those for which equipment is used in a beneficiary’s home for fewer than 30 consecutive days. Initial rental transactions must not be used by the provider to bill a month in advance. Arkansas Medicaid will only pay after services are rendered. An example of an initial rental transaction is that of a hospital bed delivered on July 2 and removed from the home after 10 days.
H. Manually priced items are those for which Arkansas Medicaid pays the manufacturer’s invoice price plus 10 percent. The provider must attach the invoice with their claim for services rendered.
I. A used item is any item that has been rented for 90 days or longer by anyone prior to the current Medicaid “rental only” or capped rental” transaction. The provider must maintain documentation that certifies a used item is reconditioned and in good working order and has no defect in workmanship or material.
J. Repair of a “rental only” item is covered in the rental fee. Repair of “purchased” items is covered separately. Total (cumulative) repair costs must not exceed 50% of the item’s total purchase cost.
|242.110 Respiratory and Diabetic Equipment, All Ages |11-1-17 |
When billed either electronically or on paper, procedure codes found in this section must be billed with certain modifiers. Modifiers in the section are indicated by the headings M1 and M2. When only the NU modifier is shown in the M1 column, the procedure code may be billed for beneficiaries of all ages. When NU and EP are listed together in the M1 column, the NU modifier must be used when billing for beneficiaries age 21 and over, and the EP modifier must be used when billing for beneficiaries under age 21. When a modifier is listed in the M2 heading, that modifier must be used in conjunction with either NU or EP.
Prior authorization requirements are shown under the heading PA. If prior authorization is needed, the information is indicated with a “Y” in the column; if not, an “N” is shown.
( Prior authorization is not required when other insurance pays at least 50% of the Medicaid maximum allowable reimbursement amount.
((…) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product. When using a procedure code with this symbol, the product must meet the indicated Arkansas Medicaid description.
|Respiratory and Diabetic Equipment, All Ages (Section 242.110) |
|National Procedure |M1 |M2 |Description |PA |Payment Method |
|Code | | | | | |
|A4230 |NU | |Infusion set for external insulin pump, non-needle cannula type|Y( |Purchase |
|A4231 |NU | |Infusion set for external insulin pump, needle type |Y( |Purchase |
|A4232 |NU | |Syringe with needle for external insulin pump, sterile, 3 cc |Y( |Purchase |
|A4627 |NU |UB |((Spacer bag or reservoir without mask, for use with metered |N |Purchase |
| | | |dose inhaler) Spacer, bag or reservoir, with or without mask, | | |
| | | |for use with metered dose inhaler | | |
|A4627 |NU | |((Spacer bag or reservoir with mask, for use with metered dose |N |Purchase |
| | | |inhaler) Spacer, bag or reservoir, with or without mask, for | | |
| | | |use with metered dose inhaler | | |
|A7045 |NU | |Exhalation port with or without swivel used with accessories |N |Purchase |
| | | |for positive airway devices, replacement only | | |
|A7046 |NU | |Water chamber for humidifier, used with positive airway |N |Purchase |
| | | |pressure device, replacement, each | | |
|E0424 |NU | |Stationary compressed gaseous oxygen system, rental; includes |Y( |Rental Only |
| | | |container, contents, regulator, flowmeter, humidifier, | | |
| | | |nebulizer, cannula or mask, and tubing | | |
|E0430 |NU | |Portable gaseous oxygen system, purchase, includes regulator, |Y( |Rental Only |
| | | |flowmeter, humidifier, cannula or mask, and tubing | | |
|E0434 |NU | |Portable liquid oxygen system, rental; includes portable |Y( |Rental Only |
| | | |container, supply reservoir, humidifier, flowmeter, refill | | |
| | | |adapter, contents gauge, cannula or mask, and tubing | | |
|E0435 |NU | |Portable liquid oxygen system, purchase; includes portable |Y( |Rental Only |
| | | |container, supply reservoir, flowmeter, humidifier, contents | | |
| | | |gauge, cannula or mask, tubing and refill adapter | | |
|E0439 |NU | |Stationary liquid oxygen system, rental; includes container, |Y( |Rental Only |
| | | |contents, regulator, flowmeter, humidifier, nebulizer, cannula | | |
| | | |or mask, and tubing | | |
|E0441 |NU | |Oxygen contents, gaseous (for use with owned gaseous stationary|Y |Purchase |
| | | |systems or when both a stationary and portable gaseous system | | |
| | | |are owned), one month’s supply = I unit | | |
|E0442 |NU | |Oxygen contents, liquid (for use with owned liquid stationary |Y |Purchase |
| | | |systems or when both a stationary and portable liquid system | | |
| | | |are owned), one month’s supply = 1 unit | | |
|E0443 |NU | |Portable oxygen contents, gaseous (for use only with portable |Y( |Purchase |
| | | |gaseous systems when no stationary gas or liquid system is | | |
| | | |used), one month’s supply=1 unit | | |
|E0444 |NU | |Portable oxygen contents, liquid (for use only with portable |Y( |Purchase |
| | | |liquid systems when no stationary gas or liquid system is | | |
| | | |used), one month’s supply=1 unit | | |
|E0470 |NU |RR |((BIPAP Device, Nasal Bi-level Positive Airway support system; |Y( |Rental Only |
| |EP |RR |includes necessary accessory items. NOTE: Complete medical |Y( | |
| | | |data pertinent to the request must be submitted with the prior | | |
| | | |authorization request.) Respiratory assist device, bi-level | | |
| | | |pressure capacity, without backup rate feature, used with | | |
| | | |noninvasive interface, e.g., nasal or facial mask (intermittent| | |
| | | |assist device with continuous positive airway pressure device) | | |
|E0471 |NU |RR |Respiratory assist device, bi-level pressure capacity, with |Y( |Rental Only |
| |EP |RR |backup rate feature, used with noninvasive interface, e.g., |Y( | |
| | | |nasal or facial mask (intermittent assist device with | | |
| | | |continuous positive airway pressure device) | | |
|E0472 |NU |RR |Respiratory assist device, bi-level pressure capacity, with |Y( |Rental Only |
| |EP |RR |backup rate feature, used with invasive interface, e.g., nasal |Y( | |
| | | |or facial mask (intermittent assist device with continuous | | |
| | | |positive airway pressure device) | | |
|E0482 |NUEP | |Cough stimulating device, alternating positive and negative |Y( |Capped Rental |
| | | |airway pressure | | |
|E0483 |NU |RR |((Bronchial Drainage System) High-frequency chest wall |Y( |Capped Rental |
| | | |oscillation air-pulse generator system (includes hoses and | | |
| | | |vest), each | | |
|E0483 |NU |UB |((Pulmonary Vest. The manufacturer invoice must be attached to|Y( |Purchase |
| | | |the claim form.) High-frequency chest wall oscillation | | |
| | | |air-pulse generator system (includes hoses and vest), each | | |
|E0560 |NU | |Humidifier, durable for supplemental humidification during IPPB|N |Purchase |
| |UE | |treatment or oxygen delivery | | |
|E0561 |NU | |Humidifier, non-heated, used w/positive airway pressure device |Y( |Purchase |
| |EP | | |Y( | |
|E0562 |NU | |Humidifier, heated, used w/positive airway pressure device |Y( |Purchase |
| |EP | | |Y( | |
|E0570 |NU | |Nebulizer, with compressor |Y( |Purchase |
| |UE | | | | |
|E0575 |NU | |Nebulizer, ultrasonic, large volume |Y( |Capped Rental |
| |UE | | | | |
|E0600 |NU | |Respiratory suction pump, home model, portable or stationary, |N |Rental Only |
| |UE | |electric | | |
|E0601 |NU |RR |((CPAP Device Nasal Continuous Positive Airway Pressure (CPAP) |Y( |Rental Only |
| | | |Device; includes necessary accessory items) NOTE: Complete | | |
| | | |medical data pertinent to the request must be submitted with | | |
| | | |the prior authorization request. NOTE: Bill E0601 as the | | |
| | | |global daily rental service. | | |
|E0784 |NU | |External ambulatory infusion pump, insulin |Y( |Purchase |
|E1354 |NU | |Oxygen accessory, wheeled cart for portable cylinder or |Y |Manually priced |
| | | |portable concentrator, any type, replacement only, each | | |
|E1390 |NU | |Oxygen concentrator, single delivery port, capable of |Y( |Rental Only |
| | | |delivering 85 % or greater oxygen concentration at the | | |
| | | |prescribed flow rate | | |
|E1391 |NU | |O2 concentrator, dual delivery port, capable of delivering 85% |Y( |Rental Only |
| | | |or greater oxygen concentration at the prescribed flow rate, | | |
| | | |each | | |
|242.111 Initial Rental of a DME Item for Individuals of All Ages |11-1-17 |
Procedure codes found in this section may be billed either electronically or on paper.
Some procedure codes have been assigned a modifier that affects the billing process. Required modifiers are indicated in the M1 column in the list below. When a modifier is shown in the M1 column, it must be listed along with the procedure code when requesting payment by Arkansas Medicaid.
Procedure codes shown in the list below are either covered for all ages (AA), only for individuals under age 21 (U21) or only for individuals age 21 and over (21+). A column in the list below defines the differences.
( Prior authorization is not required when other insurance pays at least 50% of the Medicaid maximum allowable reimbursement amount.
((…) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product. When using a procedure code with this symbol, the product must meet the indicated Arkansas Medicaid description.
|Initial Rental of a DME Item for Individuals of All Ages (Section 242.111) |
|National Procedure |M1 |Description |All |
|Code | | |U21 |
| | | |21+ |
|E0181 | |Pressure pad, alternating with pump, heavy-duty |U21 |
|E0200 | |Heat lamp, without stand (table model), includes bulb, or infrared element |U21 |
|E0205 | |Heat lamp, with stand includes bulb, or infrared element |U21 |
|E0217 | |Water circulating heat pad with pump |U21 |
|E0225 | |Hydrocollator unit, includes pad |U21 |
|E0236 | |Pump for water circulating pad |U21 |
|E0239 | |Hydrocollator unit, portable |U21 |
|E0250( | |Hospital bed, fixed height, with any type side rails, with mattress |U21 |
|E0250( |U1 |Hospital bed, fixed height, with any type side rails, with mattress |U21 |
|E0250( |UE |Hospital bed, fixed height, with any type side rails, with mattress |21+ |
|E0255( | |Hospital bed, variable height; hi-lo, with any type side rails, with mattress |U21 |
|E0255 |KH |Hospital bed, variable height; hi-lo, with any type side rails, with mattress |21+ |
|E0260( | |Hospital bed, semi-electric (head and foot adjustment), with any type side rails with |U21 |
| | |mattress | |
|E0260( |KH |Hospital bed, semi-electric (head and foot adjustment), with any type side rails with |21+ |
| | |mattress | |
|E0271 | |Mattress, inner spring |U21 |
|E0272 | |Mattress, foam rubber |U21 |
|E0303 | |Hospital bed, heavy-duty, extra wide, with weight capacity > 350 but < or = 600, any |AA |
| | |type side rails, w/mattress | |
|E0424 | |Stationary compressed gaseous oxygen system, rental; includes container, contents, |AA |
| | |regulator flowmeter, humidifier, nebulizer cannula or mask, and tubing | |
|E0430( | |Portable gaseous oxygen system, purchase, includes regulator, flowmeter, humidifier, |AA |
| | |cannula, or mask, and tubing | |
|E0434 | |Portable liquid oxygen system, rental; includes portable container, supply reservoir, |AA |
| | |humidifier, flowmeter, refill adaptor, contents gauge, cannula or mask, and tubing | |
|E0435( | |Portable liquid oxygen system, purchase; includes portable container, supply reservoir,|AA |
| | |flowmeter, humidifier, contents gauge, cannula or mask, tubing and refill adapter | |
|E0439 | |Stationary liquid oxygen system, rental; includes container, contents, regulator, |AA |
| | |flowmeter, humidifier, nebulizer, cannula or mask, and tubing | |
|E0445( | |Oximeter for measuring blood oxygen levels non-invasively. ( (Pulse oximeter, |AA |
| | |including 4 disposable probes) | |
|E0480 | |Percussor, electric or pneumatic, home model |U21 |
|E0565( | |Compressor, air power source for equipment which is not self-contained or cylinder |U21 |
| | |driven | |
|E0575( | |Nebulizer, ultrasonic, large volume |AA |
|E0585 | |Nebulizer, with compressor and heater |U21 |
|E0600 | |Respiratory suction pump, home model, portable or stationary, electric |AA |
|E0606 | |Vaporizer, room type |U21 |
|E0630( | |Patient lift, hydraulic, with seat or sling |U21 |
|E0630 |KH |Patient lift, hydraulic, with seat or sling |21+ |
|E0650( | |Pneumatic compressor, nonsegmental home model |U21 |
|E0667( | |Segmental pneumatic appliance for use with pneumatic compressor, full leg |U21 |
|E0668( | |Segmental pneumatic appliance for use with pneumatic compressor, full arm |U21 |
|E0691 | |Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection;|U21 |
| | |treatment area two square feet or less | |
|E0692 | |Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection;|U21 |
| | |four foot panel | |
|E0693 | |Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection;|U21 |
| | |six foot panel | |
|E0694 | |Ultraviolet multidirectional light therapy system in six foot cabinet includes |U21 |
| | |bulbs/lamps, timer and eye protection | |
|E0720( | |TENS, two lead, localized stimulation |U21 |
|E0730( | |Transcutaneous electrical nerve stimulation (TENS) device, four or more leads, for |AA |
| | |multiple nerve stimulation | |
|E0730( |KH |Transcutaneous electrical nerve stimulation (TENS) device, four or more leads, for |21+ |
| | |multiple nerve stimulation | |
|E0745( | |Neuromuscular stimulator, electronic shock unit |U21 |
|E0779( | |((Ambulatory infusion device, payable only when services are provided to patients |AA |
| | |receiving chemotherapy, pain management or antibiotic treatment in the home) | |
| | |Ambulatory infusion device pump, mechanical, reusable, for infusion 8 hours or greater | |
|E0910 | |Trapeze bars, also known as Patient Helper, attached to bed, with grab bar |AA |
|E0910 |KH |Trapeze bars, also known as Patient Helper, attached to bed, with grab bar |21+ |
|E0911 | |Trapeze bar, heavy-duty, for patient weight capacity greater than 250 pounds, attached |AA |
| | |to bed, with grab bar | |
|E0920 | |Fracture frame, attached to bed, includes weights |U21 |
|E0930 | |Fracture frame, freestanding, includes weights |U21 |
|E0935( | |Passive motion exercise device |U21 |
|E0940 | |Trapeze bar, freestanding, complete with grab bar |U21 |
|E0941 | |Gravity assisted traction device, any type |U21 |
|E1130( | |Standard wheelchair, fixed full-length arms, fixed or swing–away, detachable footrests |U21 |
|E1130( |KH |Standard wheelchair, fixed full-length arms, fixed or swing–away, detachable footrests |21+ |
|E1224( | |Wheelchair with detachable arms, elevating legrests |AA |
|E1224( |U1 |((Footrests wheelchair with detachable arms, elevating leg rests) Wheelchair with |21+ |
| | |detachable arms, elevating legrests | |
|E1390 | |Oxygen concentrator, single delivery port, capable of delivering 85% or greater oxygen |AA |
| | |concentration at the prescribed flow rate | |
|E1391 | |Oxygen concentrator, dual delivery port, capable of delivering 85 percent or greater |AA |
| | |oxygen concentration at the prescribed flow rate, each | |
Providers will be reimbursed for a minimum of 30 days of rental when the equipment is used less than 30 days. Initial rental codes must be billed when equipment is used less than 30 days during the first month of rental.
Arkansas Medicaid will only reimburse for one initial minimum 30 days of rental per state fiscal year period per beneficiary per procedure code. The provider will not be reimbursed for the same procedure code utilizing another modifier for the same time period.
|242.112 Home Blood Glucose Monitor and Supplies – Pregnant Women Only, All Ages |11-1-17 |
Procedure codes found in this section must be billed either electronically or on paper with modifier NU for individuals of all ages. When a second modifier is listed, that modifier must be used in conjunction with the NU modifier.
Modifiers in the section are indicated by the headings M1 and M2. Prior authorization is indicated by the heading PA.
|National Procedure |M1 |M2 |Description |PA |Payment Method |
|Code | | | | | |
|E0607 |NU |U1 |Home Blood Glucose Monitor |N |Purchase |
|A4253 |NU |U1 |Blood glucose test or reagent strips for home glucose monitor, per|N |Purchase |
| | | |50 strips | | |
|A4259 |NU |U2 |Lancets, per box of 100 |N |Purchase |
|242.120 Medical Supplies for Beneficiaries of All Ages |8-15-18 |
Procedure codes found in this section must be billed either electronically or on paper using modifier NU for beneficiaries of all ages. When a second modifier is listed, that modifier must be used in conjunction with the modifier NU.
Modifiers in this section are indicated by the headings M1 and M2
1 Not all medical supplies require prior authorization. Supplies with this symbol require prior authorization. Form DMS-679A must be used to request prior authorization. Note: Compression burn garments are manually priced. The manufacturer’s invoice must be submitted with the request for compression burn garments. View or print form DMS-679A and instructions for completion.
((…) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product. When using a procedure code with this symbol, the product must meet the indicated Arkansas Medicaid description.
|Medical Supplies, All Ages (Section 242.120) |
|National Procedure |M1 |M2 |Description |
|Code | | | |
|A4206 |NU | |Syringe with needle, sterile, 1 cc., each |
|A4207 |NU | |Syringe with needle, sterile, 2 cc., each |
|A4209 |NU | |Syringe with needle, sterile, 5 cc. or greater, each |
|A4213 |NU | |Syringe, sterile, 20 cc. or greater, each |
|A4216 |NU | |Sterile water/saline and/or dextrose, diluent/flush, 10 ml. |
|A4217 |NU | |Sterile water/saline, 500 ml. |
|A42211 |NU | |Supplies for maintenance of drug infusion catheter, per week (list drug separately) |
|A42221 |NU | |Supplies for external drug infusion pump, per cassette or bag (list drug separately) |
|A4224 |NU | |Supplies for maintenance of insulin infusion catheter, per week |
|A4225 |NU | |Supplies for external insulin infusion pump, syringe type cartridge, sterile, each |
|A4253 |NU |UB |((Blood glucose test or reagent strips for home blood glucose monitor, per 25 strips) |
|A4253 |NU | |Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips |
|A4256 |NU | |Normal, low, and high calibrator solution/chips |
|A4259 |NU | |Lancets, per box of 100 |
|A4265 |NU | |Paraffin, per lb. |
|A4310 |NU | |Insertion tray without drainage bag and without catheter (accessories only) |
|A4311 |NU | |Insertion tray without drainage bag with indwelling catheter, Foley type, 2-way latex with |
| | | |coating (Teflon, silicone, silicone elastomer or hydrophilic, etc.) |
|A4312 |NU | |Insertion tray without drainage bag with indwelling catheter, Foley type, 2-way, all silicone |
|A4313 |NU | |Insertion tray without drainage bag with indwelling catheter, Foley type, 3-way, for continuous|
| | | |irrigation |
|A4314 |NU | |Insertion tray with drainage bag with indwelling catheter, Foley type, 2-way latex with coating|
| | | |(Teflon, silicone, silicone elastomer or hydrophilic, etc.) |
|A4315 |NU | |Insertion tray with drainage bag with indwelling catheter, Foley type, 2-way, all silicone |
|A4316 |NU | |Insertion tray with drainage bag with indwelling catheter, Foley type, 3-way, for continuous |
| | | |irrigation |
|A4320 |NU | |Irrigation tray with bulb or piston syringe, any purpose |
|A4322 |NU | |Irrigation syringe, bulb or piston, each |
|A4326 |NU | |Male external catheter with integral collection chamber, any type each |
|A4327 |NU | |Female external urinary collection device; metal cup, each |
|A4328 |NU | |Female external urinary collection device; pouch, each |
|A4330 |NU | |Perianal fecal collection pouch with adhesive, each |
|A4331 |NU | |Extension drainage tubing, any type, any length, with connector/adaptor, for use with urinary |
| | | |leg bag or urostomy pouch, each |
|A4338 |NU | |Indwelling catheter, Foley type, 2-way latex with coating (Teflon, silicone, silicone elastomer|
| | | |or hydrophilic, etc.), each |
|A4340 |NU | |Indwelling catheter; specialty type (e.g., Coude, mushroom, wing, etc.), each |
|A4344 |NU | |Indwelling catheter, Foley type, 2-way, all silicone, each |
|A4346 |NU | |Indwelling catheter, Foley type, 3-way for continuous irrigation, each |
|A4349 |NU | |Male external catheter with or without adhesive, disposable, each |
|A4351 |NU | |Intermittent urinary catheter; straight tip, with or without coating (Teflon, silicone, |
| | | |silicone elastomer or hydrophilic, etc.), each |
|A4351 |NU |U1 |Intermittent urinary catheter; disposable straight tip, with or without coating (Teflon, |
| | | |silicone, silicone elastomer or hydrophilic, etc.), each |
|A4352 |NU | |Intermittent urinary catheter; Coude (curved) tip, with or without coating (Teflon, silicone, |
| | | |silicone elastomeric or hydrophilic, etc.), each |
|A4352 |NU |U1 |Intermittent urinary catheter; Coude (curved) tip, with or without coating (Teflon, silicone, |
| | | |silicone elastomeric or hydrophilic, etc.), each |
|A4353 |NU | |Intermittent urinary catheter, with insertion supplies |
|A4353 |NU |U2 |Intermittent urinary catheter, with insertion supplies |
|A4354 |NU | |Insertion tray with drainage bag but without catheter |
|A4355 |NU | |Irrigation tubing set for continuous bladder irrigation through a 3-way indwelling Foley |
| | | |catheter, each |
|A4356 |NU | |External urethral clamp or compression device (not to be used for catheter clamp), each |
|A4357 |NU | |Bedside drainage bag, day or night, with or without anti reflux device, with or without tube, |
| | | |each |
|A4358 |NU | |Urinary drainage bag, leg or abdomen, vinyl, with or without tube, with straps, each |
|A4361 |NU | |Ostomy faceplate, each |
|A4362 |NU | |Skin barrier; solid, four by four or equivalent; each |
|A4364 |NU | |Adhesive, liquid, or equal, any type, per oz. |
|A4367 |NU | |Ostomy belt, each |
|A4368 |NU | |Ostomy filter, any type, each |
|A4369 |NU | |Ostomy skin barrier, liquid, (spray, brush, etc.), per oz. |
|A4371 |NU | |Ostomy skin barrier, powder, per oz. |
|A4394 |NU | |Ostomy deodorant, with or without lubricant, for use in ostomy pouch, per fl. oz. |
|A4397 |NU | |Irrigation supply; sleeve, each |
|A4398 |NU | |Ostomy irrigation supply; bag, each |
|A4399 |NU | |Ostomy irrigation supply; cone/catheter, including brush |
|A4400 |NU | |Ostomy irrigation set |
|A4402 |NU | |Lubricant, per oz. |
|A4404 |NU | |Ostomy ring, each |
|A4405 |NU | |Ostomy skin barrier, nonpectin-based, paste, per oz. |
|A4406 |NU | |Ostomy skin barrier, pectin-based, paste, per oz. |
|A4407 |NU | |Ostomy skin barrier, with flange (solid, flexible, or accordion), extended wear, with built-in |
| | | |convexity, 4 x 4 in. or smaller, each |
|A4414 |NU | |Ostomy skin barrier, with flange (solid, flexible or accordion), without built-in convexity, 4 |
| | | |x 4 in. or smaller, each |
|A4425 |NU | |Ostomy pouch, drainable; for use on barrier with non-locking flange, with filter (2 piece |
| | | |system), each |
|A4435 |NU | |Ostomy pouch, drainable, high output, with extended wear barrier (one piece system), with or |
| | | |without filter, each |
|A4450 |NU |U1 |Tape, nonwaterproof, per 18 sq. in. |
|A4452 |NU | |Tape, waterproof, per 18 sq. in. |
|A4455 |NU | |Adhesive remover or solvent (for tape, cement or other adhesive), per oz. |
|A4456 |NU | |Adhesive remover; any type |
|A4483 |NU |U1 |((non-vent, trach nose) Moisture exchanger, disposable, for use with invasive mechanical |
| | | |ventilation |
|A4558 |NU | |Conductive gel or paste, for use with electrical device (e.g., TENS, NMES), per oz. |
|A4561 |NU |U1 |Pessary, rubber, any type |
|A4562 |NU | |Pessary, non-rubber, any type |
|A4623 |NU | |Tracheostomy, inner cannula |
|A4624 |NU | |Tracheal suction catheter, any type other than closed system, each |
|A4625 |NU | |Tracheostomy care kit for new tracheostomy |
|A4626 |NU | |Tracheostomy cleaning brush, each |
|A4628 |NU | |Oropharyngeal suction catheter, each |
|A4629 |NU | |Tracheostomy care kit for established tracheostomy |
|A4772 |NU | |Blood glucose test strips, for dialysis, per 50 |
|A4927 |NU | |Gloves, non-sterile, per 100 |
|A5051 |NU | |Ostomy pouch, closed; with barrier attached (1 piece), each |
|A5052 |NU | |Ostomy pouch, closed; without barrier attached (1 piece), each |
|A5053 |NU | |Ostomy pouch, closed; for use on faceplate, each |
|A5054 |NU | |Ostomy pouch, closed; for use on barrier with flange (2 piece), each |
|A5055 |NU | |Stoma cap |
|A5056 |NU | |Ostomy pouch, drainable; with extended wear barrier attached, with filter, 1 piece, each |
|A5057 |NU | |Ostomy pouch, drainable; with extended wear barrier attached, with built in convexity, with |
| | | |filter, 1 piece, each |
|A5061 |NU |U1 |Ostomy pouch, drainable; with barrier attached (1 piece), each |
|A5062 |NU | |Ostomy pouch, drainable; without barrier attached (1 piece), each |
|A5063 |NU | |Ostomy pouch, drainable; for use on barrier with flange (2-piece system), each |
|A5071 |NU | |Ostomy pouch, urinary; with barrier attached (1 piece), each |
|A5072 |NU | |Ostomy pouch, urinary; without barrier attached (1 piece), each |
|A5073 |NU | |Ostomy pouch, urinary; for use on barrier with flange (2 piece), each |
|A5081 |NU | |Continent device; plug for continent stoma |
|A5082 |NU | |Continent device; catheter for continent stoma |
|A5093 |NU | |Ostomy accessory; convex insert |
|A5102 |NU | |Bedside drainage bottle, with or without tubing, rigid or expandable, each |
|A5105 |NU | |Urinary suspensory with leg bag, with or without tube, each |
|A5112 |NU | |Urinary leg bag; latex |
|A5113 |NU | |Leg strap; latex, replacement only, per set |
|A5114 |NU | |Leg strap; foam or fabric, replacement only, per set |
|A5120 |NU | |Skin barrier, wipes or swabs, each |
|A5121 |NU | |Skin barrier; solid, 6 x 6 or equivalent, each |
|A5122 |NU | |Skin barrier; solid, 8 x 8 or equivalent, each |
|A5126 |NU | |Adhesive or non-adhesive; disk or foam pad |
|A5131 |NU | |Appliance cleaner, incontinence and ostomy appliances, per 16 oz. |
|A6021 |NU | |Collagen dressing, sterile, size 16 sq. in. or less, each |
|A6022 |NU | |Collagen dressing, sterile, size more than 16 sq. in. but less than or equal to 48 sq. in., |
| | | |each |
|A6023 |NU | |Collagen dressing, sterile, size more than 48 sq. in., each |
|A6024 |NU | |Collagen dressing wound filler, sterile, per 6 in. |
|A6154 |NU | |Wound pouch, each |
|A6196 |NU | |Alginate or other fiber gelling dressing, wound cover, pad size 16 sq. in. or less, each |
| | | |dressing |
|A6197 |NU | |Alginate or other fiber gelling dressing, wound cover, sterile, pad size more than 16 sq. in. |
| | | |but less than or equal to 48 sq. in., each dressing |
|A6197 |NU |UB |Alginate or other fiber gelling dressing, wound cover, sterile, pad size more than 16 sq. in. |
| | | |but less than or equal to 48 sq. in., each dressing ((1 linear yard) |
|A6198 |NU | |Alginate or other fiber gelling dressing, wound cover, sterile, pad size more than 48 sq. in., |
| | | |each dressing |
|A6203 |NU | |Composite dressing, sterile, pad size 16 sq. in. or less, with any size adhesive border, each |
| | | |dressing |
|A6204 |NU | |Composite dressing, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. |
| | | |in., with any size adhesive border, each dressing |
|A6205 |NU | |Composite dressing, sterile, pad size more than 48 sq. in., with any size adhesive border, each|
| | | |dressing |
|A6209 |NU | |Foam dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing|
|A6210 |NU | |Foam dressing, wound cover, pad size more than 16 sq. in., but less than or equal to 48 sq. |
| | | |in., without adhesive border, each dressing |
|A6211 |NU | |Foam dressing, wound cover, sterile, pad size more than 48 sq. in., without adhesive border, |
| | | |each dressing |
|A6212 |NU | |Foam dressing, wound cover, sterile, pad size 16 sq. in. or less, with any size adhesive |
| | | |border, each dressing |
|A6213 |NU | |Foam dressing, wound cover, sterile, pad size more than 16 sq. in but less than or equal to 48 |
| | | |sq. in., with any size adhesive border, each dressing |
|A6216 |NU | |Gauze, nonimpregnated, non-sterile, pad size 16 sq. in. or less, without adhesive border, each |
| | | |dressing |
|A6219 |NU | |Gauze, nonimpregnated, sterile, 16 sq. in. or less with any size adhesive border, each dressing|
|A6220 |NU | |Gauze, non-impregnated, sterile, pad size more than 16 sq. in., but less than or equal to 48 |
| | | |sq. in., with any size adhesive border, each dressing |
|A6221 |NU | |Gauze, non-impregnated, sterile, pad size more than 48 sq. in., with any size adhesive border, |
| | | |each dressing |
|A6228 |NU | |Gauze, impregnated, water or normal saline, sterile, pad, size 16 sq. in. or less, without |
| | | |adhesive border, each dressing |
|A6229 |NU | |Gauze, impregnated, water or normal saline, sterile, pad size more than 16 sq. in., but less |
| | | |than or equal to 48 sq. in., without adhesive border, each dressing |
|A6230 |NU | |Gauze, impregnated, water or normal saline, sterile, pad size more than 48 sq. in., without |
| | | |adhesive border, each dressing |
|A6234 |NU | |Hydrocolloid dressing, wound cover, sterile, pad size 16 sq. in. or less, without adhesive |
| | | |border, each dressing |
|A6234 |NU |U1 |((Hydrocolloid dressing, wound cover, sterile, pad size greater than 16 sq. in. , without |
| | | |adhesive border, each dressing) |
|A6235 |NU | |Hydrocolloid dressing, wound cover, sterile, pad size more than 16 sq. in., but less than or |
| | | |equal to 48 sq. in., without adhesive border, each dressing |
|A6236 |NU | |Hydrocolloid dressing, wound cover, sterile, pad size more than 48 sq. in., without adhesive |
| | | |border, each dressing |
|A6237 |NU | |Hydrocolloid dressing, wound cover, sterile, pad size 16 sq. in. or less, with any size |
| | | |adhesive border, each dressing |
|A6237 |NU |U1 |((Hydrocolloid dressing, wound cover, sterile, pad size greater than 16 sq. in., with any size |
| | | |adhesive border, each dressing) |
|A6238 |NU | |Hydrocolloid dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or |
| | | |equal to 48 sq. in., with any size adhesive border, each dressing |
|A6238 |NU |U1 |Hydrocolloid dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or |
| | | |equal to 48 sq. in., with any size adhesive border, each dressing |
|A6239 |NU | |Hydrocolloid dressing, wound cover, sterile, pad size more than 48 sq. in., with any size |
| | | |adhesive border, each dressing |
|A6241 |NU | |Hydrocolloid dressing, wound filler, dry form, sterile, per gram |
|A6242 |NU | |Hydrogel dressing, wound cover, sterile, pad size 16 sq. in. or less, without adhesive border, |
| | | |each dressing |
|A6242 |NU |U1 |((Hydrogel dressing, wound cover, sterile, pad size greater than 16 sq. in., without adhesive |
| | | |border, each dressing) |
|A6243 |NU | |Hydrogel dressing, wound cover, sterile, pad size more than 16 sq. in., but less than or equal |
| | | |to 48 sq. in., without adhesive border, each dressing |
|A6244 |NU | |Hydrogel dressing, wound cover, sterile, pad size more than 48 sq. in. without adhesive border,|
| | | |each dressing |
|A6245 |NU | |Hydrogel dressing, wound cover, sterile, pad size 16 sq. in. or less, with any size adhesive |
| | | |border, each dressing |
|A6246 |NU | |Hydrogel dressing, wound cover, sterile, pad size more than 16 sq. in., but less than or equal |
| | | |to 48 sq. in., with any size adhesive border, each dressing |
|A6247 |NU | |Hydrogel dressing, wound cover, sterile, pad size more than 48 sq. in. with any size adhesive |
| | | |border, each dressing |
|A6248 |NU | |Hydrogel dressing, wound filler, gel, sterile, per fl. oz. |
|A6248 |NU |U1 |Hydrogel dressing, wound filler, gel, sterile, per fl. oz. |
|A6257 |NU | |Transparent film, sterile, 16 sq. in. or less, each dressing |
|A6258 |NU | |Transparent film, sterile, more than 16 sq. in., but less than or equal to 48 sq. in., each |
| | | |dressing |
|A6259 |NU | |Transparent film, sterile, more than 48 sq. in., each dressing |
|A6403 |NU | |Gauze, nonimpregnated, sterile, pad size more than 16 sq. in. less than 48 sq. in., without |
| | | |adhesive border, each dressing |
|A6404 |NU | |Gauze, nonimpregnated, sterile, pad size more than 48 sq. in., without adhesive border, each |
| | | |dressing |
|A6441 |NU | |Padding bandage, nonelastic, nonwoven/nonknitted, width greater than or equal to 3 in. and less|
| | | |than 5 in., per yd. |
|A6442 |NU | |Conforming bandage, nonelastic, knitted/woven, nonsterile, width less than 3 in., per yd. |
|A6443 |NU | |Conforming bandage, nonelastic, knitted/woven, nonsterile, width greater than or equal to 3 in.|
| | | |and less than 5 in., per yd. |
|A6444 |NU | |Conforming bandage, nonelastic, knitted/woven, nonsterile, width greater than or equal to 5 |
| | | |in., per yd. |
|A6445 |NU | |Conforming bandage, nonelastic, knitted/woven sterile, width less than 3 in., per yd. |
|A6446 |NU | |Conforming bandage, nonelastic, knitted/woven, sterile, width greater than or equal to 3 in. |
| | | |and less than 5 in., per yd. |
|A6447 |NU | |Conforming bandage, nonelastic, knitted/woven, sterile, width greater than or equal to 5 in., |
| | | |per yd. |
|A6448 |NU | |Light compression bandage, elastic, knitted/woven width less than 3in., per yd. |
|A6449 |NU | |Light compression bandage, elastic, knitted/woven, width greater than or equal to 3 in. and |
| | | |less than 5 in., per yd. |
|A6450 |NU | |Light compression bandage, elastic, knitted/woven, width greater than or equal to 5 in., per |
| | | |yd. |
|A6451 |NU | |Moderate compress bandage, elastic, knitted/woven load resistance of 1.25 to 1.34 ft. lbs. at |
| | | |50% maximum stretch, width greater than or equal to 3 in. and less than 5 in., per yd. |
|A6452 |NU | |High compress bandage, elastic, knitted/woven, load resistance greater than or equal to 1.35 |
| | | |ft. lbs. at 50 % maximum stretch, width greater than or equal to 3 in. and less than 5 in., per|
| | | |yd. |
|A6453 |NU | |Self-adherent bandage, elastic, nonknitted/nonwoven, width less than 3 in., per yd. |
|A6454 |NU | |Self-adherent bandage, elastic, nonknitted/nonwoven, width greater than or equal to 3 in and |
| | | |less than 5 in., per yd. |
|A6455 |NU | |Self-adherent bandage, elastic, nonknitted/nonwoven, width greater than or equal to 5 in., per |
| | | |yd. |
|A65011 |NU | |Compression burn garment, bodysuit (head to foot), custom fabricated |
|A65021 |NU | |Compression burn garment, chin strap, custom fabricated |
|A65031 |NU | |Compression burn garment, facial hood, custom fabricated |
|A65041 |NU | |Compression burn garment, glove to wrist, custom fabricated |
|A65051 |NU | |Compression burn garment, glove to elbow, custom fabricated |
|A65061 |NU | |Compression burn garment, glove to axilla, custom fabricated |
|A65071 |NU | |Compression burn garment, foot to knee length, custom fabricated |
|A65081 |NU | |Compression burn garment, foot to thigh length, custom fabricated |
|A65091 |NU | |Compression burn garment, upper trunk to waist including arm openings (vest), custom fabricated|
|A65101 |NU | |Compression burn garment, trunk including arms down to leg openings (leotard), custom |
| | | |fabricated |
|A65111 |NU | |Compression burn garment, lower trunk including leg openings (panty), custom fabricated |
|A65121 |NU | |Compression burn garment, not otherwise classified |
|A65131 |NU | |Compression burn mask, face and/or neck, plastic or equal, custom fabricated |
|A7520 |NU | |Tracheostomy/laryngectomy tube, noncuffed, polyvinylchloride (PVC), silicone or equal, each |
|A7521 | | |Tracheostomy/laryngectomy tube, cuffed, polyvinylchloride (PVC), silicone or equal, each |
|A7522 | | |Tracheostomy/laryngectomy tube, stainless steel or equal, (sterilizable and reusable), each |
|A7524 | | |Tracheostoma stent/stud/button, each |
|A7525 | | |Tracheostomy mask, each |
|B4087 |NU | |Gastrostomy/jejunostomy tube, standard, any material, any type, each |
|E0776 |NU | |IV pole |
|E0779 |NU |RR |((Ambulatory infusion device, payable only when services are provided to patients receiving |
| | | |chemotherapy, pain management or antibiotic treatment in the home) Ambulatory infusion pump, |
| | | |mechanical, reusable, for infusion 8 hours or greater |
|J1642 |NU | |Injection, heparin sodium, (heparin lock flush), per 10 units |
|242.121 Food Thickeners, All Ages |11-1-17 |
Food thickeners, including “Thick-It,” “Thick-It II,” “Simply Thick,” “Thick and Easy” and “Thick and Clear” are not subject to the $250 medical supply benefit limit.
The modifier NU must be used with the procedure code found in this section and when food thickeners are to be administered enterally, the modifier “BA” must be used in conjunction with the procedure code.
When food thickeners are billed, total units are to be calculated to the nearest full ounce. Partial units may not be rounded up. When a date span is billed, the product cannot be billed until the end date has elapsed.
The maximum number of units allowed for food thickeners is 16 units per date of service.
|National Procedure |M1 |M2 |Description |
|Code | | | |
|B4100 |NU | |Food thickener, administered orally, per oz. |
|B4100 |NU |BA |Food thickener, administered enterally, per oz. |
|242.122 Jobst Stocking for Beneficiaries of All Ages |11-1-17 |
The gradient compression stocking (Jobst) is payable for beneficiaries of all ages. However, before supplying the item, the Jobst stocking must be prior authorized by AFMC. View or print form DMS-679A and instructions for completion. Documentation accompanying form DMS-679A must indicate that the beneficiary has severe varicose veins with edema, or a venous statis ulcer, unresponsive to conventional therapy such as wrappings, over-the-counter stockings and Unna boots. The documentation must include clinical medical records from a physician detailing the failure of conventional therapy.
|National Procedure |M1 |M2 |Description |Maximum Units |
|Code | | | | |
|A6530 |NU | |Gradient compression stocking, below knee, 18-30mm Hg, |Maximum 4 units per date of |
| |EP | |each |service |
|A6549 |NU | |Gradient compression stocking, NOS (Jobst); 1 unit = 1 |Maximum 4 units per date of |
| | | |stocking |service |
|242.123 Negative Pressure Wound Therapy Pump Accessories and Supplies for Beneficiaries Ages 2 Years and Older |11-1-17 |
Effective for dates of service on or after May 11, 2012, procedure codes found in this section must be billed either electronically or on paper with modifier EP for beneficiaries aged 2-20 years or modifier NU for beneficiaries aged 21 and over.
Modifiers in this section are indicated by the heading M1. Prior authorization is indicated by the heading PA. If prior authorization is required, that information is indicated with a “Y” in the column, or if not, an “N” is shown.
|Negative Pressure Wound Therapy Pump Accessories and Supplies for Beneficiaries Ages 2 Years and Older (Section 242.123) |
|National Procedure |M1 | |Description |PA |Age Restriction |
|Code | | | | | |
|A6550 |NU | |Wound care set, for negative pressure wound therapy |Y |21 years and over |
| | | |electrical pump, includes all supplies and accessories | | |
|A6550 |EP | |Wound care set, for negative pressure wound therapy |Y |2-20 years |
| | | |electrical pump, includes all supplies and accessories | | |
|A7000 |NU | |Disposable canister, used with suction pump, each |Y |21 years and over |
|A7000 |EP | |Disposable canister, used with suction pump, each |Y |2-20 years |
|E2402 |NU | |Negative pressure wound therapy electrical pump, stationary |Y |21 years and over |
| | | |or portable | | |
|E2402 |EP | |Negative pressure wound therapy electrical pump, stationary |Y |2-20 years |
| | | |or portable | | |
|242.130 Diapers and Underpads for Beneficiaries Ages 3 Years and Older |11-1-17 |
Procedure codes found in this section must be billed either electronically or on paper with modifier EP for beneficiaries under 21 years of age or modifier NU for beneficiaries age 21 and over. When a second modifier is listed, that modifier must be used in conjunction with either EP or NU.
Modifiers in this section are indicated by the headings M1 and M2. Prior authorization is indicated by the heading PA. If prior authorization is required, that information is indicated with a “Y” in the column, or if not, an “N” is shown.
((…) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product. When using a procedure code with this symbol, the product must meet the indicated Arkansas Medicaid description.
|Diapers and Underpads, 3 Years Old and Older (Section 242.130) |
|National Procedure |M1 |M2 |Description |PA |Payment Method |
|Code | | | | | |
|A4335 |NU |UB |Incontinence supply; miscellaneous |N |Purchase |
|A4554 |NU | |Disposable underpads, all sizes (e.g., Chux’s) |N |Purchase |
|T4521 |NU | |Adult-sized disposable incontinence product, brief/diaper, |N |Purchase |
| | | |small, each | | |
|T4522 |NU | |Adult-sized disposable incontinence product, brief/diaper, |N |Purchase |
| | | |medium, each | | |
|T4523 |NU | |Adult-sized disposable incontinence product, brief/diaper, |N |Purchase |
| | | |large, each | | |
|T4524 |NU | |Adult-sized disposable incontinence product, brief/diaper, |N |Purchase |
| | | |extra large, each | | |
|T4526 |NU | |Adult-sized disposable incontinence product, protective |N |Purchase |
| |EP | |underwear/pull-on, medium size, each | | |
|T4527 |NU | |Adult-sized disposable incontinence product, protective |N |Purchase |
| |EP | |underwear/pull-on, large size, each | | |
|T4528 |NU | |Adult-sized disposable incontinence product, protective |N |Purchase |
| |EP | |underwear/pull-on, extra large size, each | | |
|T4529 |EP | |((Small diaper) Pediatric-sized disposable incontinence |N |Purchase |
| | | |product, brief/diaper, small/medium size, each | | |
|T4529 |EP |U1 |((Medium diaper) Pediatric-sized disposable incontinence |N |Purchase |
| | | |product, brief/diaper, small/medium size, each | | |
|T4530 |NU | |Pediatric-sized disposable incontinence product, |N |Purchase |
| |EP | |brief/diaper, large size, each | | |
|T4531 |EP | |((Small diaper) Pediatric-sized disposable incontinence |N |Purchase |
| | | |product, protective underwear/pull-on, small/medium size, | | |
| | | |each | | |
|T4531 |EP |U1 |((Medium diaper) Pediatric-sized disposable incontinence |N |Purchase |
| | | |product, protective underwear/pull-on, small/medium size, | | |
| | | |each | | |
|T4532 |NU | |((Large diaper) Pediatric-sized disposable incontinence |N |Purchase |
| |EP | |product, protective underwear/pull-on, large size, each | | |
|T4532 |NU |U1 |((Extra large diaper) Pediatric-sized disposable |N |Purchase |
| |EP |U1 |incontinence product, protective underwear/pull-on, large | | |
| | | |size, each | | |
|T4533 |NU | |Youth-sized disposable incontinence product, brief/diaper, |N |Purchase |
| |EP | |each | | |
|T4535 |NU | |((Pantyliners/Bladder Pads/Diaper Doubles) Disposable |N |Purchase |
| |EP | |liner/shield/guard/pad/ undergarment for incontinence, each | | |
|T4535 |NU |U1 |((Under Garment One Size Fits All) Disposable |N |Purchase |
| |EP |U1 |liner/shield/guard/pad/ undergarment for incontinence, each | | |
|T4543 |NU | |Disposable incontinence product, brief/diaper, bariatric, |N |Purchase |
| | | |each | | |
|T4544 |NU | |Adult-sized disposable incontinence product, protective | | |
| | | |underwear/pull-on, above extra large each | | |
Reimbursement is based on a per unit basis with one unit equaling one item (diaper, underpad). When billing for these services that are benefit limited to a dollar amount per month, providers must bill according to the calendar month.
Providers must not span calendar months when billing for diapers and/or underpads. The date of delivery is the date of service. Providers should not bill “from” and “through” dates of service.
Refer to Section 212.100 of this manual for coverage information on diapers and underpads.
|242.140 Electronic Blood Pressure Monitor and Cuff, All Ages |11-1-17 |
The procedure code found in this section must be billed either electronically or on paper using modifier NU for individuals of all ages.
Modifiers in this section are indicated by the headings M1 and M2. Prior authorization requirements are shown under the heading PA. If prior authorization is needed, that information is indicated with a “Y” in the column; if not, an “N” is shown.
(Prior authorization is not required when other insurance pays at least 50% of the Medicaid maximum allowable reimbursement amount.
|National Procedure |M1 |M2 |Description |PA |Payment Method |
|Code | | | | | |
|A4670 |NU | |Automatic blood pressure monitor |Y( |Rental Only |
Included with the rental of this monitor, the provider will need to supply one (1) disposable blood pressure cuff each month.
|242.150 Nutritional Formulae for Child Health Services (EPSDT) Beneficiaries Under Twenty-one (21) Years of Age |12-1-20 |
The following list provides the enteral formula HCPCS procedure codes, any associated modifiers, code descriptions, and the formula covered for each HCPCS code. The code description lists the formula included in the category of nutrients.
The coverage listed is payable only if the service is prescribed as a result of a Child Health Services (EPSDT) screening/referral.
No prior authorization is required for nutritional formulae for EPSDT beneficiaries from age five (5) years through twenty (20) years.
Prior authorization is required for beneficiaries from birth through four (4) years. Use of modifier U7 in the following list will be necessary, as indicated.
To request prior authorization, providers should complete the Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components (DMS-679A), attaching a copy of the EPSDT screening/referral as well as a prescription signed by the beneficiary’s PCP. View or print form DMS-679A. View or print contact information for how to submit the request.
NOTE: The Women, Infant, and Children program (WIC) must be accessed before the Medicaid program for children from birth to five (5) years of age.
The Arkansas Medicaid program mirrors coverage of approved WIC nutritional formulae. As stated in current policy, the WIC Program must be accessed first for Arkansas Medicaid beneficiaries aged zero (0) to five (5) years, prior to requesting supplemental amounts of WIC-approved nutritional formula. The Medicaid nutritional formula list will be updated accordingly to continue compliance with the WIC Program in Arkansas. Changes will be reflected in the appropriate Medicaid provider manual.
For beneficiaries from birth through four (4) years of age, the use of modifier U8, as well as additional documentation, will be required when a non-WIC formula is prescribed, or WIC guidelines are not followed when prescribing special formula.
An EPSDT screening, which documents the PCP’s medical rationale for prescribing a formula, as well as medical records documenting the beneficiary’s failed trials of WIC formula, must be submitted for review. Flavor preferences for formulae will not be considered for medical necessity.
Exceptions to Use of Formulae
The following exceptions must be followed in order to use formulae listed in this section.
A. Nutramigen LIPIL – Sensitivity or allergy to milk or soy protein; chronic diarrhea, food allergies, GI bleeds. Similac Advance must first have been tried.
B. Nutramigen Enflora LGG – Sensitivity or allergy to milk or soy protein; chronic diarrhea, food allergies, GI bleeds. Similac Advance must first have been tried.
C. Pregestimil – Allergy to milk or soy protein; chronic diarrhea, short gut; cystic fibrosis; fat malabsorption due to GI or liver disease.
D. Gerber Extensive HA – Allergy to milk or soy protein; severe malnutrition; chronic diarrhea; short bowel syndrome; known or suspected corn allergy. Similac Advance must first have been tried.
E. Alfamino Junior – Allergy to cow’s milk, multiple food protein intolerance, and food allergy associated conditions: short bowel syndrome, gastroesophageal reflux disease (GERD), eosinophilic esophagitis, malabsorption, and other GI disorders. Neocate Junior with Prebiotics is intended for children over the age of one (1) year.
F. Alfamino Infant – Allergy to cow’s milk, multiple food protein intolerance, and food allergy associated conditions: short bowel syndrome, gastroesophageal reflux disease (GERD), eosinophilic esophagitis, malabsorption, and other GI disorders. Similac Expert Care Alimentum, Nutramigen, or Pregestimil must first have been tried.
G. Portagen – Pancreatic insufficiency, bile acid deficiency, or lymphatic anomalies; biliary atresia; liver disease; chylothorax.
H. Similac PM 60/40 – Renal, cardiac, or other condition that requires lowered minerals.
I. Periflex Infant – PKU; Hyperphenylalaninemia; for infants and toddlers.
J. PKU Periflex Junior Plus – Hyperphenylalaninemia; for children and adults.
K. Gerber Good Start Premature 24– Preterm, low birth weight. Not intended for feeding low birth weight infants after they reach a weight of 3600 g (approximately eight (8) lbs.). Not approved for an infant previously on term formula or a term infant for increased calories.
L. Enfamil EnfaCare – Preterm infant transitional formula for use between premature formula and term formula. Not approved for an infant previously on term formula or a term infant for increased calories.
Procedure codes found in this section must be billed either electronically or on paper with modifier EP for beneficiaries under twenty-one (21) years of age. Modifier BO is used to bill for oral usage. When a second or third modifier is listed, that modifier must be used in conjunction with EP.
For beneficiaries from birth through four (4) years of age, the use of modifier U7, as well as additional documentation will be required when a non-WIC formula is prescribed, or WIC guidelines are not followed when prescribing special formula.
Modifiers in this section are indicated by the headings M1, M2, M3 and M4.
|Nutritional Formulae for Child Health Services (EPSDT) Beneficiaries Under Twenty-one (21) Years of Age (Section 242.150) |
|National Procedure |M1 |M2 |M3 |M4 |Description |Covered Formulae |
|Code | | | | | | |
|B4149 |EP | | | |Enteral formula, blenderized natural | |
|B4149 |EP |BO | | |foods with intact nutrients, includes | |
| | | | | |proteins, fats, carbohydrates, vitamins,| |
|B4149 |EP |U7 | | |and minerals, may include fiber, | |
|B4149 |EP |U7 |BO | |administered through an enteral feeding | |
|Ages 0 – 4 Years | | | | |tube, 100 calories = 1 unit | |
|requires PA | | | | | | |
|B4150 |EP | | | |Enteral formula, nutritionally complete | |
|B4150 |EP |BO | | |with intact nutrients, includes | |
| | | | | |proteins, fats, carbohydrates, vitamins,| |
|B4150 |EP |U7 | | |and minerals, may include fiber, | |
|B4150 |EP |U7 |BO | |administered through an enteral feeding | |
|Ages 0 – 4 Years | | | | |tube, 100 calories = 1 unit | |
|requires PA | | | | | | |
|B4150 |EP |U1 |BO | |Enteral formula, nutritionally complete | |
| | | | | |with intact nutrients, includes | |
|B4150 |EP |U1 |U7 |BO |proteins, fats, carbohydrates, vitamins,| |
|Ages 0 – 4 Years | | | | |and minerals, may include fiber, | |
|requires PA | | | | |administered through an enteral feeding | |
| | | | | |tube, 100 calories = 1 unit | |
|B4152 |EP | | | |Enteral formula, nutritionally complete,| |
|B4152 |EP |BO | | |calorically dense (equal to or greater | |
| | | | | |than 1.5 Kcal/ml), with intact | |
|B4152 |EP |U7 | | |nutrients, includes proteins, fats, | |
|B4152 |EP |U7 |BO | |carbohydrates, vitamins, and minerals, | |
|Ages 0 – 4 Years | | | | |may include fiber, administered through | |
|requires PA | | | | |an enteral feeding tube, 100 calories = | |
| | | | | |1 unit | |
|B4153 |EP | | | |Enteral formula, nutritionally complete,| |
|B4153 |EP |BO | | |hydrolyzed proteins (amino acids and | |
| | | | | |peptide chain), includes fats, | |
|B4153 |EP |U7 | | |carbohydrates, vitamins, and minerals, | |
|B4153 |EP |U7 |BO | |may include fiber, administered through | |
|Ages 0 – 4 Years | | | | |an enteral feeding tube, 100 calories = | |
|requires PA | | | | |1 unit | |
|B4154 |EP | | | |Enteral formula, nutritionally complete,| |
|B4154 |EP |BO | | |for special metabolic needs, includes | |
| | | | | |inherited disease of metabolism, | |
|B4154 |EP |U7 | | |includes altered composition of | |
|B4154 |EP |U7 |BO | |proteins, fats, carbohydrates, vitamins,| |
|Ages 0 – 4 Years | | | | |or minerals, may include fiber, | |
|requires PA | | | | |administered through an enteral feeding | |
| | | | | |tube, 100 calories = 1 unit | |
|B4155 |EP | | | |Enteral formula, nutritionally |MCT Oil |
|B4155 |EP |BO | | |incomplete/modular nutrients, includes |Procel Protein Supplement |
| | | | | |specific nutrients, carbohydrates (e.g.,|Provimin |
| | | | | |glucose polymers), proteins/amino acids | |
| | | | | |(e.g., glutamine, arganine), fat (e.g., | |
| | | | | |medium chain triglycerides), or | |
| | | | | |combination, administered through an | |
| | | | | |enteral feeding tube, 100 calories = 1 | |
| | | | | |unit | |
|B4155 |EP | | | |Enteral formula, nutritionally |MCT Oil |
|B4155 |EP |U7 |BO | |incomplete/modular nutrients, includes |Procel Protein Supplement |
|Ages 0 – 4 Years | | | | |specific nutrients, carbohydrates (e.g.,|Provimin |
|requires PA | | | | |glucose polymers), proteins/amino acids | |
| | | | | |(e.g., glutamine, arganine), fat (e.g., | |
| | | | | |medium chain triglycerides), or | |
| | | | | |combination, administered through an | |
| | | | | |enteral feeding tube, 100 calories = 1 | |
| | | | | |unit | |
|B4155 |EP |U1 | | |Enteral formula, nutritionally |SolCarb |
|B4155 |EP |U1 |BO | |incomplete/modular nutrients, includes |Scandical |
| | | | | |specific nutrients, carbohydrates (e.g.,| |
|B4155 |EP |U1 |U7 | |glucose polymers), proteins/amino acids | |
|B4155 |EP |U1 |U7 |BO |(e.g., glutamine, arganine), fat (e.g., | |
|Ages 0 – 4 Years | | | | |medium chain triglycerides), or | |
|requires PA | | | | |combination, administered through an | |
| | | | | |enteral feeding tube, 100 calories = 1 | |
| | | | | |unit | |
|B4155 |EP |U2 | | |Enteral formula, nutritionally |Microlipid |
|B4155 |EP |U2 |BO | |incomplete/modular nutrients, includes | |
| | | | | |specific nutrients, carbohydrates (e.g.,| |
|B4155 |EP |U2 |U7 | |glucose polymers), proteins/amino acids | |
|B4155 |EP |U2 |U7 |BO |(e.g., glutamine, arganine), fat (e.g., | |
|Ages 0 – 4 Years | | | | |medium chain triglycerides), or | |
|requires PA | | | | |combination, administered through an | |
| | | | | |enteral feeding tube, 100 calories = 1 | |
| | | | | |unit | |
|B4155 |EP |U3 | | |Enteral formula, nutritionally | |
|B4155 |EP |U3 |BO | |incomplete/modular nutrients, includes | |
| | | | | |specific nutrients, carbohydrates (e.g.,| |
|B4155 |EP |U3 |U7 | |glucose polymers), proteins/amino acids | |
|B4155 |EP |U3 |U7 |BO |(e.g., glutamine, arganine), fat (e.g., | |
|Ages 0 – 4 Years | | | | |medium chain triglycerides), or | |
|requires PA | | | | |combination, administered through an | |
| | | | | |enteral feeding tube, 100 calories = 1 | |
| | | | | |unit | |
|B4158 |EP | | | |Enteral formula, for pediatrics, | |
|B4158 |EP |BO | | |nutritionally complete with intact | |
| | | | | |nutrients, includes proteins, fats, | |
|B4158 |EP |U7 | | |carbohydrates, vitamins and minerals, | |
|B4158 |EP |U7 |BO | |may include fiber, or iron, administered| |
|Ages 0 – 4 Years | | | | |through an enteral feeding tube, 100 | |
|requires PA | | | | |calories = 1 unit | |
|B4159 |EP | | | |Enteral formula, for pediatrics, | |
|B4159 |EP |BO | | |nutritionally complete soy base with | |
| | | | | |intact nutrients, includes proteins, | |
|B4159 |EP |U7 | | |fats, carbohydrates, vitamins and | |
|B4159 |EP |U7 |BO | |minerals, may include fiber, or iron, | |
|Ages 0 – 4 Years | | | | |administered through an enteral feeding | |
|requires PA | | | | |tube, 100 calories = 1 unit | |
|B4159 |EP | | | |Enteral formula, for pediatrics, | |
|B4159 |EP |BO | | |nutritionally complete soy base with | |
| | | | | |intact nutrients, includes proteins, | |
|B4159 |EP |U8 |U7 | |fats, carbohydrates, vitamins and | |
|B4159 |EP |U8 |U7 |BO |minerals, may include fiber, or iron, | |
|Ages 0 – 4 Years | | | | |administered through an enteral feeding | |
|requires PA | | | | |tube, 100 calories = 1 unit | |
|B4160 |EP | | | |Enteral formula, for pediatrics, | |
|B4160 |EP |BO | | |nutritionally complete calorically dense| |
| | | | | |(equal to or greater than 0.7Kcal/ml) | |
|B4160 |EP |U7 | | |with intact nutrients, includes | |
|B4160 |EP |U7 |BO | |proteins, fats, carbohydrates, vitamins,| |
|Ages 0 – 4 Years | | | | |and minerals, may include fiber, | |
|requires PA | | | | |administered through an enteral feeding | |
| | | | | |tube, 100 calories = 1 unit | |
|B4160 |EP | | | |Enteral formula, for pediatrics, | |
|B4160 |EP |BO | | |nutritionally complete calorically dense| |
| | | | | |(equal to or greater than 0.7 Kcal/ml) | |
|B4160 |EP |U8 |U7 | |with intact nutrients, includes | |
|B4160 |EP |U8 |U7 |BO |proteins, fats, carbohydrates, vitamins,| |
|Ages 0 – 4 Years | | | | |and minerals, may include fiber, | |
|requires PA | | | | |administered through an enteral feeding | |
| | | | | |tube, 100 calories = 1 unit | |
|B4160 |EP |U1 | | |Enteral formula, for pediatrics, | |
|B4160 |EP |U1 |BO | |nutritionally complete calorically | |
| | | | | |dense (equal to or greater than 0.7 | |
|B4160 |EP |U1 |U7 | |Kcal/ml) with intact nutrients, | |
|B4160 |EP |U1 |U7 |BO |includes proteins, fats, carbohydrates,| |
|Ages 0 – 4 Years | | | | |vitamins, and minerals, may include | |
|requires PA | | | | |fiber, administered through an enteral | |
| | | | | |feeding tube, 100 calories = 1 unit | |
|B4160 |EP |U1 |U8 | |Enteral formula, for pediatrics, | |
|B4160 |EP |U1 |U8 |BO |nutritionally complete calorically | |
|Ages 0 – 4 Years | | | | |dense (equal to or greater than 0.7 | |
|requires PA | | | | |Kcal/ml) with intact nutrients, | |
| | | | | |includes proteins, fats, carbohydrates,| |
| | | | | |vitamins, and minerals, may include | |
| | | | | |fiber, administered through an enteral | |
| | | | | |feeding tube, 100 calories = 1 unit | |
|B4161 |EP | | | |Enteral formula, for pediatrics, | |
|B4161 |EP |BO | | |hydrolyzed/amino acids and peptide chain| |
| | | | | |proteins, includes fats, carbohydrates, | |
|B4161 |EP |U7 | | |vitamins, and minerals, may include | |
|B4161 |EP |U7 |BO | |fiber, administered through an enteral | |
|Ages 0 – 4 Years | | | | |feeding tube, 100 calories = 1 unit | |
|requires PA | | | | | | |
|B4161 |EP | | | |Enteral formula, for pediatrics, | |
|B4161 |EP |BO | | |hydrolyzed/amino acids and peptide chain| |
| | | | | |proteins, includes fats, carbohydrates, | |
|B4161 |EP |U7 |U8U8 |BO |vitamins, and minerals, may include | |
|B4161 |EP |U7 | | |fiber, administered through an enteral | |
|Ages 0 – 4 Years | | | | |feeding tube, 100 calories = 1 unit | |
|requires PA | | | | | | |
|B4162 |EP | | | |Enteral formula, for pediatrics, special| |
|B4162 |EP |BO | | |metabolic needs for inherited disease of| |
| | | | | |metabolism, includes fats, | |
|B4162 |EP |U7 | | |carbohydrates, vitamins, and minerals, | |
|B4162 |EP |U7 |BO | |may include fiber, administered through | |
|Ages 0 – 4 Years | | | | |an enteral feeding tube, 100 calories = | |
|requires PA | | | | |1 unit | |
|B4162 |EP |U1 | | |Enteral formula, for pediatrics, | |
|B4162 |EP |U1 |BO | |special metabolic needs for inherited | |
| | | | | |disease of metabolism, includes fats, | |
|B4162 |EP |U1 |U7 | |carbohydrates, vitamins, and minerals, | |
|B4162 |EP |U1 |U7 |BO |may include fiber, administered through| |
|Ages 0 – 4 Years | | | | |an enteral feeding tube, 100 calories =| |
|requires PA | | | | |1 unit | |
One (1) unit of service equals one-hundred (100) calories with a reimbursable maximum of thirty (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.
|242.151 Pedia-Pop |11-1-17 |
The procedure code found in this section must be billed with modifier EP. Pedia-Pop is only for oral consumption, and is only in frozen form.
Modifiers in this section are indicated by the headings M1 and M2.
|National Procedure |M1 |M2 |Description |Maximum Units |Deleted Local Code|
|Code | | | | | |
|B4103 |EP |U1 |(Pedia-Pop; 1 unit equals 1 box |2 units per date of service |Z2487 |
|242.152 Enteral Nutrition Infusion Pump and Enteral Feeding Pump Supply Kit |11-1-17 |
Procedure codes found in this section must be billed either electronically or on paper with modifier EP for beneficiaries under 21 years of age. When a second modifier is listed, that modifier must be used in conjunction with EP.
The procedure codes require prior authorization from AFMC.
Modifiers in this section are indicated by the headings M1 and M2. Prior authorization requirements are shown under the heading PA. If prior authorization is needed, that information is indicated with a “Y” in the column; if not, an “N” is shown.
((…) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product.
|National Procedure |M1 |M2 |Description |Maximum Units |PA |Payment Method |
|Code | | | | | | |
|B4035 |EP | |Enteral feeding supply kit, pump fed, per|1 per day |Y |Purchase |
| | | |day | | | |
| | | |(1 unit = 1 day) | | | |
|B9000 |EP | |Enteral nutrition infusion pump – without|1 per day |Y |Rent to Purchase |
| | | |alarm | | | |
| | | |(1 day = 1 unit) | | | |
|B9002 |EP | |Enteral nutrition infusion pump – with |1 per day |Y |Rent to Purchase |
| | | |alarm | | | |
| | | |(1 day = 1 unit) | | | |
|K0739 |EP |U2 |((Repair or non-routine service for | |Y | |
| | | |enteral nutrition infusion pump, | | | |
| | | |requiring the skill of a technician, | | | |
| | | |parts and labor) | | | |
Enteral Nutrition Infusion Pump
Reimbursement for the enteral nutrition infusion pump is based on a rent-to-purchase methodology. Each unit reimbursed by Medicaid will apply towards the purchase price established by Medicaid.
Reimbursement will only be approved for new equipment. Used equipment will not be prior authorized. Procedure codes B9000 and B9002 represent a new piece of equipment being reimbursed by Medicaid on the rent-to-purchase plan.
Codes B9000 and B9002 are reimbursed on a per unit basis with 1 day equaling 1 unit of service per day.
Medicaid will reimburse on the rent-to-purchase plan for a total of 304 units of service. After reimbursement has been made for 304 units, the equipment will become the property of the Medicaid beneficiary.
Prior authorization is required for codes B9000 and B9002. The prior authorization request must include the serial number of the infusion pump being provided to the beneficiary.
See Section 236.000 for reimbursement when the Medicaid Program is billed for repairs made to the enteral infusion pump.
|242.153 Low-Profile Skin Level Gastrostomy Tube (Low-Profile Button) |12-1-20 |
|and Low-Profile Percutaneous Cecostomy Tube and Supplies for Beneficiaries of All Ages | |
NOTE: When billing for the Low-Profile Percutaneous Cecostomy Tube or supplies, an additional third modifier UA will be required.
Modifiers in this section are indicated by the headings M1 and M2. Prior authorization requirements are shown under the heading PA.
|National Procedure |M1 |M2 |PA |Description |Payment Method |
|Code | | | | | |
|B9998 | | |Y |Low-Profile Kit |Purchase |
|B9998 |NU |U1 |Y |SECUR-LOK Extension Set with 2 Port ‘Y’ and Clamp 12” Length |Purchase |
|B9998 |NU |U2 |Y |SECUR-LOK Extension Set with 2 Port ‘Y’ and Clamp 24” Length |Purchase |
|B9998 |NU |U3 |Y |Bolus Extension Set with Single Port Clamp 12” Length |Purchase |
|B9998 |NU |U4 |Y |Bolus Extension Set with Single Port Clamp 24” Length |Purchase |
|B9998 |NU |U5 |Y |Bolus SECUR-LOK Extension Set Single Port w/Clamp 12” Length |Purchase |
|B9998 |NU |U6 |Y |Bolus SECUR-LOK Extension Set Single Port w/Clamp 24” Length |Purchase |
|B9998 |NU |U7 |Y |Microvasive Adapter |Purchase |
|B9998 |NU |U8 |Y |Microvasive Decompression Tube |Purchase |
|242.154 Nasogastric Tubing for Individuals Under Age 21 |11-1-17 |
The procedure code found in this section must be billed with modifier EP for beneficiaries under 21 years of age. The code is payable only for beneficiaries under age 21.
|National Procedure |M1 |M2 |PA |Description |Payment Method |
|Code | | | | | |
|B4082 |EP | |N |Nasogastric tubing without stylet |Purchase |
|242.155 Billing and Reimbursement Protocol for FM (Frequency Modulation) System and Replacement Cochlear Implant Parts |11-1-17 |
Procedure codes L8621, L8622 and L8624 in the table below require paper claim submission with a manufacturer’s invoice attached that demonstrates the specific cost per item. The invoice must clearly indicate the specific item(s) supplied to the beneficiary for whom the claim is billed. Procedure codes L8615, L8616, L8617, L8618, L8619, L8623, L8627, L8628 and L8629 may be submitted electronically or on a paper claim form. Procedure code V5273 may be submitted electronically or on a paper claim form. For provider charges for an FM system that is meant to be used with a cochlear implant, V5273 should reflect the retail price. For reimbursement of an FM system to be used with a cochlear implant, V5273 will be at 68 percent of the retail price.
|National Procedure |M1 |Description |PA |PA Criteria |Units Allowed per |
|Code | | | | |Date of Service |
|L8615* |EP |Headset/headpiece for use with cochlear |Y |1 per 3 years |2 |
| | |implant device, replacement | | | |
|L8616* |EP |Microphone for use with cochlear implant |Y |1 per year |2 |
| | |device, replacement | | | |
|L8617* |EP |Transmitting coil for use with cochlear |Y |1 per year |2 |
| | |implant device, replacement | | | |
|L8618* |EP |Transmitter cable for use with cochlear |Y |4 per 6 months |8 |
| | |implant device, replacement | | | |
|L8619* |EP |Cochlear implant external speech |Y |5 years |2 |
| | |processor, and controller, integrated | | | |
| | |system, replacement | | | |
|L8621* |EP |Zinc air battery for use with cochlear |Y |180 units per 6 |360 |
| | |implant device replacement, each | |months | |
|L8622* |EP |Alkaline battery for use with cochlear |Y |180 units per 6 |360 |
| | |implant device, any size, replacement, | |months | |
| | |each | | | |
|L8623* |EP |Lithium ion battery for use with cochlear|Y |1 (set of 2) per |2 |
| | |implant device speech processor, other | |year | |
| | |than ear level, replacement, each | |Unilateral | |
|L8624* |EP |Lithium ion battery for use with cochlear|Y |1 (set of 2) per |2 |
| | |implant device speech processor, ear | |year | |
| | |level, replacement, each | |Unilateral | |
|L8627* |EP |Cochlear implant, external speech |Y |Prior authorized |2 |
| | |processor, component, replacement | |when not under | |
| | | | |warranty | |
|L8628* |EP |Cochlear implant, external controller |Y |Prior authorized |2 |
| | |component, replacement | |when not under | |
| | | | |warranty | |
|L8629* |EP |Transmitting coil and cable, integrated, |Y |1 per year |2 |
| | |for use with cochlear implant device, | | | |
| | |replacement | | | |
|V5273 |EP |Assistive listening device, for use with |Y |Prior authorized |1 |
| | |cochlear implant | |when not covered | |
| | | | |through IDEA | |
*Denotes paper claim
|242.160 Durable Medical Equipment, All Ages |11-1-17 |
Procedure codes found in this section must be billed either electronically or on paper with modifier EP for beneficiaries under 21 years of age or modifier NU for beneficiaries age 21 and older. When a second modifier is listed, that modifier must be used in conjunction with either EP or NU. Modifier UE is required when billing for used equipment.
Modifiers in this section are indicated by the headings M1 and M2. Prior authorization requirements are shown under the heading PA. If prior authorization is needed, that information is indicated with a “Y” in the column; if not, an “N” is shown.
* The purchase of wheelchairs for individuals age 21 and older is limited to one per five-year period.
*** This procedure code may not be billed for used equipment.
( Prior authorization is not required when other insurance pays at least 50% of the Medicaid maximum allowable reimbursement amount.
((…) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product. When using a procedure code with this symbol, the product must meet the indicated Arkansas Medicaid description.
3 This item is a capped rental for 90 days only, and requires PA and a review.
|Durable Medical Equipment, All Ages (Section 242.160) |
|National Procedure |M1 |M2 |M3 |PA |Description |Payment Method |
|Code | | | | | | |
|A4566 |NU | | |N |Shoulder sling or vest design, abduction restrainer, |Manually Priced |
| |EP | | | |with or without swathe control, prefabricated, includes | |
| | | | | |fitting and adjustment | |
|A4635 |NU | | |N |Underarm pad, crutch, replacement, each |Purchase |
| |EP | | | | | |
| |UE | | | | | |
|A4636 |NU | | |N |Replacement, handgrip, cane, crutch, or walker, each |Purchase |
| |EP | | | | | |
| |UE | | | | | |
|A4637 |NU | | |N |Replacement, tip, cane, crutch, walker, each |Purchase |
| |EP | | | | | |
| |UE | | | | | |
|A7020 |NU | | |Y |Interface for cough stimulating device, includes all |Manually Priced |
| |EP | | | |components, replacement only | |
|A9999 |NU | | |Y |((Unlisted Durable Medical Equipment. The |Purchase |
| | | | | |manufacturer’s invoice must be attached to the claim | |
| | | | | |form.) Misc. DME supply or accessory, not otherwise | |
| | | | | |specified | |
|E0100 |NU | | |N |Cane, includes canes of all materials, adjustable or |Purchase |
| |EP | | | |fixed, with tip | |
| |UE | | | | | |
|E0105 |NU | | |N |Cane, quad or three-prong, includes canes of all |Purchase |
| |EP | | | |materials, adjustable or fixed, with tips | |
| |UE | | | | | |
|E0110 |NU | | |N |Crutches, forearm, includes crutches of various |Purchase |
| |EP | | | |materials, adjustable or fixed, pair, complete with tips| |
| |UE | | | |and handgrips | |
|E0111 |NU | | |N |Crutch, forearm, includes crutches of various materials,|Purchase |
| |EP | | | |adjustable or fixed, each, with tip and handgrip | |
| |UE | | | | | |
|E0111 |NU |U1 | |N |Crutch, forearm, includes crutches of various materials,|Purchase |
| | | | | |adjustable or fixed, each, with tip and handgrip | |
|E0112 |NU | | |N |Crutches, underarm, wood, adjustable or fixed, pair, |Purchase |
| |EP | | | |with pads, tips and handgrips | |
| |UE | | | | | |
|E0113 |NU | | |N |Crutch, underarm, wood, adjustable or fixed, each, with |Purchase |
| |EP | | | |pad, tip and handgrip | |
| |UE | | | | | |
|E0114 |NU | | |N |Crutches, underarm, other than wood, adjustable or |Purchase |
| |EP | | | |fixed, pair, with pads, tips and handgrips | |
| |UE | | | | | |
|E0116 |NU | | |N |Crutch, underarm, other than wood, adjustable or fixed, |Purchase |
| |EP | | | |each, with pad, tip and handgrip | |
| |UE | | | | | |
|E0130 |NU | | |N |Walker, rigid (pickup), adjustable or fixed height |Purchase |
| |EP | | | | | |
| |UE | | | | | |
|E0135 |NU | | |N |Walker, folding (pickup), adjustable or fixed height |Purchase |
| |EP | | | | | |
| |UE | | | | | |
|E0140 |NU | | |N |Walker, w/trunk support, adjustable or fixed height, any|Purchase |
| |EP | | | |type | |
|E0141 |NU | | |N |Walker, rigid, wheeled, adjustable or fixed height |Purchase |
| |EP | | | | | |
| |UE | | | | | |
|E0143 |NU | | |N |Walker, folding, wheeled, adjustable or fixed height |Purchase |
| |EP | | | | | |
| |UE | | | | | |
|E0147 |NU | | |N |Walker, heavy-duty, multiple braking system, variable |Purchase |
| |EP | | | |wheel resistance | |
| |UE | | | | | |
|E0153 |NU | | |N |Platform attachment, forearm crutch, each |Purchase |
| |EP | | | | | |
| |UE | | | | | |
|E0154 |NU | | |N |Platform attachment, walker, each |Purchase |
| |EP | | | | | |
| |UE | | | | | |
|E0155 |NU | | |N |Wheel attachment, rigid pick-up walker, per pair seat |Purchase |
| |EP | | | |attachment, walker | |
| |UE | | | | | |
|E0156 |NU | | |N |Seat attachment, walker |Purchase |
| |EP | | | | | |
|E0157 |NU | | |N |Crutch attachment, walker, each |Purchase |
| |EP | | | | | |
| |UE | | | | | |
|E0158 |NU | | |N |Leg extensions for walker, per set of four (4) |Purchase |
| |EP | | | | | |
| |UE | | | | | |
|E0159 |NU | | |N |Brake attachment for wheeled walker, replacement, each |Purchase |
| |EP | | | | | |
|E0160 |NU | | |N |Sitz type bath or equipment, portable, used with or |Purchase |
| |EP | | | |without commode | |
| |UE | | | | | |
|E0161 |NU | | |N |Sitz type bath or equipment, portable, used with or |Purchase |
| |EP | | | |without commode, with faucet attachment(s) | |
| |UE | | | | | |
|E0163 |NU | | |N |Commode chair, stationary, with fixed arms |Purchase |
| |EP | | | | | |
| |UE | | | | | |
|E0167 |NU | | |N |Pail or pan for use with commode chair |Purchase |
| |EP | | | | | |
| |UE | | | | | |
|E0175 |NU | | |N |Foot rest, for use with commode chair, each |Purchase |
| |EP | | | | | |
| |UE | | | | | |
|E0181 |NU | | |N |Pressure pad, alternating with pump, heavy-duty |Capped Rental |
| |EP | | | | | |
| |UE | | | | | |
|E0182 |NU | | |N |Pump for alternating pressure pad |Purchase |
| |EP | | | | | |
| |UE | | | | | |
|E0184 |NU | | |N |Dry pressure mattress |Purchase |
| |EP | | | | | |
| |UE | | | | | |
|E0185 |NU | | |N |Gel or gel-like pressure pad for mattress, standard |Purchase |
| |EP | | | |mattress length and width | |
| |UE | | | | | |
|E0186 |NU | | |Y |Air pressure mattress |Purchase |
| |EP | | | | | |
|E0187 |NU | | |Y |Water pressure mattress |Purchase |
| |EP | | | | | |
|E0189 |NU | | |N |Lamb’s wool sheepskin pad, any size |Purchase |
| |EP | | | | | |
| |UE | | | | | |
|E0190 |NU | | |N |Positioning cushion/pillow/wedge, any shape or size |Purchase |
| |UE | | | | | |
|E0190 |EP | | |N |( (Tumble Form Therapy Roll 4“) Positioning |Purchase |
| | | | | |cushion/pillow/wedge, any shape or size | |
|E0190 |EP |U1 | |N |( (Tumble Form Therapy Roll 6”) Positioning |Purchase |
| | | | | |cushion/pillow/wedge, any shape or size | |
|E0190 |EP |U2 | |N |( (Tumble Form Therapy Wedge 4”) Positioning |Purchase |
| | | | | |cushion/pillow/wedge, any shape or size | |
|E0190 |EP |U3 | |N |( (Tumble Form Therapy Roll 8”) Positioning |Purchase |
| | | | | |cushion/pillow/wedge, any shape or size | |
|E0190 |EP |U4 | |N |( (Tumble Form Therapy Wedge 6”) Positioning |Purchase |
| | | | | |cushion/pillow/wedge, any shape or size | |
|E0190 |EP |U5 | |N |( (Floor Sitter Wedge 4”) Positioning |Purchase |
| | | | | |cushion/pillow/wedge, any shape or size | |
|E0190 |EP |U6 | |N |( (Tumble Form Therapy Roll 12”) Positioning |Purchase |
| | | | | |cushion/pillow/wedge, any shape or size | |
|E0190 |EP |U7 | |N |( (Deluxe Wedge with strap 4”) Positioning |Purchase |
| | | | | |cushion/pillow/wedge, any shape or size | |
|E0190 |EP |U8 | |N |( (Deluxe Wedge with strap 6”) Positioning |Purchase |
| | | | | |cushion/pillow/wedge, any shape or size | |
|E0190 |EP |U9 | |N |( (Tumble Form Therapy Wedge 10”) Positioning |Purchase |
| | | | | |cushion/pillow/wedge, any shape or size | |
|E0190 |EP |KA |U1 |N |( (Tumble Form Therapy Roll 14”) Positioning |Purchase |
| | | | | |cushion/pillow/wedge, any shape or size | |
|E0190 |EP |KA |U2 |N |(Tumble Form Therapy Roll 16”) Positioning |Purchase |
| | | | | |cushion/pillow/wedge, any shape or size ( | |
|E0190 |EP |KA |U3 |N |( (Tumble Form Therapy Wedge 8”) Positioning |Purchase |
| | | | | |cushion/pillow/wedge, any shape or size | |
|E0191 |NU | | |N |Heel or elbow protector, each |Purchase |
| |EP | | | | | |
| |UE | | | | | |
|E01943 |NU | | |Y |((Clinitron Bed) Air fluidized bed |Capped Rental |
| |EP | | | | | |
|E0196 |NU | | |N |Gel pressure mattress |Purchase |
| |EP | | | | | |
|E0197 |NU | | |N |Air pressure pad for mattress, standard mattress length |Purchase |
| |EP | | | |and width | |
| |UE | | | | | |
|E0198 |NU | | |Y |Water pressure pad for mattress, standard mattress |Purchase |
| |EP | | | |length and width | |
|E0200 |NU | | |N |Heat lamp, without stand (table model), includes bulb, |Capped Rental |
| |EP | | | |or infrared element | |
| |UE | | | | | |
|E0202 |NU | | |N |Phototherapy (bilirubin) light with photometer |Rental Only |
| |EP | | | | | |
| |UE | | | | | |
|E0202 |UE |U1 | |N |Phototherapy (bilirubin) light with photometer |Capped |
| | | | | | |Rental |
|E0205 |NU | | |N |Heat lamp, with stand includes bulb, or infrared element|Capped Rental |
| |EP | | | | | |
| |UE | | | | | |
|E0217 |NU | | |N |Water circulating heat pad with pump |Capped Rental |
| |EP | | | | | |
| |UE | | | | | |
|E0225 |NU | | |N |Hydrocollator unit, includes pad |Capped Rental |
| |EP | | | | | |
| |UE | | | | | |
|E0235 |NU | | |N |Paraffin bath unit, portable (see medical supply code |Purchase |
| |EP | | | |A4265 for paraffin) | |
| |UE | | | | | |
|E0236 |NU | | |N |Pump for water circulating pad |Capped Rental |
| |EP | | | | | |
| |UE | | | | | |
|E0239 |NU | | |N |Hydrocollator unit, portable |Capped Rental |
| |EP | | | | | |
| |UE | | | | | |
|E0240 |NU | | |N |Bath/shower chair w/wo wheels, any size |Purchase |
| |EP | | | | | |
|E0240 |NU |U1 | |N |Bath/shower chair w/wo wheels, any size |Purchase |
| |EP |U1 | | | | |
|E0240 |NU |U2 | |N |Bath/shower chair w/wo wheels, any size |Purchase |
| |EP |U2 | | | | |
|E0240 |NU |U3 | |N |Bath/shower chair w/wo wheels, any size |Purchase |
| |EP |U3 | | | | |
|E0244 |NU | | |N |Raised toilet seat |Purchase |
| |EP | | | | | |
|E0245*** |NU |U1 | |N |((Bath Frame Support, Large) Tub stool or bench |Purchase |
| |EP |U1 | | | | |
|E0247 |NU | | |N |Transfer bench, tub/toilet, w/wo commode opening |Purchase |
| |EP | | | | | |
|E0247 |NU |U1 | |N |Transfer bench, tub/toilet, w/wo commode opening |Purchase |
| |EP |U1 | | | | |
|E0248 |NU | | |N |Transfer bench, heavy-duty, tub/toilet w/wo commode |Purchase |
| |EP | | | |opening | |
|E0248 |NU |U1 | |N |Transfer bench, heavy-duty, tub/toilet w/wo commode |Purchase |
| |EP |U1 | | |opening | |
|E0249 |NU | | |N |Pad for water circulating heat unit |Purchase |
| |EP | | | | | |
| |UE | | | | | |
|E0250 |NU | | |Y( |((Hospital bed, with side rails, fixed height, with |Purchase |
| |EP | | | |mattress, purchase) Hospital bed, fixed height, with | |
| | | | | |any type side rails, with mattress | |
|E0250 |NU |RR | |Y( |Hospital bed, fixed height, with any type side rails, |Capped Rental |
| |EP |RR | | |with mattress | |
|E0255 |NU | | |Y( |Hospital bed, variable height; hi-lo, with any type side|Purchase |
| |EP | | | |rails, with mattress | |
|E0255 |NU |RR | |Y( |Hospital bed, variable height; hi-lo, with any type side|Capped Rental |
| |EP |RR | | |rails, with mattress | |
|E0255 |NU |U1 | |Y( |((Hospital bed, with side rails, variable height; hi-lo,|Purchase |
| | | | | |with mattress, purchase) Hospital bed, variable height;| |
| | | | | |hi-lo, with any type side rails, with mattress | |
|E0255 |UE | | |Y( |Hospital bed, variable height; hi-lo, with any type side|Capped Rental |
| | | | | |rails, with mattress | |
|E0260 |NU | | |Y( |((Hospital bed, with side rails, semi-electric, head and|Purchase |
| |EP | | | |foot adjustments, with mattress, purchase) Hospital | |
| |UE | | | |bed, semi-electric, head and foot adjustment, with any | |
| | | | | |type side rails with mattress | |
|E0260 |NU |RR | |Y( |Hospital bed, semi-electric, head and foot adjustment, |Capped Rental |
| |EP |RR | | |with any type side rails with mattress | |
|E0271 |NU | | |N |Mattress, inner spring |Capped Rental |
| |EP | | | | | |
| |UE | | | | | |
|E0272 |NU | | |N |Mattress, foam rubber |Capped Rental |
| |EP | | | | | |
| |UE | | | | | |
|E0273 |NU | | |N |Bed board |Purchase |
| |EP | | | | | |
| |UE | | | | | |
|E0275 |NU | | |N |Bed pan, standard, metal or plastic |Purchase |
| |EP | | | | | |
| |UE | | | | | |
|E0276 |NU | | |N |Bed pan, fracture, metal or plastic |Purchase |
| |EP | | | | | |
| |UE | | | | | |
|E02773 |NU | | |Y |((Low Air Loss Mattress) Powered pressure-reducing air |Capped Rental |
| |EP | | | |mattress | |
|E0280 |NU | | |N |Bed cradle, any type |Purchase |
| |EP | | | | | |
| |UE | | | | | |
|E0300 |EP | | |Y |Pediatric crib, hospital grade, fully enclosed |Purchase |
|E0480 |NU | | |N |Percussor, electric or pneumatic, home model |Capped Rental |
| |EP | | | | | |
| |UE | | | | | |
|E0570 |NU | | |Y |Nebulizer, with compressor |Purchase |
| |UE | | | | | |
|E0585 |NU | | |N |Nebulizer, with compressor and heater |Capped Rental |
| |EP | | | | | |
| |UE | | | | | |
|E0630 |NU | | |Y( |Patient lift, hydraulic, with seat or sling |Capped Rental |
| |EP | | | | | |
| |UE | | | | | |
|E0650 |NU | | |Y( |Pneumatic compressor, nonsegmental home model |Capped Rental |
| |EP | | | | | |
| |UE | | | | | |
|E0667 |NU | | |Y( |Segmental pneumatic appliance for use with pneumatic |Capped Rental |
| |EP | | | |compressor, full leg | |
|E0668 |NU | | |Y( |Segmental pneumatic appliance for use with pneumatic |Capped Rental |
| |EP | | | |compressor, full arm | |
|E0670 |NU | | |N |Segmental pneumatic appliance for use with pneumatic |Purchase |
| |EP | | | |compressor, integrated, 2 full legs and trunk | |
|E0691 |NU | | |N |Ultraviolet light therapy system panel, includes |Rental Only |
| |EP | | | |bulbs/lamps, timer and eye protection; treatment area | |
| | | | | |two square feet or less | |
|E0692 |NU | | |N |Ultraviolet light therapy system panel, includes |Rental Only |
| |EP | | | |bulbs/lamps, timer and eye protection; four foot panel | |
|E0730 |NU | | |Y( |Transcutaneous electrical nerve stimulation (TENS) |Capped Rental |
| |EP | | | |device, four or more leads, for multiple nerve | |
| |UE | | | |stimulation | |
|E0740 |NU | | |N |Incontinence treatment system, pelvic floor stimulator, |Purchase |
| |EP | | | |monitor, sensor and/or trainer | |
| |UE | | | | | |
|E0745 |NU | | |Y( |Neuromuscular stimulator, electronic shock unit |Capped Rental |
| |EP | | | | | |
| |UE | | | | | |
|E0747 |NU | | |Y( |Osteogenesis stimulator, electrical noninvasive, other |Rental Only |
| |EP | | | |than spinal applications | |
| |UE | | | | | |
|E0748 |NU | | |Y |Osteogenesis stimulator, electrical noninvasive, spinal |Rental Only |
| |EP | | | |applications | |
|E0760 |NU | | |Y |Osteogenesis stimulator, low intensity ultrasound, |Rental Only |
| |EP | | | |noninvasive | |
|E0779 |NU |RR | |Y( |((Ambulatory infusion device, payable only when services|Rental Only |
| | | | | |are provided to patients receiving chemotherapy, pain | |
| | | | | |management or antibiotic treatment in the home) | |
| | | | | |Ambulatory infusion pump, mechanical, reusable, for | |
| | | | | |infusion 8 hours or greater | |
|E0840 |NU | | |N |Traction frame, attached to headboard, cervical traction|Purchase |
| |EP | | | | | |
| |UE | | | | | |
|E0850 |NU | | |N |Traction stand, freestanding, cervical traction |Purchase |
| |EP | | | | | |
| |UE | | | | | |
|E0860 |NU | | |N |Traction equipment, overdoor, cervical |Purchase |
| |EP | | | | | |
| |UE | | | | | |
|E0870 |NU | | |N |Traction frame, attached to footboard, extremity |Purchase |
| |EP | | | |traction (e.g., Buck’s) | |
| |UE | | | | | |
|E0880 |NU | | |N |Traction stand, freestanding, extremity traction (e.g., |Purchase |
| |EP | | | |Buck’s) | |
| |UE | | | | | |
|E0890 |NU | | |N |Traction frame, attached to footboard, pelvic traction |Purchase |
| |EP | | | | | |
| |UE | | | | | |
|E0900 |NU | | |N |Traction stand, freestanding, pelvic traction (e.g., |Purchase |
| |EP | | | |Buck’s) | |
| |UE | | | | | |
|E0910 |NU | | |N |Trapeze bars, also known as Patient Helper, attached to |Capped Rental |
| |EP | | | |bed, with grab bar | |
| |UE | | | | | |
|E0910 |NU |RR | |N |Trapeze bars, also known as Patient Helper, attached to |Capped Rental |
| | | | | |bed, with grab bar | |
|E0920 |NU | | |N |Fracture frame, attached to bed, includes weights |Capped Rental |
| |EP | | | | | |
| |UE | | | | | |
|E0930 |NU | | |N |Fracture frame, freestanding, includes weights |Capped Rental |
| |EP | | | | | |
| |UE | | | | | |
|E0935 |NU | | |Y( |Continuous passive motion exercise device for use on |Capped Rental |
| |EP | | | |knee only | |
| |UE | | | | | |
|E0940 |NU | | |N |Trapeze bar, freestanding, complete with grab bar |Capped Rental |
| |EP | | | | | |
| |UE | | | | | |
|E0941 |NU | | |N |Gravity assisted traction device, any type |Capped Rental |
| |EP | | | | | |
| |UE | | | | | |
|E0942 |NU | | |N |Cervical head harness/halter |Purchase |
| |EP | | | | | |
| |UE | | | | | |
|E0944 |NU | | |N |Pelvic belt/harness/boot |Purchase |
| |EP | | | | | |
| |UE | | | | | |
|E0945 |NU | | |N |Extremity belt/harness |Purchase |
| |EP | | | | | |
| |UE | | | | | |
|E0946 |NU | | |N |Fracture frame, dual with cross bars, attached to bed |Purchase |
| |EP | | | |(e.g., Balken, Four Poster) | |
| |UE | | | | | |
|E0947 |NU | | |N |Fracture frame, attachments for complex pelvic traction |Purchase |
| |EP | | | | | |
| |UE | | | | | |
|E0948 |NU | | |N |Fracture frame, attachments for complex cervical |Purchase |
| |EP | | | |traction | |
| |UE | | | | | |
|E0950 |NU | | |N |Wheelchair accessory, tray, each |Purchase |
| |EP | | | | | |
| |UE | | | | | |
|E1036 |NU | | |Y |Multi-positional patient transfer system, with |Purchase |
| |EP | | | |integrated seat, operated by care giver; patient weight | |
| | | | | |capacity up to and including 300 lbs | |
|E1130* |NU | | |Y( |Standard wheelchair, fixed full-length arms, fixed or |Capped Rental |
| |EP | | | |swing–away, detachable footrests | |
| |UE | | | | | |
|E1130* |NU |U1 | |Y( |Standard wheelchair, fixed full-length arms, fixed or |Rental Only |
| | | | | |swing–away, detachable footrests | |
|E1140* |NU | | |Y( |Wheelchair, detachable arms, desk or full-length, |Capped Rental |
| |EP | | | |swing–away, detachable footrests | |
|E1150* |NU | | |Y( |Wheelchair; detachable arms, desk or |Capped Rental |
| |EP | | | |full-length, swing–away, detachable, elevating leg rests| |
|E1160* |NU | | |Y( |Wheelchair; fixed full-length arms, |Capped Rental |
| |EP | | | |swing–away, detachable, elevating leg rests | |
|E1224* |NU | | |Y( |Wheelchair with detachable arms, elevating leg rests |Capped Rental |
| |EP | | | | | |
| |UE | | | | | |
|E1224* |NU |U1 | |Y( |((Footrests wheelchair with detachable arms, elevating |Rental Only |
| | | | | |leg rests) Wheelchair with detachable arms, elevating | |
| | | | | |leg rests | |
|E1399 |NU | | |N |Durable medical equipment, miscellaneous |Manually Priced |
|K0105 |NU | | |N |IV hanger, each |Purchase |
| |EP | | | | | |
|K0606 |NU | | |Y |Automatic external defibrillator, with integrated |Capped Rental |
| |EP | | | |electrocardiogram analysis, garment type (covered only | |
| | | | | |for beneficiaries ages 18 and over) | |
|K0739 |NU | | |N |((DME Repair, Parts only. Repairs will not be approved |Manually Priced |
| | | | | |for more than the allowed purchase price of new | |
| | | | | |equipment. The manufacturer’s invoice must be attached | |
| | | | | |to the repair claim for all parts.) | |
|K0739 |NU |U4 | |N |((Maintenance for Capped Rental items) Repair or |Manually Priced |
| | | | | |non-routine service for durable medical equipment | |
| | | | | |requiring the skill of a technician, labor component, | |
| | | | | |per 15 minutes | |
|K0739 |NU |U1 | |N |((Labor only, Repair or non-routine service for durable |Manually Priced |
| |EP |U1 | | |medical equipment requiring the skill of a technician, | |
| | | | | |labor component, per 15 minutes. A maximum of twenty | |
| | | | | |units per date of service is allowable, 20 units=5 hours| |
| | | | | |of labor) | |
|K0739 |NU |U3 | |N |((Unlisted Repairs/Parts Only wheelchairs; applicable |Manually Priced |
| |EP |U3 | | |pages from the manufacturer’s catalog must be attached | |
| | | | | |to the claim form. Repair or non-routine service for | |
| | | | | |durable medical equipment requiring the skill of a | |
| | | | | |technician, labor component, per 15 minutes.) | |
|S8096*** |NU | | |N |((Peak flow meter used by asthmatic patients) Portable |Purchase |
| |EP | | | |peak flow meter | |
Procedure codes E0250(, E0255( and E0260( must be billed when hospital beds are purchased for Medicaid beneficiaries of all ages. Providers must only provide these purchase-only services to beneficiaries who are expected to require the bed for a long period of time. Each procedure code for hospital beds listed above may only be billed once every 10 years.
Procedure codes E0250(, E0255( and E0260( must also be used to bill for equipment that does not meet the purchase-only criteria. They are reimbursed on a capped rental basis. The capped rental items must be used until the equipment is no longer repairable or until it is no longer appropriate for the beneficiary as verified by the physician.
|242.161 Reserved |1-1-10 |
|242.170 Apnea Monitors for Beneficiaries Under 1 Year of Age |5-22-19 |
Procedure codes found in this section must be billed either electronically or on paper with modifier EP for beneficiaries under 21 years of age. Modifier UE must be used to bill for used equipment.
Modifiers in this section are indicated by the headings M1 and M2. Prior authorization requirements are shown under the heading PA. If prior authorization is needed, that information is indicated with a “Y” in the column; if not, an “N” is shown.
Sections 212.300 and 222.200 contain information regarding specific coverage and restrictions.
( Prior authorization is not required when other insurance pays at least 50% of the Medicaid maximum allowable reimbursement amount.
((…) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product. When using a procedure code with this symbol, the product must meet the indicated Arkansas Medicaid description.
|National Procedure |M1 |M2 |Description |PA |Payment Method |Deleted Local Code |
|Code | | | | | | |
|E0619 | | |((Initial setup of Apnea monitor, includes 60 |N |First 60 Days |N/A |
| | | |days rental) Apnea monitor, with recording | |Rental | |
| | | |feature | | | |
|E0619 |EP | |Apnea monitor, with recording feature |Y (on 61st |Rental Only (Daily |N/A |
| | | | |day)( |Rental) | |
|E0619 |EP |U1 |Technician and Lab Processing for setting up |N |Purchase |Z1684 |
| | | |Pneumogram or event | | | |
|242.180 Orthotic Appliances for Beneficiaries of All Ages |8-15-18 |
Procedure codes found in this section must be billed either electronically or on paper with modifier EP for beneficiaries under 21 years of age or modifier NU for beneficiaries age 21 and older. When a second modifier is listed, that modifier must be used in conjunction with either EP or NU.
Modifiers in this section are indicated by the headings M1 and M2. Prior authorization requirements are shown under the heading PA. If prior authorization is needed for individuals age 21 and older, that information is indicated with a “Y” in the column; if not, an “N” is shown. When prior authorization is not applicable (for U21) that information is shown with an “N/A” in the column.
When codes are payable for all ages, “All” is indicated in the column, “U21” is shown when the code is payable only for individuals under age 21 and “21+” is shown when the code is payable only for those individuals age 21 and older.
** This item is not a covered service for the diagnosis of Carpal Tunnel Syndrome prior to surgery.
((…) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product. When using a procedure code with this symbol, the product must meet the indicated Arkansas Medicaid description.
■ This procedure code does not require prior authorization; however, the beneficiary’s medical condition must fall within the following diagnosis codes. (View ICD codes.)
+ This item is limited to one every twelve months for beneficiaries age 21 and over.
|Orthotic Appliances, All Ages (Section 242.180) |
|National Procedure |M1 |M2 |Description |All |PA 21+ |Payment Method |
|Code | | | |U21 | | |
| | | | |21+ | | |
|A5500ν |NU | |For diabetics only, fitting (including follow-up) custom |21+ |N |Purchase |
| | | |preparation and supply of off-the-shelf depth-inlay shoe | | | |
| | | |manufactured to accommodate multi-density insert(s), per | | | |
| | | |shoe | | | |
|A5501ν |NU | |For diabetics only, fitting (including follow-up) custom |21+ |N |Purchase |
| | | |preparation and supply of molded from cast(s) of | | | |
| | | |patient’s foot (custom molded shoe), per shoe | | | |
|A5503ν |NU | |For diabetics only, modification (including fitting) of |21+ |N |Purchase |
| | | |off-the-shelf depth-inlay shoe or custom molded shoe with| | | |
| | | |roller or rigid rocker bottom, per shoe | | | |
|A5504ν |NU | |For diabetics only, modification (including fitting) of |21+ |N |Purchase |
| | | |off-the-shelf depth-inlay shoe or custom molded shoe with| | | |
| | | |wedge(s), per shoe | | | |
|A5505ν |NU | |For diabetics only, modification (including fitting) of |21+ |N |Purchase |
| | | |off-the-shelf depth-inlay shoe or custom molded shoe with| | | |
| | | |metatarsal bar, per shoe | | | |
|A5506ν |NU | |For diabetics only, modification (including fitting) of |21+ |N |Purchase |
| | | |off-the-shelf depth-inlay shoe or custom molded shoe with| | | |
| | | |off-set heel(s), per shoe | | | |
|A5507 |NU | |For diabetics only, not otherwise specified modification |21+ |Y |Purchase |
| | | |(including fitting) of off-the-shelf depth-inlay shoe or | | | |
| | | |custom molded shoe, per shoe | | | |
|A5510ν |NU | |For diabetics only, direct formed, compression molded to |21+ |N |Purchase |
| | | |patient’s foot without external heat source, | | | |
| | | |multiple-density insert(s) prefabricated, per shoe | | | |
|A5512ν |NU | |For diabetics only, multiple density insert, direct |21+ |N |Purchase |
| | | |formed, molded to foot after external heat source of 230 | | | |
| | | |degrees Fahrenheit or higher, total contact with | | | |
| | | |patient’s foot, including arch, base layer minimum of ¼ | | | |
| | | |inch material of shore a 35 durometer of 3/16 inch | | | |
| | | |material of shore a 40 durometer (or higher), | | | |
| | | |prefabricated, each | | | |
|A5513ν |NU | |For diabetics only, multiple density insert, custom |21+ |N |Purchase |
| | | |molded from model of patient’s foot, total contact with | | | |
| | | |patient’s foot, including arch, base layer minimum of | | | |
| | | |3/16 inch material of shore a 35 durometer or higher, | | | |
| | | |includes arch filler and other shaping material custom | | | |
| | | |fabricated, each | | | |
|E1810 |NU | |Dynamic adjustable knee extension/flexion device, |All |N |Purchase |
| |EP | |includes soft interface material | | | |
|K0672 |NU | |Addition to lower extremity orthotic, removable soft |All |N |Purchase |
| |EP | |interface, all components, replacement only, each. | | | |
|L0120 |NU | |Cervical, flexible, nonadjustable (foam collar) |All |N |Purchase |
| |EP | | | | | |
|L0130 |NU | |Cervical, flexible, thermoplastic collar, molded to |All |N |Purchase |
| |EP | |patient | | | |
|L0140 |NU | |Cervical, semi-rigid, adjustable (plastic collar) |All |N |Purchase |
| |EP | | | | | |
|L0150 |NU | |Cervical, semi-rigid, adjustable molded chin cup (plastic|All |N |Purchase |
| |EP | |collar with mandibular/occipital piece) | | | |
|L0160 |NU | |Cervical, semi-rigid, wire frame occipital/mandibular |All |N |Purchase |
| |EP | |support | | | |
|L0170 |NU | |Cervical, collar, molded to patient model |All |N |Purchase |
| |EP | | | | | |
|L0172 |NU | |Cervical, collar, semi-rigid thermoplastic foam, two |All |N |Purchase |
| |EP | |piece | | | |
|L0174 |NU | |Cervical, collar, semi-rigid thermoplastic foam, two |All |N |Purchase |
| |EP | |piece with thoracic extension | | | |
|L0180 |NU | |Cervical, multiple post collar, occipital/mandibular |All |N |Purchase |
| |EP | |supports, adjustable | | | |
|L0190 |NU | |Cervical, multiple post collar, occipital/mandibular |All |N |Purchase |
| |EP | |supports, adjustable cervical bars (SOMI, Guilford, | | | |
| | | |Taylor types) | | | |
|L0200 |NU | |Cervical, multiple post collar, occipital/mandibular |All |N |Purchase |
| |EP | |supports, adjustable cervical bars, and thoracic | | | |
| | | |extension | | | |
|L0220 |NU | |Thoracic, rib belt, custom fabricated |All |N |Purchase |
| |EP | | | | | |
|L0450 |NU | |TLSO, flexible, provides trunk support, upper thoracic |All |N |Purchase |
| |EP | |region, produces intracavitary pressure to reduce load on| | | |
| | | |the intervertebral disks with rigid stays or panel(s), | | | |
| | | |includes shoulder straps and closures, prefabricated, | | | |
| | | |includes fitting and adjustment | | | |
|L0452 |NU | |TLSO, flexible, provides trunk support, upper thoracic |All |N |Purchase |
| |EP | |region, produces intracavitary pressure to reduce load on| | | |
| | | |the intervertebral disks with rigid stays or panel(s), | | | |
| | | |includes shoulder straps and closures, custom fabricated | | | |
|L0454 |NU | |TLSO, flexible, provides trunk support, extends from |All |N |Purchase |
| |EP | |sacrococcygeal junction to above T-9 vertebra, restricts | | | |
| | | |gross trunk motion in the sagittal plane, produces | | | |
| | | |intracavitary pressure to reduce load on the | | | |
| | | |intervertebral disks with rigid stays or panel(s), | | | |
| | | |includes shoulder straps and closures, prefabricated, | | | |
| | | |includes fitting and adjustment | | | |
|L0456 |NU | |TLSO, flexible, provides trunk support, thoracic region, |All |N |Purchase |
| |EP | |rigid posterior panel and soft anterior apron, extends | | | |
| | | |from sacrococcygeal junction and terminates just inferior| | | |
| | | |to the scapular spine, restricts gross trunk motion in | | | |
| | | |the sagittal plane, produces intracavitary pressure to | | | |
| | | |reduce load on the intervertebral disks, includes straps | | | |
| | | |and closures, prefabricated, includes fitting and | | | |
| | | |adjustment | | | |
|L0458 |NU | |TLSO, triplanar control, modular segmented spinal system,|All |Y |Purchase |
| |EP | |two rigid plastic shells, posterior extends from | | | |
| | | |sacrococcygeal junction and terminates just inferior to | | | |
| | | |the scapular spine, anterior extends from the symphysis | | | |
| | | |pubis to the xiphoid, soft liner, restricts gross trunk | | | |
| | | |motion in the sagittal, coronal and transverse planes, | | | |
| | | |lateral strength is provided by overlapping plastic and | | | |
| | | |stabilizing closures, includes straps and closures, | | | |
| | | |prefabricated, includes fitting and adjustment | | | |
|L0460 |NU | |TLSO, triplanar control modular segmented spinal system, |All |Y |Purchase |
| |EP | |two rigid plastic shells, posterior extends from the | | | |
| | | |sacrococcygeal junction and terminates just inferior to | | | |
| | | |the scapular spine, anterior extends from the symphysis | | | |
| | | |pubis to the sternal notch, soft liner, restricts gross | | | |
| | | |trunk motion in the sagittal, coronal and transverse | | | |
| | | |planes, lateral strength is provided by overlapping | | | |
| | | |plastic and stabilizing closures, including straps and | | | |
| | | |closures, prefabricated, includes fitting and adjustment | | | |
|L0462 |NU | |TLSO, triplanar control modular segmented spinal system, |All |Y |Purchase |
| |EP | |three rigid plastic shells, posterior extends from | | | |
| | | |sacrococcygeal junction and terminates just inferior to | | | |
| | | |the scapular spine, anterior extends from the symphysis | | | |
| | | |pubis to the sternal notch, soft liner, restricts gross | | | |
| | | |trunk motion in the sagittal, coronal and transverse | | | |
| | | |planes, lateral strength is provided by overlapping | | | |
| | | |plastic and stabilizing closures, including straps and | | | |
| | | |closures, prefabricated, includes fitting and adjustment | | | |
|L0464 |NU | |TLSO, triplanar control modular segmented spinal system, |All |Y |Purchase |
| |EP | |four rigid plastic shells, posterior extends from | | | |
| | | |sacrococcygeal junction and terminates just inferior to | | | |
| | | |the scapular spine, anterior extends from the symphysis | | | |
| | | |pubis to the sternal notch, soft liner, restricts gross | | | |
| | | |trunk motion in sagittal, coronal and transverse planes, | | | |
| | | |lateral strength is provided by overlapping plastic and | | | |
| | | |stabilizing closures, including straps and closures, | | | |
| | | |prefabricated, includes fitting and adjustment | | | |
|L0466 |NU | |TLSO, sagittal control, rigid posterior frame and |All |N |Purchase |
| |EP | |flexible soft anterior apron with straps, closures and | | | |
| | | |padding, restricts gross trunk motion in sagittal plane, | | | |
| | | |produces intracavitary pressure to reduce load on | | | |
| | | |intervertebral disks, includes fitting and shaping the | | | |
| | | |frame, prefabricated, includes fitting and adjustment | | | |
|L0468 |NU | |TLSO, sagittal-coronal control, rigid posterior frame and|All |N |Purchase |
| |EP | |flexible soft anterior apron with straps, closures and | | | |
| | | |padding, extends from sacrococcygeal junction over | | | |
| | | |scapulae, lateral strength provided by pelvic, thoracic, | | | |
| | | |and lateral frame pieces, restricts gross trunk motion in| | | |
| | | |sagittal and coronal planes, produces intracavitary | | | |
| | | |pressure to reduce load on intervertebral disks, includes| | | |
| | | |fitting and shaping the frame, prefabricated, includes | | | |
| | | |fitting and adjustment | | | |
|L0470 |NU | |TLSO, triplanar control, rigid posterior frame and |All |N |Purchase |
| |EP | |flexible soft anterior apron with straps, closures and | | | |
| | | |padding, extends from sacrococcygeal junction to scapula,| | | |
| | | |lateral strength provided by pelvic, thoracic, and | | | |
| | | |lateral frame pieces, rotational strength provided by | | | |
| | | |subclavicular extensions, restricts gross trunk motion in| | | |
| | | |sagittal, coronal and transverse planes, produces | | | |
| | | |intracavitary pressure to reduce load on intervertebral | | | |
| | | |disks, includes fitting and shaping the frame, | | | |
| | | |prefabricated, includes fitting and adjustment | | | |
|L0472 |NU | |TLSO, triplanar control, hyperextension, rigid anterior |All |N |Purchase |
| |EP | |and lateral frame extends from symphysis pubis to sternal| | | |
| | | |notch with two anterior components (one pubic and one | | | |
| | | |sternal) posterior and lateral pads with straps and | | | |
| | | |closures, limits spinal flexion, restricts gross trunk | | | |
| | | |motion in sagittal, coronal and transverse planes, | | | |
| | | |includes fitting and shaping the frame, prefabricated, | | | |
| | | |includes fitting and adjustment | | | |
|L0480 |NU | |TLSO, triplanar control, one-piece rigid plastic shell |All |Y |Purchase |
| |EP | |without interface liner, with multiple straps and | | | |
| | | |closures, posterior extends from sacrococcygeal junction | | | |
| | | |and terminates just inferior to scapular spine, anterior | | | |
| | | |extends from symphysis pubis to sternal notch, anterior | | | |
| | | |or posterior opening, restricts gross trunk motion in | | | |
| | | |sagittal, coronal and transverse planes, includes a | | | |
| | | |carved plaster or CAD-CAM model, custom fabricated | | | |
|L0482 |NU | |TLSO, triplanar control, one-piece rigid plastic shell |All |Y |Purchase |
| |EP | |with interface liner, multiple straps and closures, | | | |
| | | |posterior extends from sacrococcygeal junction and | | | |
| | | |terminates just inferior to scapular spine, anterior | | | |
| | | |extends from symphysis pubis to sternal notch, anterior | | | |
| | | |or posterior opening, restricts gross trunk motion in | | | |
| | | |sagittal, coronal and transverse planes, includes a | | | |
| | | |carved plaster or CAD-CAM model, custom fabricated | | | |
|L0484 |NU | |TLSO, triplanar control, two-piece rigid plastic shell |All |Y |Purchase |
| |EP | |without interface liner, with multiple straps and | | | |
| | | |closures, posterior extends from sacrococcygeal junction | | | |
| | | |and terminates just inferior to scapular spine, anterior | | | |
| | | |extends from symphysis pubis to sternal notch, lateral | | | |
| | | |strength is enhanced by overlapping plastic, restricts | | | |
| | | |gross trunk motion in the sagittal, coronal and | | | |
| | | |transverse planes, includes a carved plaster or CAD-CAM | | | |
| | | |model, custom fabricated | | | |
|L0486 |NU | |TLSO, triplanar control, two-piece rigid plastic shell |All |Y |Purchase |
| |EP | |with interface liner, multiple straps and closures, | | | |
| | | |posterior extends from sacrococcygeal junction and | | | |
| | | |terminates just inferior to scapular spine, anterior | | | |
| | | |extends from symphysis pubis to sternal notch, lateral | | | |
| | | |strength is enhanced by overlapping plastic, restricts | | | |
| | | |gross trunk motion in the sagittal, coronal and | | | |
| | | |transverse planes, includes a carved plaster or CAD-CAM | | | |
| | | |model, custom fabricated | | | |
|L0488 |NU | |TLSO, triplanar control, one-piece rigid plastic shell |All |Y |Purchase |
| |EP | |with interface liner, multiple straps and closures, | | | |
| | | |posterior extends from sacrococcygeal junction and | | | |
| | | |terminates just inferior to scapular spine, anterior | | | |
| | | |extends from symphysis pubis to sternal notch, anterior | | | |
| | | |or posterior opening, restricts gross trunk motion in | | | |
| | | |sagittal, coronal and transverse planes, prefabricated, | | | |
| | | |includes fitting and adjustment | | | |
|L0490 |NU | |TLSO, sagittal-coronal control, one-piece rigid plastic |All |Y |Purchase |
| |EP | |shell with overlapping reinforced anterior, with multiple| | | |
| | | |straps and closures, posterior extends from | | | |
| | | |sacrococcygeal junction and terminates at or before the | | | |
| | | |T-9 vertebra, anterior extends from symphysis pubis to | | | |
| | | |xiphoid, anterior opening, restricts gross trunk motion | | | |
| | | |in sagittal and coronal planes, prefabricated, includes | | | |
| | | |fitting and adjustment | | | |
|L0621 |NU | |Sacroiliac orthosis, flexible, provides pelvic-sacral |All |N |Purchase |
| |EP | |support, reduces motion about the sacroiliac joint, | | | |
| | | |includes straps, closures, may include pendulous abdomen | | | |
| | | |design, prefabricated, includes fitting and adjustment | | | |
|L0622 |NU | |Sacroiliac orthosis, flexible, provides pelvic-sacral |All |N |Purchase |
| |EP | |support, reduces motion about the sacroiliac joint, | | | |
| | | |includes straps, closures, may include pendulous abdomen | | | |
| | | |design, custom fabricated | | | |
|L0623 |NU | |Sacroiliac orthosis, provides pelvic-sacral support, |All |N |Purchase |
| |EP | |with rigid or semi-rigid panels over the sacrum and | | | |
| | | |abdomen, reduces motion about the sacroiliac joint, | | | |
| | | |includes straps, closures, may include pendulous abdomen | | | |
| | | |design, prefabricated, includes fitting and adjustment | | | |
|L0624 |NU | |Sacroiliac orthosis, provides pelvic-sacral support, with|All |N |Manually Priced |
| |EP | |rigid or semi-rigid panels over the sacrum and abdomen, | | | |
| | | |reduces motion about the sacroiliac joint, includes | | | |
| | | |straps, closures, may include pendulous abdomen design, | | | |
| | | |custom fabricated | | | |
|L0625 |NU | |Lumbar orthosis, flexible, provides lumbar support, |All |N |Purchase |
| |EP | |posterior extends from L-1 to below L-5 vertebra, | | | |
| | | |produces intracavitary pressure to reduce load on the | | | |
| | | |intervertebral discs, includes straps, closures, may | | | |
| | | |include pendulous abdomen design, shoulder straps, stays,| | | |
| | | |prefabricated, includes fitting and adjustment | | | |
|L0626 |NU | |Lumbar orthosis, sagittal control, with rigid posterior |All |N |Purchase |
| |EP | |panel(s), posterior extends from L-1 to below L-5 | | | |
| | | |vertebra, produces intracavitary pressure to reduce load | | | |
| | | |on the intervertebral discs, includes straps, closures, | | | |
| | | |may include padding, stays, shoulder straps, pendulous | | | |
| | | |abdomen design, prefabricated, includes fitting and | | | |
| | | |adjustment | | | |
|L0627 |NU | |Lumbar orthosis, sagittal control, with rigid anterior |All |N |Purchase |
| |EP | |and posterior panel(s), posterior extends from L-1 to | | | |
| | | |below L-5 vertebra, produces intracavitary pressure to | | | |
| | | |reduce load on the intervertebral discs, includes straps,| | | |
| | | |closures, may include padding, shoulder straps, pendulous| | | |
| | | |abdomen design, prefabricated, includes fitting and | | | |
| | | |adjustment | | | |
|L0628 |NU | |Lumbar-sacral orthosis, flexible, provides lumbo-sacral |All |N |Purchase |
| |EP | |support, posterior extends from sacrococcygeal junction | | | |
| | | |to T-9 vertebra, produces intracavitary pressure to | | | |
| | | |reduce load on the intervertebral discs, includes straps,| | | |
| | | |closures, may include stays, shoulder straps, pendulous | | | |
| | | |abdomen design, prefabricated, includes fitting and | | | |
| | | |adjustment | | | |
|L0629 |NU | |Lumbar-sacral orthosis, flexible, provides lumbo-sacral |All |N |Manually Priced |
| |EP | |support, posterior extends from sacrococcygeal junction | | | |
| | | |to T-9 vertebra, produces intracavitary pressure to | | | |
| | | |reduce load on the intervertebral discs, includes straps,| | | |
| | | |closures, may include stays, shoulder straps, pendulous | | | |
| | | |abdomen design, custom fabricated | | | |
|L0630 |NU | |Lumbar-sacral orthosis, sagittal control, with rigid |All |N |Purchase |
| |EP | |posterior panel(s), posterior extends from sacrococcygeal| | | |
| | | |junction to T-9 vertebra, produces intracavitary pressure| | | |
| | | |to reduce load on the intervertebral discs, includes | | | |
| | | |straps, closures, may include padding, stays, shoulder | | | |
| | | |straps, pendulous abdomen design, prefabricated, includes| | | |
| | | |fitting and adjustment | | | |
|L0631 |NU | |Lumbar-sacral orthosis, sagittal control, with rigid |All |N |Purchase |
| |EP | |anterior and posterior panel(s), posterior extends from | | | |
| | | |sacrococcygeal junction to T-9 vertebra, produces | | | |
| | | |intracavitary pressure to reduce load on the | | | |
| | | |intervertebral discs, includes straps, closures, may | | | |
| | | |include padding, shoulder straps, pendulous abdomen | | | |
| | | |design, prefabricated, includes fitting and adjustment | | | |
|L0632 |NU | |Lumbar-sacral orthosis, sagittal control, with rigid |All |N |Manually Priced |
| |EP | |anterior and posterior panels, posterior extends from | | | |
| | | |sacrococcygeal junction to T-9 vertebra, produces | | | |
| | | |intracavitary pressure to reduce load on the | | | |
| | | |intervertebral discs, includes straps, closures, may | | | |
| | | |include padding, shoulder straps, pendulous abdomen | | | |
| | | |design, custom fabricated | | | |
|L0633 |NU | |Lumbar-sacral orthosis, sagittal-coronal control, with |All |N |Purchase |
| |EP | |rigid posterior frame/panel(s), posterior extends from | | | |
| | | |sacrococcygeal junction to T-9 vertebra, lateral strength| | | |
| | | |provided by rigid lateral frame/panels, produces | | | |
| | | |intracavitary pressure to reduce load on the | | | |
| | | |intervertebral discs, includes straps, closures, may | | | |
| | | |include padding, stays, shoulder straps, pendulous | | | |
| | | |abdomen design, prefabricated, includes fitting and | | | |
| | | |adjustment | | | |
|L0634 |NU | |Lumbar-sacral orthosis, sagittal-coronal control, with |All |N |Manually Priced |
| |EP | |rigid posterior frame/panel(s), posterior extends from | | | |
| | | |sacrococcygeal junction to T-9 vertebra, lateral strength| | | |
| | | |provided by rigid lateral frame/panel(s), produces | | | |
| | | |intracavitary pressure to reduce load on the | | | |
| | | |intervertebral discs, includes straps, closures, may | | | |
| | | |include padding, stays, shoulder straps, pendulous | | | |
| | | |abdomen design, custom fabricated | | | |
|L0635 |NU | |Lumbar-sacral orthosis, sagittal-coronal control, lumbar |All |N |Purchase |
| |EP | |flexion, rigid posterior frame/panel(s), lateral | | | |
| | | |articulating design to flex the lumbar spine, posterior | | | |
| | | |extends from sacrococcygeal junction to T-9 vertebra, | | | |
| | | |lateral strength provided by rigid lateral | | | |
| | | |frame/panel(s), produces intracavitary pressure to reduce| | | |
| | | |load on the intervertebral discs, includes straps, | | | |
| | | |closures, may include padding, anterior panel, pendulous | | | |
| | | |abdomen design, prefabricated, includes fitting and | | | |
| | | |adjustment | | | |
|L0636 |NU | |Lumbar-sacral orthosis, sagittal-coronal control, lumbar |All |N |Purchase |
| |EP | |flexion, rigid posterior frame/panel(s), lateral | | | |
| | | |articulating design to flex the lumbar spine, posterior | | | |
| | | |extends from sacrococcygeal junction to T-9 vertebra, | | | |
| | | |lateral strength provided by rigid lateral frame/panels, | | | |
| | | |produces intracavitary pressure to reduce load on the | | | |
| | | |intervertebral discs, includes straps, closures, may | | | |
| | | |include padding, anterior panel, pendulous abdomen | | | |
| | | |design, custom fabricated | | | |
|L0637 |NU | |Lumbar-sacral orthosis, sagittal-coronal control, with |All |N |Purchase |
| |EP | |rigid anterior and posterior frame/panels, posterior | | | |
| | | |extends from sacrococcygeal junction to T-9 vertebra, | | | |
| | | |lateral strength provided by rigid lateral frame/panels, | | | |
| | | |produces intracavitary pressure to reduce load on the | | | |
| | | |intervertebral discs, includes straps, closures, may | | | |
| | | |include padding, shoulder straps, pendulous abdomen | | | |
| | | |design, prefabricated, includes fitting and adjustment | | | |
|L0638 |NU | |Lumbar-sacral orthosis, sagittal-coronal control, with |All |N |Purchase |
| |EP | |rigid anterior and posterior frame/panels, posterior | | | |
| | | |extends from sacrococcygeal junction to T-9 vertebra, | | | |
| | | |lateral strength provided by rigid lateral frame/panels, | | | |
| | | |produces intracavitary pressure to reduce load on the | | | |
| | | |intervertebral discs, includes straps, closures, may | | | |
| | | |include padding, shoulder straps, pendulous abdomen | | | |
| | | |design, custom fabricated | | | |
|L0639 |NU | |Lumbar-sacral orthosis, sagittal-coronal control, rigid |All |N |Purchase |
| |EP | |shell(s)/panel(s), posterior extends from sacrococcygeal | | | |
| | | |junction to T-9 vertebra, anterior extends from symphysis| | | |
| | | |pubis to xiphoid, produces intracavitary pressure to | | | |
| | | |reduce load on the intervertebral discs, overall strength| | | |
| | | |provided by overlapping rigid material and stabilizing | | | |
| | | |closures, includes straps, closures, may include soft | | | |
| | | |interface, pendulous abdomen design, prefabricated, | | | |
| | | |includes fitting and adjustment | | | |
|L0640 |NU | |Lumbar-sacral orthosis, sagittal-coronal control, rigid |All |N |Purchase |
| |EP | |shell(s)/panel(s), posterior extends from sacrococcygeal | | | |
| | | |junction to T-9 vertebra, anterior extends from symphysis| | | |
| | | |pubis to xiphoid, produces intracavitary pressure to | | | |
| | | |reduce load on the intervertebral discs, overall strength| | | |
| | | |provided by overlapping rigid material and stabilizing | | | |
| | | |closures, includes straps, closures, may include soft | | | |
| | | |interface, pendulous abdomen design, custom fabricated | | | |
|L0700 |NU | |Cervical-thoracic-lumbar-sacral orthoses (CTLSO), |All |Y |Purchase |
| |EP | |anterior-posterior-lateral control, molded to patient | | | |
| | | |model (Minerva type) | | | |
|L0710 |NU | |CTLSO, anterior-posterior-lateral control, molded to |All |Y |Purchase |
| |EP | |patient model, with interface material (Minerva type) | | | |
|L0810 |NU | |Halo procedure, cervical halo incorporated into jacket |All |Y |Purchase |
| |EP | |vest | | | |
|L0820 |NU | |Halo procedure, cervical halo incorporated into plaster |All |Y |Purchase |
| |EP | |body jacket | | | |
|L0830 |NU | |Halo procedure, cervical halo incorporated into Milwaukee|All |Y |Purchase |
| |EP | |type orthosis | | | |
|L0859 |NU | |Addition to halo procedure, magnetic resonance image |All |Y |Purchase |
| |EP | |compatible system, rings and pins, any material | | | |
|L0970 |NU | |TLSO, corset front |All |N |Purchase |
| |EP | | | | | |
|L0972 |NU | |LSO, corset front |All |N |Purchase |
| |EP | | | | | |
|L0974 |NU | |TLSO, full corset |All |N |Purchase |
| |EP | | | | | |
|L0976 |NU | |LSO, full corset |All |N |Purchase |
| |EP | | | | | |
|L0978 |NU | |Axillary crutch extension |All |N |Purchase |
| |EP | | | | | |
|L0980 |NU | |Peroneal straps, pair |All |N |Purchase |
| |EP | | | | | |
|L0982 |NU | |Stocking supporter grips, set of four (4) |All |N |Purchase |
| |EP | | | | | |
|L0984 |NU | |Protective body sock, each |21+ |N |Purchase |
|L1000 |NU | |CTLSO (Milwaukee), inclusive of furnishing initial |All |Y |Purchase |
| |EP | |orthosis, including model | | | |
|L1010 |NU | |Addition to CTLSO or scoliosis orthosis, axilla sling |All |N |Purchase |
| |EP | | | | | |
|L1020 |NU | |Addition to CTLSO or scoliosis orthosis, kyphosis pad |All |N |Purchase |
| |EP | | | | | |
|L1025 |NU | |Addition to CTLSO or scoliosis orthosis, kyphosis pad, |All |N |Purchase |
| |EP | |floating | | | |
|L1030 |NU | |Addition to CTLSO or scoliosis orthosis, lumbar bolster |All |N |Purchase |
| |EP | |pad | | | |
|L1040 |NU | |Addition to CTLSO or scoliosis orthosis, lumbar or lumbar|All |N |Purchase |
| |EP | |rib pad | | | |
|L1050 |NU | |Addition to CTLSO or scoliosis orthosis, sternal pad |All |N |Purchase |
| |EP | | | | | |
|L1060 |NU | |Addition to CTLSO or scoliosis orthosis, thoracic pad |All |N |Purchase |
| |EP | | | | | |
|L1070 |NU | |Addition to CTLSO or scoliosis orthosis, trapezius sling |All |N |Purchase |
| |EP | | | | | |
|L1080 |NU | |Addition to CTLSO or scoliosis orthosis, outrigger |All |N |Purchase |
| |EP | | | | | |
|L1085 |NU | |Addition to CTLSO or scoliosis orthosis, outrigger, |All |N |Purchase |
| |EP | |bilateral with vertical extensions | | | |
|L1090 |NU | |Addition to CTLSO or scoliosis orthosis, lumbar sling |All |N |Purchase |
| |EP | | | | | |
|L1100 |NU | |Addition to CTLSO or scoliosis orthosis, ring flange, |All |N |Purchase |
| |EP | |plastic or leather | | | |
|L1110 |NU | |Addition to CTLSO or scoliosis orthosis, ring flange, |All |N |Purchase |
| |EP | |plastic or leather, molded to patient model | | | |
|L1120 |NU | |Addition to CTLSO, scoliosis orthosis, cover for upright,|All |N |Purchase |
| |EP | |each | | | |
|L1200 |NU | |Thoracic-lumbar-sacral-orthosis (TLSO), inclusive of |All |Y |Purchase |
| |EP | |furnishing initial orthosis only | | | |
|L1210 |NU | |Addition to TLSO (low profile), lateral thoracic |All |N |Purchase |
| |EP | |extension | | | |
|L1220 |NU | |Addition to TLSO (low profile), anterior thoracic |All |N |Purchase |
| |EP | |extension | | | |
|L1230 |NU | |Addition to TLSO (low profile), Milwaukee type |All |N |Purchase |
| |EP | |superstructure | | | |
|L1240 |NU | |Addition to TLSO (low profile), lumbar derotation pad |All |N |Purchase |
| |EP | | | | | |
|L1250 |NU | |Addition to TLSO (low profile), anterior ASIS pad |All |N |Purchase |
| |EP | | | | | |
|L1260 |NU | |Addition to TLSO (low profile), anterior thoracic |All |N |Purchase |
| |EP | |derotation pad | | | |
|L1270 |NU | |Addition to TLSO (low profile), abdominal pad |All |N |Purchase |
| |EP | | | | | |
|L1280 |NU | |Addition to TLSO (low profile), rib gusset (elastic), |All |N |Purchase |
| |EP | |each | | | |
|L1290 |NU | |Addition to TLSO (low profile), lateral trochanteric pad |All |N |Purchase |
| |EP | | | | | |
|L1300 |NU | |Other scoliosis procedure, body jacket molded to patient |All |Y |Purchase |
| |EP | |model | | | |
|L1310 |NU | |Other scoliosis procedure, post-operative body jacket |All |Y |Purchase |
| |EP | | | | | |
|L1499 |NU | |Spinal orthosis, not otherwise specified. ((The |All |Y |Manually Priced |
| |EP | |manufacturer’s invoice must be attached to all claims.) | | | |
|L1600 |NU | |HO, abduction control of hip joints, flexible, Frejka |All |N |Purchase |
| |EP | |type with cover, prefabricated, includes fitting and | | | |
| | | |adjustment | | | |
|L1610 |NU | |HO, abduction control of hip joints, flexible (Frejka |All |N |Purchase |
| |EP | |cover only), prefabricated, includes fitting and | | | |
| | | |adjustment | | | |
|L1620 |NU | |HO, abduction control of hip joints, flexible (Pavlik |All |N |Purchase |
| |EP | |harness), prefabricated, includes fitting and adjustment | | | |
|L1630 |NU | |HO, abduction control of hip joints, semi-flexible (Von |All |N |Purchase |
| |EP | |Rosen type), custom fabricated | | | |
|L1640 |NU | |HO, abduction control of hip joints, static, pelvic band |All |N |Purchase |
| |EP | |or spreader bar, thigh cuffs, custom fabricated | | | |
|L1650 |NU | |HO, abduction control of hip joints, static, adjustable, |All |N |Purchase |
| |EP | |custom fitted (Ilfled type), prefabricated, includes | | | |
| | | |fitting and adjustment | | | |
|L1660 |NU | |HO, abduction control of hip joints, static, plastic, |All |N |Purchase |
| |EP | |prefabricated, includes fitting and adjustment | | | |
|L1680 |NU | |HO; abduction control of hip joints, dynamic, pelvic |All |Y |Purchase |
| |EP | |control, adjustable hip motion control, thigh cuffs | | | |
| | | |(Rancho hip action type), custom fabricated | | | |
|L1685 |NU | |HO, abduction control of hip joint, post operative hip |All |Y |Purchase |
| |EP | |abduction type, custom fabricated | | | |
|L1686 |NU | |HO, abduction control of hip joint, post operative hip |All |Y |Purchase |
| |EP | |abduction type, prefabricated, includes fitting and | | | |
| | | |adjustments | | | |
|L1690 |NU | |Combination, bilateral, lumbo-sacral, hip, femur orthosis|All |Y |Purchase |
| |EP | |providing adduction and internal rotation control, | | | |
| | | |prefabricated, includes fitting and adjustment | | | |
|L1700 |NU | |Legg Perthes orthosis (Toronto type), custom fabricated |All |Y |Purchase |
| |EP | | | | | |
|L1710 |NU | |Legg Perthes orthosis (Newington type), custom fabricated|All |Y |Purchase |
| |EP | | | | | |
|L1720 |NU | |Legg Perthes orthosis, trilateral (Tachdijan type), |All |Y |Purchase |
| |EP | |custom fabricated | | | |
|L1730 |NU | |Legg Perthes orthosis (Scottish Rite type) custom |All |Y |Purchase |
| |EP | |fabricated | | | |
|L1755 |NU | |Legg Perthes orthosis (Patten bottom type), custom |All |Y |Purchase |
| |EP | |fabricated | | | |
|L1810 |NU | |KO, elastic with joints, prefabricated, includes fitting |All |N |Purchase |
| |EP | |and adjustment | | | |
|L1820 |NU | |KO, elastic with condylar pads and joints, prefabricated,|All |N |Purchase |
| |EP | |includes fitting and adjustment | | | |
|L1830 |NU | |KO, immobilizer, canvas longitudinal, prefabricated, |All |N |Purchase |
| |EP | |includes fitting and adjustment | | | |
|L1832 |NU | |Knee orthosis, adjustable knee joints (unicentric or |All |N |Purchase |
| |EP | |polycentric), positional orthosis, rigid support, | | | |
| | | |prefabricated, includes fitting and adjustment | | | |
|L1834 |NU | |KO, without knee joint, rigid, custom fabricated |All |N |Purchase |
| |EP | | | | | |
|L1840 |NU | |KO, derotation, medial-lateral, anterior cruciate |All |Y |Purchase |
| |EP | |ligament, custom fabricated | | | |
|L1843 |NU | |Knee orthosis, single upright, thigh and calf, with |21+ |Y |Purchase |
| | | |adjustable flexion and extension joint (unicentric or | | | |
| | | |polycentric), medial-lateral and rotation control, with | | | |
| | | |or without varus/valgus adjustment, prefabricated, | | | |
| | | |includes fitting and adjustment | | | |
|L1844 |NU | |Knee orthosis, single upright, thigh and calf, with |21+ |Y |Purchase |
| | | |adjustable flexion and extension joint (unicentric or | | | |
| | | |polycentric), medial-lateral and rotation control, with | | | |
| | | |or without varus/valgus adjustment, custom fabricated | | | |
|L1845 |NU | |Knee orthosis, double upright, thigh and calf, with |All |Y |Purchase |
| |EP | |adjustable flexion and extension joint (unicentric or | | | |
| | | |polycentric), medial-lateral and rotation control with or| | | |
| | | |without varus/valgus adjustment, prefabricated, includes | | | |
| | | |fitting and adjustment | | | |
|L1846 |NU | | Knee orthosis, double upright, thigh and calf, with |All |Y |Purchase |
| |EP | |adjustable flexion and extension joint (unicentric or | | | |
| | | |polycentric), medial-lateral and rotation control with or| | | |
| | | |without varus/valgus adjustment, custom fabricated | | | |
|L1847 |NU | |Knee orthosis, double upright with adjustable joint, with|21+ |N |Purchase |
| | | |inflatable air support chamber(s) prefabricated, includes| | | |
| | | |fitting and adjustment | | | |
|L1850 |NU | |KO, Swedish type, prefabricated, includes fitting and |All |N |Purchase |
| |EP | |adjustment | | | |
|L1851 |NU | |Knee orthosis (ko), single upright, thigh and calf, with |All |N |Purchase |
| |EP | |adjustable flexion and extension joint (unicentric or | | | |
| | | |polycentric), medial-lateral and rotation control, with | | | |
| | | |or without varus/valgus adjustment, prefabricated, | | | |
| | | |off-the-shelf | | | |
|L1852 |NU | |Knee orthosis (ko), double upright, thigh and calf, with |All |Y |Purchase |
| |EP | |adjustable flexion and extension joint (unicentric or | | | |
| | | |polycentric), medial-lateral and rotation control, with | | | |
| | | |or without varus/valgus adjustment, prefabricated, | | | |
| | | |off-the-shelf | | | |
|L1860 |NU | |KO, modification of supracondylar prosthetic socket, |All |Y |Purchase |
| |EP | |custom fabricated (SK) | | | |
|L1900 |NU | |AFO, spring wire, dorsiflexion assist calf band, custom |All |N |Purchase |
| |EP | |fabricated | | | |
|L1902 |NU | |AFO, ankle gauntlet, prefabricated, includes fitting and |All |N |Purchase |
| |EP | |adjustment | | | |
|L1904 |NU | |AFO, molded ankle gauntlet, custom fabricated |All |N |Purchase |
| |EP | | | | | |
|L1906 |NU | |AFO, multiligamentus ankle support, prefabricated, |All |N |Purchase |
| |EP | |includes fitting and adjustment | | | |
|L1907 |NU | |AFO, supramalleolar with straps, with or without |All |N |Purchase |
| |EP | |interface/pads, custom fabricated | | | |
|L1910 |NU | |AFO, posterior, single bar, clasp attachment to shoe |All |N |Purchase |
| |EP | |counter prefabricated, includes fitting and adjustment | | | |
|L1920 |NU | |((Custom night “A” frame-KAFO, torsion control, bilateral|All |N |Purchase |
| |EP | |night “A” frame) AFO, single upright with static or | | | |
| | | |adjustable stop (Phelps or Perlstein type), custom | | | |
| | | |fabricated | | | |
|L1930 |NU | |AFO, plastic or other material, prefabricated, includes |All |N |Purchase |
| |EP | |fitting and adjustment | | | |
|L1932 |NU | |AFO, rigid anterior tibial section, total carbon fiber or|All |N |Purchase |
| |EP | |equal material, prefabricated, includes fitting and | | | |
| | | |adjustment | | | |
|L1940 |NU | |AFO, plastic or other material, custom-fabricated |All |N |Purchase |
| |EP | | | | | |
|L1945 |NU | |AFO, molded to patient model, plastic, rigid anterior |All |Y |Purchase |
| |EP | |tibial section (floor reaction), custom fabricated | | | |
|L1950 |NU | |AFO, spiral (Institute of Rehabilitative Medicine type), |All |N |Purchase |
| |EP | |plastic, custom fabricated | | | |
|L1951 |NU | |Ankle foot orthosis, spiral (Institute of Rehabilitative |All |N |Purchase |
| |EP | |Medicine type), plastic, or other material, | | | |
| | | |prefabricated, includes fitting and adjustment | | | |
|L1960 |NU | |AFO, posterior solid ankle, plastic, custom fabricated |All |N |Purchase |
| |EP | | | | | |
|L1970 |NU | |AFO, plastic, with ankle joint, custom fabricated |All |N |Purchase |
| |EP | | | | | |
|L1980 |NU | |AFO, single upright free plantar dorsiflexion, solid |All |N |Purchase |
| |EP | |stirrup, calf band/cuff (single bar BK orthosis), custom | | | |
| | | |fabricated | | | |
|L1990 |NU | |AFO, double upright free plantar dorsiflexion, solid |All |N |Purchase |
| |EP | |stirrup, calf band/cuff (double bar BK orthosis), custom | | | |
| | | |fabricated | | | |
|L2000 |NU | |KAFO, single upright, free knee, free ankle, solid |All |Y |Purchase |
| |EP | |stirrup, thigh and calf bands/cuffs (single bar AK | | | |
| | | |orthosis), custom fabricated | | | |
|L2005 |NU | |KAFO, any material, single or double upright, stance |All |N |Purchase |
| |EP | |control, automatic lock and swing phase release, | | | |
| | | |mechanical activation, includes ankle joint, any type, | | | |
| | | |custom fabricated | | | |
|L2010 |NU | |KAFO, single upright, free knee, free ankle, solid |All |Y |Purchase |
| |EP | |stirrup, thigh and calf bands/cuffs (single bar AK | | | |
| | | |orthosis), without knee joint, custom fabricated | | | |
|L2020 |NU | |KAFO, double upright, free knee, free ankle, solid |All |Y |Purchase |
| |EP | |stirrup, thigh and calf bands/cuffs (double bar AK | | | |
| | | |orthosis), custom fabricated | | | |
|L2030 |NU | |KAFO, double upright, free knee, free ankle, solid |All |Y |Purchase |
| |EP | |stirrup, thigh and calf bands/cuffs, (double bar AK | | | |
| | | |orthosis), without knee joint, custom fabricated | | | |
|L2035 |NU | |Knee ankle foot orthosis, full plastic, static (pediatric|21+ |N |Purchase |
| | | |size) without free motion ankle, prefabricated, includes | | | |
| | | |fitting and adjustment | | | |
|L2036 |NU | |Knee ankle foot orthosis, full plastic, double upright, |All |Y |Purchase |
| |EP | |with or without free motion knee, with or without free | | | |
| | | |motion ankle, custom fabricated | | | |
|L2037 |NU | |Knee ankle foot orthosis, full plastic, single upright, |All |Y |Purchase |
| |EP | |with or without free motion knee, with or without free | | | |
| | | |motion ankle, custom fabricated | | | |
|L2038 |NU | |Knee ankle foot orthosis, full plastic, with or without |All |Y |Purchase |
| |EP | |free motion knee , multi-axis ankle, custom fabricated | | | |
|L2040 |NU | |HKAFO, torsion control, bilateral rotation straps, pelvic|All |N |Purchase |
| |EP | |band/belt, custom fabricated | | | |
|L2040 |NU |U1 |((Night “A” frame-KAFO, torsion control, bilateral night |All |N |Manually Priced |
| | | |“A” frame) HKAFO, torsion control, bilateral rotation | | |Purchase |
| |EP |U1 |straps, pelvic band/belt, custom fabricated | | | |
|L2050 |NU | |HKAFO, torsion control, bilateral torsion cables, hip |All |N |Purchase |
| |EP | |joint, pelvic band/belt, custom fabricated | | | |
|L2060 |NU | |HKAFO, torsion control, bilateral torsion cables, ball |All |N |Purchase |
| |EP | |bearing hip joint, pelvic band/belt, custom fabricated | | | |
|L2070 |NU | |HKAFO, torsion control, unilateral rotation straps, |All |N |Purchase |
| |EP | |pelvic band/belt, custom fabricated | | | |
|L2080 |NU | |HKAFO, torsion control, unilateral torsion cable, hip |All |N |Purchase |
| |EP | |joint, pelvic band/belt, custom fabricated | | | |
|L2090 |NU | |HKAFO, torsion control, unilateral torsion cable, ball |All |N |Purchase |
| |EP | |bearing hip joint, pelvic band/belt, custom fabricated | | | |
|L2106 |NU | |AFO, fracture orthosis, tibial fracture cast orthosis, |All |N |Purchase |
| |EP | |thermoplastic type casting material, custom fabricated | | | |
|L2108 |NU | |AFO, fracture orthosis, tibial fracture cast orthosis, |All |Y |Purchase |
| |EP | |custom fabricated | | | |
|L2112 |NU | |AFO, fracture orthosis, tibial fracture orthosis, soft, |All |N |Purchase |
| |EP | |prefabricated, includes fitting and adjustment | | | |
|L2114 |NU | |AFO, fracture orthosis, tibial fracture orthosis, |All |N |Purchase |
| |EP | |semi-rigid, prefabricated, includes fitting and | | | |
| | | |adjustment | | | |
|L2116 |NU | |AFO, fracture orthosis, tibial fracture orthosis, rigid, |All |N |Purchase |
| |EP | |prefabricated, includes fitting and adjustment | | | |
|L2126 |NU | |KAFO, fracture orthosis, femoral fracture cast orthosis, |All |Y |Purchase |
| |EP | |thermoplastic type casting material, custom fabricated | | | |
|L2128 |NU | |KAFO, fracture orthosis, femoral fracture cast orthosis, |All |Y |Purchase |
| |EP | |custom fabricated | | | |
|L2132 |NU | |KAFO, fracture orthosis, femoral fracture cast orthosis, |All |Y |Purchase |
| |EP | |soft, prefabricated, includes fitting and adjustment | | | |
|L2134 |NU | |KAFO, fracture orthosis, femoral fracture cast orthosis, |All |Y |Purchase |
| |EP | |semi-rigid prefabricated, includes fitting and adjustment| | | |
|L2136 |NU | |KAFO, fracture orthosis, femoral fracture cast orthosis, |All |Y |Purchase |
| |EP | |rigid, prefabricated, includes fitting and adjustment | | | |
|L2180 |NU | |Addition to lower extremity fracture orthosis, plastic |All |N |Purchase |
| |EP | |shoe insert with ankle joints | | | |
|L2182 |NU | |Addition to lower extremity fracture orthosis, drop lock |All |N |Purchase |
| |EP | |knee joint | | | |
|L2184 |NU | |Addition to lower extremity fracture orthosis, limited |All |N |Purchase |
| |EP | |motion knee joint | | | |
|L2186 |NU | |Addition to lower extremity fracture orthosis, adjustable|All |N |Purchase |
| |EP | |motion knee joint, Lerman type | | | |
|L2188 |NU | |Addition to lower extremity fracture orthosis, |All |N |Purchase |
| |EP | |quadrilateral brim | | | |
|L2190 |NU | |Addition to lower extremity fracture orthosis, waist belt|All |N |Purchase |
| |EP | | | | | |
|L2192 |NU | |Addition to lower extremity fracture orthosis, hip joint,|All |N |Purchase |
| |EP | |pelvic band, thigh flange, and pelvic belt | | | |
|L2200 |NU | |Additions to lower extremity, limited ankle motion, each |All |N |Purchase |
| |EP | |joint | | | |
|L2210 |NU | |Addition to lower extremity, dorsiflexion assist (plantar|All |N |Purchase |
| |EP | |flexion resist), each joint | | | |
|L2220 |NU | |Addition to lower extremity, dorsiflexion and plantar |All |N |Purchase |
| |EP | |flexion assist/resist, each joint | | | |
|L2230 |NU | |Addition to lower extremity, split flat caliper stirrups |All |N |Purchase |
| |EP | |and plate attachment | | | |
|L2232 |NU | |Addition to lower extremity orthosis, rocker bottom for |All |N |Manually Priced |
| |EP | |total contact ankle foot orthosis, for custom fabricated | | | |
| | | |orthosis only | | | |
|L2240 |NU | |Addition to lower extremity, round caliper and plate |All |N |Purchase |
| |EP | |attachment | | | |
|L2250 |NU | |Addition to lower extremity, foot plate, molded to |All |N |Purchase |
| |EP | |patient model, stirrup attachment | | | |
|L2260 |NU | |Addition to lower extremity, reinforced solid stirrup |All |N |Purchase |
| |EP | |(Scott-Craig type) | | | |
|L2265 |NU | |Addition to lower extremity, long tongue stirrup |All |N |Purchase |
| |EP | | | | | |
|L2270 |NU | |Addition to lower extremity, varus/valgus correction (T) |All |N |Purchase |
| |EP | |strap, padded/lined or malleolus pad | | | |
|L2275 |NU | |Addition to lower extremity, varus/valgus correction, |All |N |Purchase |
| |EP | |plastic modification, padded/lined | | | |
|L2280 |NU | |Addition to lower extremity, molded inner boot |All |N |Purchase |
| |EP | | | | | |
|L2300 |NU | |Addition to lower extremity, abduction bar (bilateral hip|All |N |Purchase |
| |EP | |involvement), jointed, adjustable | | | |
|L2310 |NU | |Addition to lower extremity, abduction bar straight |All |N |Purchase |
| |EP | | | | | |
|L2320 |NU | |Addition to lower extremity, nonmolded lacer, for custom |All |N |Purchase |
| |EP | |fabricated orthosis only | | | |
|L2330 |NU | |Addition to lower extremity, lacer molded to patient |All |N |Purchase |
| |EP | |model, for custom fabricated orthosis only | | | |
|L2335 |NU | |Addition to lower extremity, anterior swing band |All |N |Purchase |
| |EP | | | | | |
|L2340 |NU | |Addition to lower extremity, pretibial shell, molded to |All |N |Purchase |
| |EP | |patient model | | | |
|L2350 |NU | |Addition to lower extremity, prosthetic type, (BK) |All |Y |Purchase |
| |EP | |socket, molded to patient model, (used for PTB, AFO | | | |
| | | |orthoses) | | | |
|L2360 |NU | |Addition to lower extremity, extended steel shank |All |N |Purchase |
| |EP | | | | | |
|L2370 |NU | |Addition to lower extremity, Patten bottom |All |N |Purchase |
| |EP | | | | | |
|L2375 |NU | |Addition to lower extremity, torsion control, ankle joint|All |N |Purchase |
| |EP | |and half solid stirrup | | | |
|L2380 |NU | |Addition to lower extremity, torsion control, straight |All |N |Purchase |
| |EP | |knee joint, each joint | | | |
|L2385 |NU | |Addition to lower extremity, straight knee joint, |All |N |Purchase |
| |EP | |heavy-duty, each joint | | | |
|L2390 |NU | |Addition to lower extremity, offset knee joint, each |All |N |Purchase |
| |EP | |joint | | | |
|L2395 |NU | |Addition to lower extremity, offset knee joint, |All |N |Purchase |
| |EP | |heavy-duty, each joint | | | |
|L2397 |NU | |Addition to lower extremity orthosis, suspension sleeve |21+ |N |Purchase |
|L2405 |NU | |Addition to knee joint, drop lock, each |All |N |Purchase |
| |EP | | | | | |
|L2415 |NU | |Addition to knee lock with integrated release mechanism ,|All |N |Purchase |
| |EP | |(bail, cable or equal, any material, each joint | | | |
|L2425 |NU | |Addition to knee joint, disc or dial lock for adjustable |All |N |Purchase |
| |EP | |knee flexion, each joint | | | |
|L2430 |NU | |Addition to knee joint, ratchet lock for active and |All |N |Purchase |
| |EP | |progressive knee extension, each joint | | | |
|L2492 |NU | |Addition to knee joint, lift loop for drop lock ring |All |N |Purchase |
| |EP | | | | | |
|L2500 |NU | |Addition to lower extremity, thigh/weight bearing, |All |N |Purchase |
| |EP | |gluteal/ischial weight bearing, ring | | | |
|L2510 |NU | |Addition to lower extremity, thigh/weight bearing, |All |N |Purchase |
| |EP | |quadri-lateral brim, molded to patient model | | | |
|L2520 |NU | |Addition to lower extremity, thigh/weight bearing, |All |N |Purchase |
| |EP | |quadri-lateral brim, custom fitted | | | |
|L2525 |NU | |Addition to lower extremity, thigh/weight bearing, |All |N |Purchase |
| |EP | |ischial containment/narrow M-L brim molded to patient | | | |
| | | |model | | | |
|L2526 |NU | |Addition to lower extremity, thigh/weight bearing, |All |N |Purchase |
| |EP | |ischial containment/narrow M-L brim, custom fitted | | | |
|L2530 |NU | |Addition to lower extremity, thigh/weight bearing, lacer,|All |N |Purchase |
| |EP | |non-molded | | | |
|L2540 |NU | |Addition to lower extremity, thigh/weight bearing, lacer,|All |N |Purchase |
| |EP | |molded to patient model | | | |
|L2550 |NU | |Addition to lower extremity, thigh/weight bearing, high |All |N |Purchase |
| |EP | |roll cuff | | | |
|L2570 |NU | |Addition to lower extremity, pelvic control, hip joint, |All |N |Purchase |
| |EP | |Clevis type two position joint, each | | | |
|L2580 |NU | |Addition to lower extremity, pelvic control, pelvic sling|All |N |Purchase |
| |EP | | | | | |
|L2600 |NU | |Addition to lower extremity, pelvic control, hip joint, |All |N |Purchase |
| |EP | |Clevis type, or thrust bearing, free, each | | | |
|L2610 |NU | |Addition to lower extremity, pelvic control, hip joint, |All |N |Purchase |
| |EP | |Clevis or thrust bearing, lock, each | | | |
|L2620 |NU | |Addition to lower extremity, pelvic control, hip joint, |All |N |Purchase |
| |EP | |heavy-duty, each | | | |
|L2622 |NU | |Addition to lower extremity, pelvic control, hip joint, |All |N |Purchase |
| |EP | |adjustable flexion, each | | | |
|L2624 |NU | |Addition to lower extremity, pelvic control, hip joint, |All |N |Purchase |
| |EP | |adjustable flexion, extension, abduction control, each | | | |
|L2627 |NU | |Addition to lower extremity, pelvic control, plastic, |All |N |Purchase |
| |EP | |molded to patient model, reciprocating hip joint and | | | |
| | | |cables | | | |
|L2628 |NU | |Addition to lower extremity, pelvic control, metal frame,|All |N |Purchase |
| |EP | |reciprocating hip joint and cables | | | |
|L2630 |NU | |Addition to lower extremity, pelvic control, band and |All |N |Purchase |
| |EP | |belt unilateral | | | |
|L2640 |NU | |Addition to lower extremity, pelvic control, band and |All |N |Purchase |
| |EP | |belt bilateral | | | |
|L2650 |NU | |Addition to lower extremity, pelvic and thoracic control,|All |N |Purchase |
| |EP | |gluteal pad, each | | | |
|L2660 |NU | |Addition to lower extremity, thoracic control, thoracic |All |N |Purchase |
| |EP | |band | | | |
|L2670 |NU | |Addition to lower extremity, thoracic control, paraspinal|All |N |Purchase |
| |EP | |uprights | | | |
|L2680 |NU | |Addition to lower extremity, thoracic control, lateral |All |N |Purchase |
| |EP | |support uprights | | | |
|L2750 |NU | |Addition to lower extremity orthosis, plating chrome or |All |N |Purchase |
| |EP | |nickel, per bar | | | |
|L2755 |NU | |((Carbon composite ankles; addition to AFO) Addition to |All |N |Purchase |
| |EP | |lower extremity orthosis, high strength, lightweight | | | |
| | | |material, all hybrid lamination/prepreg composite, per | | | |
| | | |segment, for custom fabricated orthosis only | | | |
|L2760 |NU | |Addition to lower extremity orthosis, extension, per |All |N |Purchase |
| |EP | |extension, per bar (for linear adjustment for growth) | | | |
|L2780 |NU | |Addition to lower extremity orthosis, non-corrosive |All |N |Purchase |
| |EP | |finish, per bar | | | |
|L2785 |NU | |Addition to lower extremity orthosis, drop lock retainer,|All |N |Purchase |
| |EP | |each | | | |
|L2795 |NU | |Addition to lower extremity orthosis, knee control, full |All |N |Purchase |
| |EP | |kneecap | | | |
|L2800 |NU | |Addition to lower extremity orthosis, knee control, |All |N |Purchase |
| |EP | |kneecap, medial or lateral pull, for use with custom | | | |
| | | |fabricated orthosis only | | | |
|L2810 |NU | |Addition to lower extremity orthosis, knee control, |All |N |Purchase |
| |EP | |condylar pad | | | |
|L2810 |EP | |((Custom night “A” frame-KAFO, torsion control, bilateral|U21 |N/A |Purchase |
| | | |night “A” frame) Addition to lower extremity orthosis, | | | |
| | | |knee control, condylar pad | | | |
|L2820 |NU | |Addition to lower extremity orthosis, soft interface for |All |N |Purchase |
| |EP | |molded plastic, below knee section | | | |
|L2830 |NU | |Addition to lower extremity orthosis, soft interface for |All |N |Purchase |
| |EP | |molded plastic, above knee section | | | |
|L2840 |NU | |Addition to lower extremity orthosis, tibial length sock,|All |N |Purchase |
| |EP | |fracture or equal, each | | | |
|L2850 |NU | |Addition to lower extremity orthosis, femoral length |All |N |Purchase |
| |EP | |sock, fracture or equal, each | | | |
|L2861 |EP | |Addition to lower extremity joint, knee or ankle, |U21 |Y |Manually Priced |
| | | |concentric adjustable torsion style mechanism for custom | | | |
| | | |fabricated orthotics only, each | | | |
|L2999 |EP | |Lower extremity orthoses, NOS |All |N |Manually Priced |
|L2999 |NU | |((Unlisted prosthetic devices or orthotic appliances; the|All |Y |Manually Priced |
| |EP | |manufacturer’s invoice must be attached to all claims.) | | | |
| | | |Lower extremity orthoses, NOS | | | |
|L3000 |NU | |Foot insert, removable, molded to patient model, UCB |All |N |Purchase |
| |EP | |type, Berkeley shell, each | | | |
|L3002 |NU | |Foot insert, removable, molded to patient model, |All |N |Manually Priced |
| |EP | |Plastazote or equal, each | | | |
|L3010 |NU | |Foot insert, removable, molded to patient model, |All |N |Purchase |
| |EP | |longitudinal arch support, each | | | |
|L3020 |NU | |Foot insert, removable, molded to patient model, |All |N |Purchase |
| |EP | |longitudinal/metatarsal support, each | | | |
|L3030 |NU | |Foot insert, removable, formed to patient foot, each |All |N |Purchase |
| |EP | | | | | |
|L3040 |NU | |Foot, arch support, removable, premolded, longitudinal, |All |N |Purchase |
| |EP | |each | | | |
|L3050 |NU | |Foot, arch support, removable, premolded, metatarsal, |All |N |Purchase |
| |EP | |each | | | |
|L3060 |NU | |Foot, arch support, removable, premolded, |All |N |Purchase |
| |EP | |longitudinal/metatarsal, each | | | |
|L3070 |NU | |Foot, arch support, non-removable, attached to shoe, |All |N |Purchase |
| |EP | |longitudinal, each | | | |
|L3080 |NU | |Foot, arch support, non-removable, attached to shoe, |All |N |Purchase |
| |EP | |metatarsal, each | | | |
|L3090 |NU | |Foot, arch support, non-removable, attached to shoe, |All |N |Purchase |
| |EP | |longitudinal/metatarsal, each | | | |
|L3100 |NU | |Hallus–valgus night dynamic splint |All |N |Purchase |
| |EP | | | | | |
|L3140 |NU | |((Bebox foot orthosis club foot abduction orthosis) |All |Y |Purchase |
| |EP |UB |Foot, abduction rotation bar, including shoes | | | |
|L3140 |NU | |((Don Joy knee orthosis) Foot, abduction rotation bar, |21+ |Y |Purchase |
| | | |including shoes | | | |
|L3150 |NU | |Foot, abduction rotation bar, without shoes |All |N |Purchase |
| |EP | | | | | |
|L3150 |EP |UB |((Custom night “A” frame-KAFO, torsion control, bilateral|U21 |N |Purchase |
| | | |night “A” frame) Foot, abduction rotation bar, without | | | |
| | | |shoes | | | |
|L3170 |NU | |Foot, plastic, silicone or equal, heel stabilizer, each |All |N |Purchase |
| |EP | | | | | |
|L3202 |EP | |Orthopedic shoe, Oxford with supinator or pronator, child|U21 |N/A |Purchase |
|L3204 |NU | |((Straight last hightop shoe, each, size 2-8) Orthopedic|All |N |Purchase |
| |EP | |shoe, hightop with supinator or pronator, infant | | | |
|L3204 |NU | |((Straight last hightop shoe, each, size 8½-12) |All |N |Purchase |
| |EP |U1 |Orthopedic shoe, hightop with supinator or pronator, | | | |
| | | |infant | | | |
|L3204 |NU | |((Regular last hightop shoe, each, size 3-6) Orthopedic |All |N |Purchase |
| |EP |U1 |shoe, hightop with supinator or pronator, infant | | | |
|L3204 |NU | |((Regular last hightop shoe, each, size 8½-12) |All |N |Purchase |
| |EP |U1 |Orthopedic shoe, hightop with supinator or pronator, | | | |
| | | |infant | | | |
|L3204 |NU | |((Reverse last closed toe) Orthopedic shoe, hightop with|All |N |Purchase |
| |EP |U1 |supinator or pronator, infant | | | |
|L3204 |NU | |((Orthopedic shoe, hightop, normal last, each, size 3-8) |21+ |N |Purchase |
| | | |Orthopedic shoe, hightop with supinator or pronator, | | | |
| | | |infant | | | |
|L3204 |NU | |((Orthopedic shoe, hightop, normal last, each, size |All |N |Purchase |
| |EP |U1 |8½-12) Orthopedic shoe, hightop with supinator or | | | |
| | | |pronator, infant | | | |
|L3206 |NU | |((Straight last hightop shoe, each, size 2-8) Orthopedic|All |N |Purchase |
| |EP | |shoe, hightop with supinator or pronator, child | | | |
|L3206 |NU | |((Straight last hightop shoe, each, size 8½-12) |All |N |Purchase |
| |EP |U1 |Orthopedic shoe, hightop with supinator or pronator, | | | |
| | | |child | | | |
|L3206 |NU | |((Regular last hightop shoe, each, size 3-6) Orthopedic |All |N |Purchase |
| |EP |U1 |shoe, hightop with supinator or pronator, child | | | |
|L3206 |NU | |((Regular last hightop shoe, each, size 8½-12) |All |N |Purchase |
| |EP |U1 |Orthopedic shoe, hightop with supinator or pronator, | | | |
| | | |child | | | |
|L3206 |NU | |((Reverse last closed toe) Orthopedic shoe, hightop with|All |N |Purchase |
| |EP |U1 |supinator or pronator, child | | | |
|L3206 |NU | |((Orthopedic shoe, hightop, normal last, each, size 3-8) |21+ |N |Purchase |
| | | |Orthopedic shoe, hightop with supinator or pronator, | | | |
| | | |child | | | |
|L3206 |NU | |((Orthopedic shoe, hightop, normal last, each, size |All |N |Purchase |
| |EP |U1 |8½-12) Orthopedic shoe, hightop with supinator or | | | |
| | | |pronator, child | | | |
|L3207 |NU | |((Straight last hightop shoe, each, size 2-8) Orthopedic|All |N |Purchase |
| |EP | |shoe, hightop with supinator or pronator, junior | | | |
|L3207 |NU | |((Straight last hightop shoe, each, size 8½-12) |All |N |Purchase |
| |EP |U1 |Orthopedic shoe, hightop with supinator or pronator, | | | |
| | | |junior | | | |
|L3207 |NU | |((Regular last hightop shoe, each, size 3-6) Orthopedic |All |N |Purchase |
| |EP |U1 |shoe, hightop with supinator or pronator, junior | | | |
|L3207 |NU | |((Regular last hightop shoe, each, size 8½-12) |All |N |Purchase |
| |EP |U1 |Orthopedic shoe, hightop with supinator or pronator, | | | |
| | | |junior | | | |
|L3207 |NU | |((Reverse last closed toe) Orthopedic shoe, hightop with|All |N |Purchase |
| |EP |U1 |supinator or pronator, junior | | | |
|L3207 |NU | |((Orthopedic shoe, hightop, normal last, each, size 3-8) |21+ |N |Purchase |
| | | |Orthopedic shoe, hightop with supinator or pronator, | | | |
| | | |junior | | | |
|L3207 |NU | |((Orthopedic shoe, hightop, normal last, each, size |All |N |Purchase |
| |EP |U1 |8½-12) Orthopedic shoe, hightop with supinator or | | | |
| | | |pronator, junior | | | |
|L3207 |NU | |((Orthopedic shoe, hightop, normal last, each, size |All |N |Purchase |
| |EP | |8½-12) Orthopedic shoe, hightop with supinator or | | | |
| | | |pronator, junior | | | |
|L3208 |EP | |Surgical boot, each, infant |U21 |N/A |Purchase |
|L3209 |EP | |Surgical boot, each, child |U21 |N/A |Purchase |
|L3211 |EP | |Surgical boot, each, junior |U21 |N/A |Purchase |
|L3215 |NU | |Orthopedic footwear, woman’s shoes, oxford, each |All |Y |Purchase |
| |EP | | | | | |
|L3216 |NU | |Orthopedic footwear, woman’s shoes, depth inlay, each |All |Y |Purchase |
| |EP | | | | | |
|L3217 |NU | |((Straight last hightop shoe, each, size 2-8) Orthopedic|All |N |Purchase |
| |EP | |footwear, woman’s shoes, hightop, depth inlay, each | | | |
|L3217 |NU |U1 |((Straight last hightop shoe, each, size 8½-12) |All |N |Purchase |
| |EP |U1 |Orthopedic footwear, woman’s shoes, hightop, depth inlay,| | | |
| | | |each | | | |
|L3217 |NU | |((Regular last hightop shoe, each, size 3-6) Orthopedic |All |N |Purchase |
| |EP |U1 |footwear, woman’s shoes, hightop, depth inlay, each | | | |
|L3217 |NU | |((Regular last hightop shoe, each, size 8½-12) |All |N |Purchase |
| |EP |U1 |Orthopedic footwear, woman’s shoes, hightop, depth inlay,| | | |
| | | |each | | | |
|L3217 |NU | |((Reverse last closed toe) Orthopedic footwear, woman’s |All |N |Purchase |
| |EP |U1 |shoes, hightop, depth inlay, each | | | |
|L3219 |NU | |Orthopedic footwear, man’s shoes, oxford, each |All |Y |Purchase |
| |EP | | | | | |
|L3221 |NU | |Orthopedic footwear, man’s shoes, depth inlay, each |All |Y |Purchase |
| |EP | | | | | |
|L3222 |NU | |((Straight last hightop shoe, each, size 2-8) Orthopedic|All |N |Purchase |
| |EP | |footwear, man’s shoes, hightop, depth inlay, each | | | |
|L3222 |NU |U1 |((Straight last hightop shoe, each, size 8½-12) |All |N |Purchase |
| |EP |U1 |Orthopedic footwear, man’s shoes, hightop, depth inlay, | | | |
| | | |each | | | |
|L3222 |NU |U1 |((Regular last hightop shoe, each, size 3-6) Orthopedic |All |N |Purchase |
| |EP |U1 |footwear, man’s shoes, high-top, depth inlay, each | | | |
|L3222 |NU |U1 |((Regular last hightop shoe, each, size 8½-12) |All |N |Purchase |
| |EP |U1 |Orthopedic footwear, man’s shoes, hightop, depth inlay, | | | |
| | | |each | | | |
|L3222 |NU |U1 |((Reverse last closed toe) Orthopedic footwear, man’s |All |N |Purchase |
| |EP |U1 |shoes, hightop, depth inlay, each | | | |
|L3224 |NU | |Orthopedic footwear, woman’s shoe, Oxford, used as an |21+ |N |Purchase |
| | | |integral part of a brace (orthosis) | | | |
|L3225 |NU | |Orthopedic footwear, man’s shoe, oxford, used as an |21+ |N |Purchase |
| | | |integral part of a brace (orthosis) | | | |
|L3230 |NU | |Orthopedic footwear, custom shoes, depth inlay, each |All |Y |Purchase |
| |EP | | | | | |
|L3250 |NU | |Orthopedic footwear, custom molded shoe, removable inner |All |Y |Purchase |
| |EP | |mold, prosthetic shoe, each | | | |
|L3253 |NU | |Foot, molded shoe Plastazote (or similar), custom fitted,|All |Y |Purchase |
| |EP | |each | | | |
|L3257 |NU | |Orthopedic footwear, additional charge for split size |All |Y |Purchase |
| |EP | | | | | |
|L3260 |NU | |Surgical boot/shoe, each |All |N |Manually Priced |
| | | | | | |Purchase |
| |EP | | | | | |
|L3265 |NU | |Plastazote sandal, each |All |N |Purchase |
| |EP | | | | | |
|L3310 |NU | |Lift, elevation, heel and sole, neoprene, per in. |All |N |Purchase |
| |EP | | | | | |
|L3332 |NU | |Lift, elevation, inside shoe, tapered, up to one-half in.|All |N |Purchase |
| |EP | | | | | |
|L3334 |NU | |Lift, elevation, heel, per inch |All |N |Purchase |
| |EP | | | | | |
|L3350 |NU | |Heel wedge |All |N |Purchase |
| |EP | | | | | |
|L3360 |NU | |Sole wedge, outside sole |All |N |Purchase |
| |EP | | | | | |
|L3370 |NU | |Sole wedge, between sole |All |N |Purchase |
| |EP | | | | | |
|L3400 |NU | |Metatarsal bar wedge, rocker |All |N |Purchase |
| |EP | | | | | |
|L3420 |NU | |Full sole and heel wedge, between sole |All |N |Purchase |
| |EP | | | | | |
|L3450 |NU | |Heel, SACH cushion type |All |N |Purchase |
| |EP | | | | | |
|L3455 |NU | |Heel, new leather, standard |All |N |Purchase |
| |EP | | | | | |
|L3465 |NU | |Heel, Thomas with wedge |All |N |Purchase |
| |EP | | | | | |
|L3540 |NU | |Orthopedic shoe addition, sole, full |All |N |Purchase |
| |EP | | | | | |
|L3580 |NU | |Orthopedic shoe addition, convert instep to Velcro |All |N |Purchase |
| |EP | |closure | | | |
|L3590 |NU | |Orthopedic shoe addition, convert firm shoe counter to |All |N |Purchase |
| |EP | |soft counter | | | |
|L3600 |NU | |Transfer of an orthosis from one shoe to another, caliper|All |N |Purchase |
| |EP | |plate, existing | | | |
|L3620 |NU | |Transfer of an orthosis from one shoe to another, solid |All |N |Purchase |
| |EP | |stirrup, existing | | | |
|L3630 |NU | |Transfer of an orthosis from one shoe to another, solid |All |N |Purchase |
| |EP | |stirrup, new | | | |
|L3649 |NU |U1 |((Unlisted prosthetic devices or orthotic appliances; the|All |Y |Manually Priced |
| |EP |U1 |manufacturer’s invoice must be attached to all claims.) | | | |
| | | |Orthopedic shoe, modification, addition or transfer, NOS | | | |
|L3649 |EP | |((Orthopedic footwear, wooden sole shoe, each) |U21 |N/A |Purchase |
| | | |Orthopedic shoe, modification, addition or transfer, NOS | | | |
|L3649 |NU | |((Orthopedic footwear, wooden sole shoe, each) |All |N |Manually Priced |
| | | |Orthopedic shoe, modification, addition or transfer, NOS | | | |
|L3650 |NU | |SO, figure of eight design abduction re-strainer |All |N |Purchase |
| |EP | |prefabricated, includes fitting and adjustment | | | |
|L3660 |NU | |SO, figure of eight design, abduction restrainer, canvas |All |N |Purchase |
| |EP | |and webbing, prefabricated, includes fitting and | | | |
| | | |adjustment | | | |
|L3670 |NU | |SO, acromio/clavicular (canvas and webbing type) |All |N |Purchase |
| |EP | |prefabricated, includes fitting and adjustment | | | |
|L3674 |NU | |Shoulder orthosis, abduction positioning (airplane |All |N |Purchase |
| |EP | |design), thoracic component and support bar, with or | | | |
| | | |without nontorsion joint/turnbuckle, may include soft | | | |
| | | |interface, straps, custom fabricated, includes fitting | | | |
| | | |and adjustment | | | |
|L3675 |NU | |SO, vest type abduction restrainer, canvas webbing type, |21+ |N |Purchase |
| | | |or equal, prefabricated, includes fitting and adjustment | | | |
|L3710 |NU | |EO, elastic with metal joints, prefabricated, includes |All |N |Purchase |
| |EP | |fitting and adjustment | | | |
|L3720 |NU | |EO, double upright with forearm/arm cuffs, free motion, |All |N |Purchase |
| |EP | |custom fabricated | | | |
|L3730 |NU | |EO, double upright with forearm/arm cuffs, |All |Y |Purchase |
| |EP | |extension/flexion assist, custom fabricated | | | |
|L3740 |NU | |EO, double upright with forearm/arm cuffs, adjustable |All |Y |Purchase |
| |EP | |position lock with active control, custom fabricated | | | |
|L3807 |NU | |WHFO, without joint(s), prefabricated, includes fitting |All |N |Purchase |
| |EP | |and adjustments, any type | | | |
|L3808 |NU | |Wrist-hand-finger orthotic (WHFO), rigid without joints, |All |N |Purchase |
| |EP | |may include soft interface material; straps, custom | | | |
| | | |fabricated, includes fitting and adjustment | | | |
|L3891 |EP | |Addition to upper extremity joint, wrist or elbow, |U21 |Y |Manually Priced |
| | | |concentric adjustable torsion style mechanism for custom | | | |
| | | |fabricated orthotics only, each | | | |
|L3900 |NU | |WHFO, dynamic flexor hinge, reciprocal wrist |All |Y |Purchase |
| |EP | |extension/flexion, finger flexion/extension, wrist or | | | |
| | | |finger driven, custom fabricated | | | |
|L3901 |NU | |WHFO, dynamic flexor hinge, reciprocal wrist |All |Y |Purchase |
| |EP | |extension/flexion, finger flexion/extension, cable | | | |
| | | |driven, custom fabricated | | | |
|L3904 |NU | |WHFO, external powered, electric, custom fabricated |All |Y |Purchase |
| |EP | | | | | |
|L3906** |NU | |Wrist hand orthosis, without joints, may include soft |All |N |Purchase |
| |EP | |interface, straps, custom fabricated, includes fitting | | | |
| | | |and adjustment | | | |
|L3908 |NU | |WHFO, wrist extension control cock-up, nonmolded, |All |N |Purchase |
| |EP | |prefabricated, includes fitting and adjustment | | | |
|L3912 |NU | |HFO, flexion glove with elastic finger control, |All |N |Purchase |
| |EP | |prefabricated, includes fitting and adjustment | | | |
|L3915+ |NU | |Wrist, hand orthosis, includes one or more nontorsion |All |N |Manually Priced |
| |EP | |joint(s), elastic bands, turnbuckles, may include soft | | | |
| | | |interface, straps, prefabricated, includes fitting and | | | |
| | | |adjustment | | | |
|L3925 |NU | |FO, proximal interphalangeal (PIP)/distal interphalangeal|All |N |Purchase |
| |EP | |(DIP), nontorsion joint/spring, extension/flexion, may | | | |
| | | |include soft interface material, prefabricated, includes | | | |
| | | |fitting and adjustment | | | |
|L3929 |NU | |HFO, includes one or more nontorsion joint(s) |All |N |Purchase |
| |EP | |turnbuckles, elastic bands/springs, may include soft | | | |
| | | |interface material, straps, prefabricated, includes | | | |
| | | |fitting and adjustment | | | |
|L3931 |NU | |WHFO, includes one or more nontorsion joint(s), |All |N |Purchase |
| |EP | |turnbuckles, elastic bands/springs, may include soft | | | |
| | | |interface material, straps, prefabricated, includes | | | |
| | | |fitting and adjustment | | | |
|L3956 |NU | |Addition of joint to upper extremity orthosis, any |21+ |N |Manually Priced |
| | | |material; per joint | | | |
|L3960 |NU | |SEWHO, abduction, positioning, airplane design, |All |Y |Purchase |
| |EP | |prefabricated, includes fitting and adjustment | | | |
|L3962 |NU | |SEWHO, abduction positioning, Erb’s palsy design, |All |N |Purchase |
| |EP | |prefabricated, includes fitting and adjustment | | | |
|L3964 |NU | |SEO, mobile arm supports attached to wheelchair, |All |N |Purchase |
| |EP | |balanced, adjustable, prefabricated, includes fitting and| | | |
| | | |adjustment | | | |
|L3965 |NU | |SEO mobile arm support attached to wheelchair, balanced, |All |Y |Purchase |
| |EP | |adjustable Rancho type, prefabricated, includes fitting | | | |
| | | |and adjustment | | | |
|L3966 |NU | |SEO, mobile arm support attached to wheelchair, balanced,|All |Y |Purchase |
| |EP | |reclining, prefabricated, includes fitting and adjustment| | | |
|L3969 |NU | |SEO, mobile arm support, monosuspension arm and hand |All |N |Purchase |
| |EP | |support, overhead elbow forearm hand sling support, yoke | | | |
| | | |type arm suspension support, prefabricated, includes | | | |
| | | |fitting and adjustment | | | |
|L3980 |NU | |Upper extremity fracture orthosis, humeral, |All |N |Purchase |
| |EP | |prefabricated, includes fitting and adjustment | | | |
|L3982 |NU | |Upper extremity fracture orthosis, radius/ulnar |All |N |Purchase |
| |EP | |prefabricated, includes fitting and adjustment | | | |
|L3984 |NU | |Upper extremity fracture orthosis, wrist, prefabricated, |All |N |Purchase |
| |EP | |includes fitting and adjustment | | | |
|L3995 |NU | |Addition to upper extremity orthosis sock, fracture or |All |N |Purchase |
| |EP | |equal, each | | | |
|L3999 |NU | |((The manufacturer’s invoice must be attached to all |All |Y |Manually Priced |
| | | |claims.) Upper limb orthosis, NOS | | |Manually Priced |
| |EP | | | | | |
|L4000 |NU | |Replace girdle for spinal orthosis (CTLSO or SO) |All |Y |Purchase |
| |EP | | | | | |
|L4002 |NU | |Replace strap, any orthosis, includes all components, any|All |N |Manually Priced |
| |EP | |length, any type | | | |
|L4010 |NU | |Replace trilateral socket brim |All |N |Purchase |
| |EP | | | | | |
|L4020 |NU | |Replace quadrilateral socket brim, molded to patient |All |N |Purchase |
| |EP | |model | | | |
|L4030 |NU | |Replace quadrilateral socket brim, custom fitted |All |N |Purchase |
| |EP | | | | | |
|L4040 |NU | |Replace molded thigh lacer, for custom fabricated |All |N |Purchase |
| |EP | |orthosis only | | | |
|L4045 |NU | |Replace nonmolded thigh lacer, for custom fabricated |All |N |Purchase |
| |EP | |orthosis only | | | |
|L4050 |NU | |Replace molded calf lacer, for custom fabricated orthosis|All |N |Purchase |
| |EP | |only | | | |
|L4055 |NU | |Replace nonmolded calf lacer, for custom fabricated |All |N |Purchase |
| |EP | |orthosis only | | | |
|L4060 |NU | |Replace high roll cuff |All |N |Purchase |
| |EP | | | | | |
|L4070 |NU | |Replace proximal and distal upright for KAFO |All |N |Purchase |
| |EP | | | | | |
|L4080 |NU | |Replace metal bands KAFO, proximal thigh |All |N |Purchase |
| |EP | | | | | |
|L4090 |NU | |((Custom night A frame-KAFO, torsion control, bilateral |All |N |Purchase |
| |EP | |night “A” frame) Replace metal bands KAFO-AFO, calf or | | | |
| | | |distal thigh | | | |
|L4100 |NU | |Replace leather cuff KAFO, proximal thigh |All |N |Purchase |
| |EP | | | | | |
|L4110 |NU | |Replace leather cuff KAFO-AFO, calf or distal thigh |All |N |Purchase |
| |EP | | | | | |
|L4130 |NU | |Replace pretibial shell |All |N |Purchase |
| |EP | | | | | |
|L4205 |NU | |Repair of orthotic device, labor component, per 15 |All |Y |Purchase |
| |EP | |minutes | | | |
|L4210 |NU | |Repair of orthotic device, repair or replace minor parts |All |Y |Purchase |
| |EP | | | | | |
|L4350 |NU | |Ankle control orthosis, stirrup style, rigid, includes |All |N |Purchase |
| |EP | |any type interface (e.g., pneumatic, gel), prefabricated,| | | |
| | | |includes fitting and adjustment | | | |
|L4360 |NU | |Walking boot, pneumatic with or without joints, with or |All |N |Purchase |
| |EP | |without interface material, prefabricated, includes | | | |
| | | |fitting and adjustment | | | |
|L4370 |NU | |Pneumatic full leg splint, prefabricated, includes |All |N |Purchase |
| |EP | |fitting and adjustment | | | |
|L4380 |NU | |Pneumatic knee splint, prefabricated, includes fitting |All |N |Purchase |
| |EP | |and adjustment | | | |
|L4392 |NU | |Replacement soft interface material, static AFO |21+ |N |Purchase |
|L4394 |NU | |Replace soft interface material, foot drop splint |21+ |N |Purchase |
|L4396 |NU | |Static ankle foot orthosis, including soft interface |21+ |N |Purchase |
| | | |material, adjustable for fit, for positioning, pressure | | | |
| | | |reduction, may be used for minimal ambulation, | | | |
| | | |prefabricated, includes fitting and adjustment | | | |
|L4398 |NU | |Foot drop splint, recumbent positioning device, |21+ |N |Purchase |
| | | |prefabricated, includes fitting and adjustment | | | |
|L5999 |NU | |((Unlisted Prosthetic Devices or Orthotic Appliances; the|All |Y |Manually Priced |
| | | |manufacturer’s invoice must be attached to all claims.) | | |Manually Priced |
| |EP | |Lower extremity prosthesis, not otherwise specified | | | |
|L7499 |NU | |((Unlisted Prosthetic Devices or Orthotic Appliances; the|All |Y |Manually Priced |
| | | |manufacturer’s invoice must be attached to all claims.) | | |Manually Priced |
| |EP | |Upper extremity prosthesis, not otherwise specified | | | |
|L7510 |NU | |Repair of prosthetic device, hourly rate |All |Y |Purchase |
| |EP |UB | | | | |
|L7520 |NU | |Repair prosthetic device, labor component, per 15 minutes|All |Y |Purchase |
| |EP | | | | | |
|L8499 |NU | |((Unlisted Prosthetic Devices or Orthotic Appliances; the|All |Y |Manually Priced |
| |EP | |manufacturer’s invoice must be attached to all claims.) | | | |
| | | |Unlisted procedure for miscellaneous prosthetic services | | | |
|242.190 Prosthetic Devices for Beneficiaries of All Ages |11-1-17 |
Procedure codes found in this section must be billed either electronically or on paper with modifier EP for beneficiaries under 21 years of age or modifier NU for beneficiaries age 21 and older. When a second modifier is listed, that modifier must be used in conjunction with either EP or NU.
Modifiers in this section are indicated by the headings M1 and M2. Prior authorization requirements are shown under the heading PA. If prior authorization is needed for beneficiaries age 21 and older, that information is indicated with a “Y” in the column; if not, an “N” is shown.
When codes are payable for all ages, “All” is indicated in the column, “U21” is shown when the code is payable only for beneficiaries under age 21 and “21+” is shown when the code is payable only for those beneficiaries age 21 and older.
1 The purchase of this component is limited to one per five-year period for beneficiaries age 21 and over.
* Replacement only
((…) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product. When using a procedure code with this symbol, the product must meet the indicated Arkansas Medicaid description.
NOTE: Procedure codes for prosthetic eyes and information regarding prosthetic eye care is located in the Arkansas Medicaid Visual Care Program Manual.
|Prosthetic Devices, All Ages (Section 242.190) |
|National Procedure Code|M1 |M2 |Description |All |PA 21+ |Payment Method |
| | | | |U21 | | |
| | | | |21+ | | |
|L1499 |NU | |((Unlisted Prosthetic Devices or Orthotic Appliances; the |All |Y |Manually Priced |
| | | |manufacturer’s invoice must be attached to all claims.) | | |Manually Priced |
| |EP | |Spinal orthosis, not otherwise specified | | | |
|L2999 |NU | |((Unlisted Prosthetic Devices or Orthotic Appliances; the |All |Y |Manually Priced |
| | | |manufacturer’s invoice must be attached to all claims.) | | |Manually Priced |
| |EP | |Lower extremity orthoses, NOS | | | |
|L3649 |NU | |Orthopedic shoe, modification, addition or transfer, NOS |All |N |Purchase |
| |EP | | | | | |
|L3649 |NU |U1 |((Unlisted Prosthetic Devices or Orthotic Appliances; the |All |Y |Manually Priced |
| | | |manufacturer’s invoice must be attached to all claims.) | | |Manually Priced |
| |EP |U1 |Orthopedic shoe, modification, addition or transfer, NOS | | | |
|L3999 |NU | |((Unlisted Prosthetic Devices or Orthotic Appliances; the |All |Y |Manually Priced |
| | | |manufacturer’s invoice must be attached to all claims.) | | |Manually Priced |
| |EP | |Upper limb orthosis, NOS | | | |
|L4205 |NU | |((Orthotics and Prosthetics Repairs) Repair of orthotic |All |Y |Manually Priced |
| | | |device, labor component, per 15 minutes | | |Purchase |
| |EP | | | | | |
|L4210 |NU | |((Orthotics and Prosthetics Repairs) Repair of orthotic |All |Y |Manually Priced |
| | | |device, repair or replace minor parts | | |Purchase |
| |EP | | | | | |
|L4386 |NU | |Walking boot, nonpneumatic, with or without joints, with or|All |N |Purchase |
| |EP | |without interface material, prefabricated, includes fitting| | | |
| | | |and adjustment | | | |
|L4631 |NU | |Ankle foot orthosis, walking boot type, varus/valgas |All |N |Purchase |
| |EP | |correction, rocker bottom, anterior tibial shell, soft | | | |
| | | |interface, custom arch support, plastic or other material, | | | |
| | | |includes straps and closures, custom fabricated | | | |
|L5000 |NU | |Partial foot, shoe insert with longitudinal arch, toe |All |N |Purchase |
| |EP | |filler | | | |
|L5010 |NU | |Partial foot, molded socket, ankle height, with toe filler |All |Y |Purchase |
| |EP | | | | | |
|L5020 |NU | |Partial foot, molded socket, tibial tubercle height, with |All |Y |Purchase |
| |EP | |toe filler | | | |
|L5050 |NU | |Ankle, Symes, molded socket, SACH foot |All |Y |Purchase |
| |EP | | | | | |
|L5060 |NU | |Ankle, Symes, metal frame, molded leather socket, |All |Y |Purchase |
| |EP | |articulated ankle/foot | | | |
|L5100 |NU | |Below knee, molded socket, shin, SACH foot |All |Y |Purchase |
| |EP | | | | | |
|L5105 |NU | |Below knee, plastic socket, joints and thigh lacer, SACH |All |Y |Purchase |
| |EP | |foot | | | |
|L5150 |NU | |Knee disarticulation (or through knee), molded socket, |All |Y |Purchase |
| |EP | |external knee joints, shin, SACH foot | | | |
|L5160 |NU | |Knee disarticulation (or through knee), molded socket, bent|All |Y |Purchase |
| |EP | |knee configuration, external knee joints, shin, SACH foot | | | |
|L5200 |NU | |Above knee, molded socket, single axis constant friction |All |Y |Purchase |
| |EP | |knee, shin, SACH foot | | | |
|L5210 |NU | |Above knee, short prosthesis, no knee joint (“stubbies”), |All |Y |Purchase |
| |EP | |with foot blocks, no ankle joints, each | | | |
|L5220 |NU | |Above knee, short prosthesis, no knee joint (“stubbies”), |All |Y |Purchase |
| |EP | |with articulated ankle/foot, dynamically aligned, each | | | |
|L5230 |NU | |Above knee, for proximal femoral focal deficiency, constant|All |Y |Purchase |
| |EP | |friction knee, shin, SACH foot | | | |
|L5250 |NU | |Hip disarticulation, Canadian type, molded socket, hip |All |Y |Purchase |
| |EP | |joint, single axis constant friction knee, shin, SACH foot | | | |
|L5270 |NU | |Hip disarticulation, tilt table type, molded socket, |All |Y |Purchase |
| |EP | |locking hip joint, single axis constant friction knee, | | | |
| | | |shin, SACH foot | | | |
|L5280 |NU | |Hemipelvectomy, Canadian type, molded socket, hip joint, |All |Y |Purchase |
| |EP | |single axis constant friction knee, shin, SACH foot | | | |
|L5301 |NU | |Below knee, molded socket, shin, SACH foot, endoskeletal |All |Y |Purchase |
| |EP | |system | | | |
|L5312 |NU | |Knee disarticulation (or through knee), molded socket, |All |Y |Purchase |
| |EP | |single axis knee, pylon, SACH foot, endoskeletal system | | | |
|L5321 |NU | |Above knee, molded socket, open end, SACH foot, |All |Y |Purchase |
| |EP | |endoskeletal system, single axis knee | | | |
|L5331 |NU | |Hip disarticulation, Canadian type, molded socket, |All |Y |Purchase |
| |EP | |endoskeletal system, hip joint, single axis knee, SACH foot| | | |
|L5341 |NU | |Hemipelvectomy, Canadian type, molded socket, endoskeletal |All |Y |Purchase |
| |EP | |system, hip joint, single axis knee, SACH foot | | | |
|L5400 |NU | |Immediate post-surgical or early fitting, application of |All |N |Purchase |
| |EP | |initial rigid dressing, including fitting, alignment, | | | |
| | | |suspension, and one cast change, below knee | | | |
|L5410 |NU | |Immediate post-surgical or early fitting, application of |All |N |Purchase |
| |EP | |initial rigid dressing, including fitting, alignment and | | | |
| | | |suspension, below knee, each additional cast change and | | | |
| | | |realignment | | | |
|L5420 |NU | |Immediate post-surgical or early fitting, application of |All |Y |Purchase |
| |EP | |initial rigid dressing, including fitting, alignment and | | | |
| | | |suspension, and one cast change “AK” or knee | | | |
| | | |disarticulation | | | |
|L5430 |NU | |Immediate post-surgical or early fitting, application of |All |N |Purchase |
| |EP | |initial rigid dressing, including fitting, alignment and | | | |
| | | |suspension , “AK” or knee disarticulation, each additional | | | |
| | | |cast change and realignment | | | |
|L5450 |NU | |Immediate post-surgical or early fitting, application of |All |N |Purchase |
| |EP | |nonweight bearing rigid dressing, below knee | | | |
|L5460 |NU | |Immediate post-surgical or early fitting, application of |All |N |Purchase |
| |EP | |nonweight bearing rigid dressing, above knee | | | |
|L5500 |NU | |Initial, below knee (“PTB” type socket, non-alignable |All |N |Purchase |
| |EP | |system, pylon, no cover, SACH foot, plaster socket, direct | | | |
| | | |formed | | | |
|L5505 |NU | |Initial, above knee-knee disarticulation (ischial level |All |Y |Purchase |
| |EP | |socket, non-alignable system, pylon, no cover, SACH foot | | | |
| | | |plaster socket, direct formed | | | |
|L5510 |NU | |Preparatory, below knee “PTB” type socket, non-alignable |All |Y |Purchase |
| |EP | |system, pylon, no cover, SACH foot, plaster socket, molded | | | |
| | | |to model | | | |
|L5520 |NU | |Preparatory, below knee “PTB” type socket, non-alignable |All |Y |Purchase |
| |EP | |pylon, no cover, SACH foot, thermoplastic or equal, direct | | | |
| | | |formed | | | |
|L5530 |NU | |Preparatory, below knee “PTB” type socket, non-alignable |All |Y |Purchase |
| |EP | |system, pylon, no cover, SACH foot, thermoplastic or equal,| | | |
| | | |molded to model | | | |
|L5535 |NU | |Preparatory, below knee “PTB” type socket, non-alignable |All |Y |Purchase |
| |EP | |system, pylon, no cover, SACH foot, prefabricated, | | | |
| | | |adjustable open end socket | | | |
|L5540 |NU | |Preparatory, below knee “PTB” type socket, non alignable, |All |Y |Purchase |
| |EP | |pylon, no cover, SACH foot, laminated socket, molded to | | | |
| | | |model | | | |
|L5560 |NU | |Preparatory, above knee-knee disarticulation ischial level |All |Y |Purchase |
| |EP | |socket, non-alignable system, pylon, no cover, SACH foot, | | | |
| | | |plaster socket, molded to model | | | |
|L5570 |NU | |Preparatory, above knee-knee disarticulation ischial level |All |Y |Purchase |
| |EP | |socket, non-alignable system, pylon, no cover, SACH foot | | | |
| | | |thermoplastic or equal, direct formed | | | |
|L5580 |NU | |Preparatory, above knee-knee disarticulation, ischial level|All |Y |Purchase |
| |EP | |socket, non-alignable system, pylon, no cover, SACH foot, | | | |
| | | |thermoplastic or equal, molded to model | | | |
|L5585 |NU | |Preparatory, above knee-knee disarticulation, ischial level|All |Y |Purchase |
| |EP | |socket, non-alignable system, pylon, no cover, SACH foot, | | | |
| | | |prefabricated adjustable open end socket | | | |
|L5590 |NU | |Preparatory, above knee-knee disarticulation, ischial level|All |Y |Purchase |
| |EP | |socket, non-alignable system, pylon, no cover, SACH foot, | | | |
| | | |laminated socket, molded to model | | | |
|L5595 |NU | |Preparatory, hip disarticulation-hemipelvectomy, pylon, no |All |Y |Purchase |
| |EP | |cover, SACH foot, thermoplastic or equal, molded to patient| | | |
| | | |model | | | |
|L5600 |NU | |Preparatory, hip disarticulation-hemipelvectomy, pylon, no |All |Y |Purchase |
| |EP | |cover, SACH foot, laminated socket, molded to patient model| | | |
|L5610 |NU | |Addition to lower extremity, endoskeletal system, above |All |Y |Purchase |
| |EP | |knee, hydracadence system | | | |
|L5611 |NU | |Addition to lower extremity, endoskeletal system, above |All |N |Purchase |
| |EP | |knee-knee disarticulation, 4-bar linkage, with friction | | | |
| | | |swing phase control | | | |
|L5613 |NU | |Addition to lower extremity, endoskeletal system, above |All |Y |Purchase |
| |EP | |knee-knee disarticulation, 4-bar linkage, with hydraulic | | | |
| | | |swing phase control | | | |
|L5614 |NU | |Addition to lower extremity, endoskeletal system, above |21+ |Y |Purchase |
| | | |knee –knee disarticulation, 4-bar linkage, with pneumatic | | | |
| | | |swing phase control | | | |
|L5616 |NU | |Addition to lower extremity, endoskeletal system above |All |Y |Purchase |
| |EP | |knee, universal multiplex system, friction swing phase | | | |
| | | |control | | | |
|L5617 |NU | |Addition to lower extremity, quick change self-aligning |21+ |Y |Purchase |
| | | |unit, above or below knee, each | | | |
|L5618 |NU | |Addition to lower extremity, test socket, Symes |All |N |Purchase |
| |EP | | | | | |
|L5620 |NU | |Addition to lower extremity, test socket, below knee |All |N |Purchase |
| |EP | | | | | |
|L5622 |NU | |Addition to lower extremity, test socket, knee |All |N |Purchase |
| |EP | |disarticulation | | | |
|L5624 |NU | |Addition to lower extremity, test socket, above knee |All |N |Purchase |
| |EP | | | | | |
|L5626 |NU | |Addition to lower extremity, test socket, hip |All |N |Purchase |
| |EP | |disarticulation | | | |
|L5628 |NU | |Addition to lower extremity, test socket, hemipelvectomy |All |N |Purchase |
| |EP | | | | | |
|L5629 |NU | |Addition to lower extremity, below knee, acrylic socket |All |N |Purchase |
| |EP | | | | | |
|L5630 |NU | |Addition to lower extremity, Symes type, expandable wall |All |N |Purchase |
| |EP | |socket | | | |
|L5631 |NU | |Addition to lower extremity, above knee or knee |All |N |Purchase |
| |EP | |disarticulation, acrylic socket | | | |
|L5632 |NU | |Addition to lower extremity, Symes type, “PTB” brim design |All |N |Purchase |
| |EP | |socket | | | |
|L5634 |NU | |Addition to lower extremity, Symes type posterior opening |All |N |Purchase |
| |EP | |(Canadian) socket | | | |
|L5636 |NU | |Additions to lower extremity, Symes type, medial opening |All |N |Purchase |
| |EP | |socket | | | |
|L5637 |NU | |Addition to lower extremity, below knee, total contact |All |N |Purchase |
| |EP | | | | | |
|L5638 |NU | |Addition to lower extremity, below knee, leather socket |All |N |Purchase |
| |EP | | | | | |
|L5639 |NU | |Addition to lower extremity, below knee, wood socket |All |N |Purchase |
| |EP | | | | | |
|L5640 |NU | |Addition to lower extremity, knee disarticulation, leather |All |N |Purchase |
| |EP | |socket | | | |
|L5642 |NU | |Addition to lower extremity, above knee, leather socket |All |N |Purchase |
| |EP | | | | | |
|L5643 |NU | |Addition to lower extremity, hip disarticulation, flexible |All |Y |Purchase |
| |EP | |inner socket, external frame | | | |
|L5644 |NU | |Addition to lower extremity, above knee, wood socket |All |N |Purchase |
| |EP | | | | | |
|L5645 |NU | |Addition to lower extremity, below knee, flexible inner |All |N |Purchase |
| |EP | |socket, external frame | | | |
|L5646 |NU | |Addition to lower extremity, below knee, air, fluid, gel or|All |N |Purchase |
| |EP | |equal, cushion socket | | | |
|L5647 |NU | |Addition to lower extremity, below knee suction socket |All |N |Purchase |
| |EP | | | | | |
|L5648 |NU | |Addition to lower extremity, above knee, air, fluid, gel or|All |N |Purchase |
| |EP | |equal, cushion socket | | | |
|L5649 |NU | |Addition to lower extremity, ischial containment/narrow M-L|All |Y |Purchase |
| |EP | |socket | | | |
|L5650 |NU | |Addition to lower extremity, total contact, above knee or |All |N |Purchase |
| |EP | |knee disarticulation socket | | | |
|L5651 |NU | |Addition to lower extremity, above knee, flexible inner |All |N |Purchase |
| |EP | |socket, external frame | | | |
|L5652 |NU | |Addition to lower extremity, suction suspension, above knee|All |N |Purchase |
| |EP | |or knee disarticulation, socket | | | |
|L5653 |NU | |Addition to lower extremity, knee disarticulation, |All |N |Purchase |
| |EP | |expandable wall socket | | | |
|L5654 |NU | |Addition to lower extremity, socket insert, Symes, (Kemblo,|All |N |Purchase |
| |EP | |Pelite, Aliplast, Plastazote or equal) | | | |
|L5655 |NU | |Addition to lower extremity, socket insert, below knee |All |N |Purchase |
| |EP | |(Kemblo, Pelite, Aliplast, Plastazote or equal) | | | |
|L5656 |NU | |Addition to lower extremity, socket insert, knee |All |N |Purchase |
| |EP | |disarticulation (Kemblo, Pelite, Aliplast, Plastazote or | | | |
| | | |equal) | | | |
|L5658 |NU | |Addition to lower extremity, socket insert, above knee |All |N |Purchase |
| |EP | |(Kemblo, Pelite, Aliplast, Plastazote or equal) | | | |
|L5661 |NU | |Addition to lower extremity, socket insert, multi-durometer|All |N |Purchase |
| |EP | |Symes | | | |
|L5665 |EP | |Addition to lower extremity, socket insert, |U21 |N/A |Purchase |
| | | |multi-durometer, below knee | | | |
|L5666 |NU | |Additions to lower extremity, below knee, cuff suspension |All |N |Purchase |
| |EP | | | | | |
|L5668 |NU | |Addition to lower extremity, below knee, molded distal |All |N |Purchase |
| |EP | |cushion | | | |
|L5670 |NU | |Addition to lower extremity, below knee, molded |All |N |Purchase |
| |EP | |supracondylar suspension (“PTS” or similar) | | | |
|L5671 |NU | |Addition to lower extremity, below knee/above knee, |All |N |Purchase |
| |EP | |suspension locking mechanism (shuttle, lanyard or equal), | | | |
| | | |excludes socket insert | | | |
|L5672 |NU | |Addition to lower extremity, below knee, removable medial |All |N |Purchase |
| |EP | |brim suspension | | | |
|L5673 |NU | |Addition to lower extremity, below knee/above knee, custom |All |N |Purchase |
| |EP | |fabricated from existing mold or prefabricated, socket | | | |
| | | |insert, silicone gel, elastomeric or equal, for use with | | | |
| | | |locking mechanism | | | |
|L5676 |NU | |Addition to lower extremity, below knee, knee joints, |All |N |Purchase |
| |EP | |single axis, pair | | | |
|L5677 |NU | |Addition to lower extremity, below knee, knee joints, |All |N |Purchase |
| |EP | |polycentric, pair | | | |
|L5678 |NU | |Addition to lower extremity, below knee, joint covers, pair|All |N |Purchase |
| |EP | | | | | |
|L5679 |NU | |Addition to lower extremity, below knee/above knee, custom |All |N |Purchase |
| |EP | |fabricated from existing mold or prefabricated, socket | | | |
| | | |insert, silicone gel, elastomeric or equal, not for use | | | |
| | | |with locking mechanism | | | |
|L5680 |NU | |Addition to lower extremity, below knee, thigh lacer, |All |N |Purchase |
| |EP | |nonmolded | | | |
|L5681 |NU | |Addition to lower extremity, below knee/above knee, custom |All |N |Purchase |
| |EP | |fabricated socket insert for congenital or atypical | | | |
| | | |traumatic amputee, silicone gel, elastomeric or equal, for | | | |
| | | |use with or without locking mechanism, initial only | | | |
|L5682 |NU | |Addition to lower extremity, below knee, thigh lacer, |All |N |Purchase |
| |EP | |gluteal/ischial, molded | | | |
|L5683 |EP | |Addition to lower extremity, below knee/above knee, custom |U21 |N |Purchase |
| | | |fabricated socket insert for other than congenital or | | | |
| | | |atypical traumatic amputee, silicone gel, elastomeric or | | | |
| | | |equal, for use with or without locking mechanism, initial | | | |
| | | |only | | | |
|L5684 |NU | |Addition to lower extremity, below knee, fork strap |All |N |Purchase |
| |EP | | | | | |
|L5685 |NU | |Addition to lower extremity prosthesis, below knee, |All |N |Manually Priced |
| |EP | |suspension/sealing sleeve, with or without valve, any | | | |
| | | |material, each | | | |
|L5686 |NU | |Addition to lower extremity, below knee, back check |All |N |Purchase |
| |EP | |(extension control) | | | |
|L5688 |NU | |Addition to lower extremity, below knee, waist belt, |All |N |Purchase |
| |EP | |webbing | | | |
|L5690 |NU | |Addition to lower extremity, below knee, waist belt, padded|All |N |Purchase |
| |EP | |and lined | | | |
|L5692 |NU | |Addition to lower extremity, above knee, pelvic control |All |N |Purchase |
| |EP | |belt, light | | | |
|L5694 |NU | |Addition to lower extremity, above knee, pelvic control |All |N |Purchase |
| |EP | |belt, padded and lined | | | |
|L5695 |NU | |Addition to lower extremity, above knee, pelvic control, |All |N |Purchase |
| |EP | |sleeve suspension, neoprene or equal, each | | | |
|L5696 |NU | |Addition to lower extremity, above knee or knee |All |N |Purchase |
| |EP | |disarticulation, pelvic joint | | | |
|L5697 |NU | |Addition to lower extremity, above knee or knee |All |N |Purchase |
| |EP | |disarticulation, pelvic band | | | |
|L5698 |NU | |Addition to lower extremity, above knee or knee |All |N |Purchase |
| |EP | |disarticulation, Silesian bandage | | | |
|L5699 |NU | |All lower extremity prosthesis, shoulder harness |All |N |Purchase |
| |EP | | | | | |
|L5700 |NU | |Replacement, socket, below knee, molded to patient model |21+ |Y |Purchase |
|L5701 |NU | |Replacement, socket, above knee/knee disarticulation, |21+ |Y |Purchase |
| | | |including attachment plate, molded to patient model | | | |
|L5702 |NU | |Replacement, socket, hip disarticulation, including hip |21+ |Y |Purchase |
| | | |joint, molded to patient model | | | |
|L5704 |NU | |Custom shaped protective cover, below knee |All |N |Purchase |
| |EP | | | | | |
|L5705 |NU | |Custom shaped protective cover, above knee |21+ |N |Purchase |
|L5706 |NU | |Custom shaped protective cover, knee disarticulation |21+ |N |Purchase |
|L5707 |NU | |Custom shaped protective cover, hip disarticulation |21+ |N |Purchase |
|L5710 |NU | |Addition, exoskeletal knee-shin system, single axis, manual|All |N |Purchase |
| |EP | |lock | | | |
|L5711 |NU | |Addition exoskeletal knee-shin system, single axis, manual |All |N |Purchase |
| |EP | |lock, ultra-light material | | | |
|L5712 |NU | |Addition exoskeletal knee-shin system, single axis, |All |N |Purchase |
| |EP | |friction swing and stance phase control (safety knee) | | | |
|L5714 |NU | |Addition, exoskeletal knee-shin system, single axis, |All |N |Purchase |
| |EP | |variable friction swing phase control | | | |
|L5716 |NU | |Addition, exoskeletal knee-shin system, polycentric, |All |N |Purchase |
| |EP | |mechanical stance phase lock | | | |
|L5718 |NU | |Addition, exoskeletal knee-shin system, polycentric, |All |N |Purchase |
| |EP | |friction swing and stance phase control | | | |
|L5722 |NU | |Addition, exoskeletal knee-shin system, single axis, |All |N |Purchase |
| |EP | |pneumatic swing, friction stance phase control | | | |
|L5724 |NU | |Addition, exoskeletal knee-shin system, single axis, fluid |All |Y |Purchase |
| |EP | |swing phase control | | | |
|L5726 |NU | |Addition, exoskeletal knee-shin system, single axis, |All |Y |Purchase |
| |EP | |external joints, fluid swing phase control | | | |
|L5728 |NU | |Addition, exoskeletal knee-shin system, single axis, fluid |All |Y |Purchase |
| |EP | |swing and stance phase control | | | |
|L5780 |NU | |Addition, exoskeletal knee-shin system, single axis, |All |N |Purchase |
| |EP | |pneumatic/hydra pneumatic swing phase control | | | |
|L5785 |NU | |Addition, exoskeletal system, below knee, ultra-light |All |N |Purchase |
| |EP | |material (titanium, carbon fiber or equal) | | | |
|L5790 |NU | |Addition, exoskeletal system, above knee, ultra-light |All |N |Purchase |
| |EP | |material (titanium, carbon fiber or equal) | | | |
|L5795 |NU | |Addition, exoskeletal system, hip disarticulation, |All |N |Purchase |
| |EP | |ultra-light material (titanium, carbon fiber or equal) | | | |
|L5810 |NU | |Addition, endoskeletal knee-shin system, single axis, |All |N |Purchase |
| |EP | |manual lock | | | |
|L5811 |NU | |Addition, endoskeletal knee-shin system, single axis, |All |N |Purchase |
| |EP | |manual lock, ultra-light material | | | |
|L5812 |NU | |Addition, endoskeletal knee-shin system, single axis, |All |N |Purchase |
| |EP | |friction swing and stance phase control (safety knee) | | | |
|L5814 |NU | |Addition, endoskeletal knee-shin system, polycentric, |21+ |Y |Purchase |
| | | |hydraulic swing phase control, mechanical stance phase lock| | | |
|L5816 |NU | |Addition, endoskeletal knee-shin system, polycentric, |All |N |Purchase |
| |EP | |mechanical stance phase lock | | | |
|L5818 |NU | |Addition, endoskeletal knee-shin system, polycentric, |All |N |Purchase |
| |EP | |friction swing, and stance phase control | | | |
|L5822 |NU | |Addition, endoskeletal knee-shin system, single axis, |All |Y |Purchase |
| |EP | |pneumatic swing, friction stance phase control | | | |
|L5824 |NU | |Addition, endoskeletal knee-shin system, single axis, fluid|All |Y |Purchase |
| |EP | |swing phase control | | | |
|L5826 |NU | |Addition, endoskeletal knee-shin system, single axis, |21+ |Y |Purchase |
| | | |hydraulic swing phase control with miniature high activity | | | |
| | | |frame | | | |
|L5828 |NU | |Addition, endoskeletal knee-shin system, single axis, fluid|All |Y |Purchase |
| |EP | |swing and stance phase control | | | |
|L5830 |NU | |Addition, endoskeletal knee-shin system, single axis, |All |Y |Purchase |
| |EP | |pneumatic/swing phase control | | | |
|L5840 |NU | |Addition, endoskeletal knee-shin system, 4-bar linkage or |21+ |N |Purchase |
| | | |multiaxial, pneumatic swing phase control | | | |
|L5845 |NU | |Addition, endoskeletal knee-shin system, stance flexion |21+ |Y |Purchase |
| | | |feature, adjustable | | | |
|L5850 |NU | |Addition, endoskeletal system, above knee or hip |All |N |Purchase |
| |EP | |disarticulation, knee extension assist | | | |
|L5855 |NU | |Addition, endoskeletal system, hip disarticulation, |21+ |N |Purchase |
| | | |mechanical hip extension assist | | | |
|L5910 |NU | |Addition, endoskeletal system, below knee, alignable system|All |N |Purchase |
| |EP | | | | | |
|L5920 |NU | |Addition, endoskeletal system, above knee or hip |All |N |Purchase |
| |EP | |disarticulation, alignable system | | | |
|L5925 |NU | |Addition, endoskeletal system, above knee, knee |21+ |N |Purchase |
| | | |disarticulation, manual lock | | | |
|L5930 |NU | |Addition, endoskeletal system, high activity knee control |21+ |Y |Purchase |
| | | |frame | | | |
|L5940 |NU | |Addition, endoskeletal system, below knee, ultra-light |All |N |Purchase |
| |EP | |material (titanium, carbon fiber or equal) | | | |
|L5950 |NU | |Addition, endoskeletal system, above knee, ultra-light |All |N |Purchase |
| |EP | |material (titanium, carbon fiber or equal) | | | |
|L5960 |NU | |Addition, endoskeletal system, hip disarticulation, |All |N |Purchase |
| |EP | |ultra-light material (titanium, carbon fiber or equal) | | | |
|L5961 |NU | |Addition, endoskeletal system, polycentric hip joint, |All |N |Manually Priced |
| |EP | |pneumatic or hydraulic control, rotation control, with or | | | |
| | | |without flexion, and/or extension control | | | |
|L5962 |NU | |Addition, endoskeletal system, below knee, flexible |All |N |Purchase |
| |EP | |protective outer surface covering system | | | |
|L5964 |NU | |Addition, endoskeletal system, above knee, flexible |21+ |N |Purchase |
| | | |protective outer surface covering system | | | |
|L5966 |NU | |Addition, endoskeletal system, hip disarticulation, |21+ |N |Purchase |
| | | |flexible protective outer surface covering system | | | |
|L5968 |NU | |Addition to lower limb prostheses, multiaxial ankle with |21+ |Y |Purchase |
| | | |swing phase active dorsiflexion feature | | | |
|L5970 |NU | |All lower extremity prostheses, foot, external keel, SACH |All |N |Purchase |
| |EP | |foot | | | |
|L5972 |NU | |All lower extremity prostheses, flexible keel foot (SAFE, |All |N |Purchase |
| |EP | |STEN, Bock Dynamic or equal) | | | |
|L5974 |NU | |All lower extremity prostheses, foot, single axis |All |N |Purchase |
| |EP | |ankle/foot | | | |
|L5975 |NU | |All lower extremity prosthesis, combination single axis |21+ |N |Purchase |
| | | |ankle and flexible keel foot | | | |
|L5976 |NU | |All lower extremity prostheses, energy storing foot |All |N |Purchase |
| |EP | |(Seattle Carbon Copy II or equal) | | | |
|L5978 |NU | |All lower extremity prostheses, foot, multiaxial ankle/foot|All |N |Purchase |
| |EP | | | | | |
|L5979 |NU | |All lower extremity prostheses, multi-axial ankle, dynamic |All |Y |Purchase |
| |EP | |response foot, one piece system | | | |
|L5980 |NU | |All lower extremity prostheses, flex-foot system |All |Y |Purchase |
| |EP | | | | | |
|L5981 |NU | |All lower extremity prostheses, flex-walk system or equal |All |Y |Purchase |
| |EP | | | | | |
|L5982 |NU | |All exoskeletal lower extremity prostheses, axial rotation |All |N |Purchase |
| |EP | |unit | | | |
|L5984 |NU | |All endoskeletal lower extremity prosthesis, axial rotation|All |N |Purchase |
| |EP | |unit, with or without adjustability | | | |
|L5985 |NU | |All endoskeletal lower extremity prostheses, dynamic |21+ |N |Purchase |
| | | |prosthetic pylon | | | |
|L5986 |NU | |All lower extremity prostheses, multi-axial rotation unit |All |N |Purchase |
| |EP | |(“MCP” or equal) | | | |
|L5987 |NU | |All lower extremity prostheses, shank foot system with |21+ |Y |Purchase |
| | | |vertical loading pylon | | | |
|L5988 |NU | |Addition to lower limb prosthesis, vertical shock reducing |21+ |Y |Purchase |
| | | |pylon feature | | | |
|L5999 |NU | |((Unlisted Prosthetic Devices or Orthotic Appliances; the |All |Y |Manually Priced |
| | | |manufacturer’s invoice must be attached to all claims.) | | |Manually Priced |
| |EP | |Lower extremity prosthesis, not otherwise specified | | | |
|L6000 |NU | |Partial hand, Robin-Aids, thumb remaining (or equal) |All |N |Purchase |
| |EP | | | | | |
|L6010 |NU | |Partial hand, Robin-Aids, little and/or ring finger |All |N |Purchase |
| |EP | |remaining (or equal) | | | |
|L6020 |NU | |Partial hand, Robin-Aids, no finger remaining (or equal) |All |N |Purchase |
| |EP | | | | | |
|L6050 |NU | |Wrist disarticulation, molded socket, flexible elbow |All |Y |Purchase |
| |EP | |hinges, triceps pad | | | |
|L6055 |NU | |Wrist disarticulation, molded socket with expandable |All |Y |Purchase |
| |EP | |interface, flexible elbow hinges, triceps pad | | | |
|L6100 |NU | |Below elbow, molded socket, flexible elbow hinge, triceps |All |Y |Purchase |
| |EP | |pad | | | |
|L6110 |NU | |Below elbow, molded socket (Muenster or Northwestern |All |Y |Purchase |
| |EP | |suspension types) | | | |
|L6120 |NU | |Below elbow, molded double wall split socket, step-up |All |Y |Purchase |
| |EP | |hinges, half cuff | | | |
|L6130 |NU | |Below elbow, molded double wall split socket, stump |All |Y |Purchase |
| |EP | |activated locking hinge, half cuff | | | |
|L6200 |NU | |Elbow disarticulation, molded socket, outside locking |All |Y |Purchase |
| |EP | |hinge, forearm | | | |
|L6205 |NU | |Elbow disarticulation, molded socket with expandable |All |Y |Purchase |
| |EP | |interface, outside locking hinges, forearm | | | |
|L6250 |NU | |Above elbow, molded double wall socket, internal locking |All |Y |Purchase |
| |EP | |elbow, forearm | | | |
|L6300 |NU | |Shoulder disarticulation, molded socket, shoulder bulkhead,|All |Y |Purchase |
| |EP | |humeral section, internal locking elbow, forearm | | | |
|L6310 |NU | |Shoulder disarticulation, passive restoration (complete |All |Y |Purchase |
| |EP | |prosthesis) | | | |
|L6320 |NU | |Shoulder disarticulation, passive restoration (shoulder cap|All |Y |Purchase |
| |EP | |only) | | | |
|L6350 |NU | |Interscapular thoracic, molded socket, shoulder bulkhead, |All |Y |Purchase |
| |EP | |humeral section, internal locking elbow, forearm | | | |
|L6360 |NU | |Interscapular thoracic, passive restoration (complete |All |Y |Purchase |
| |EP | |prosthesis) | | | |
|L6370 |NU | |Interscapular thoracic, passive restoration (shoulder cap |All |Y |Purchase |
| |EP | |only) | | | |
|L6380 |NU | |Immediate post-surgical or early fitting, application of |All |N |Purchase |
| |EP | |initial rigid dressing, including fitting alignment and | | | |
| | | |suspension of components, and one cast change, wrist | | | |
| | | |disarticulation or below elbow | | | |
|L6382 |NU | |Immediate post-surgical or early fitting, application of |All |N |Purchase |
| |EP | |initial rigid dressing including fitting alignment and | | | |
| | | |suspension of components, and one cast change, elbow | | | |
| | | |disarticulation or above elbow | | | |
|L6384 |NU | |Immediate post-surgical or early fitting, application of |All |Y |Purchase |
| |EP | |initial rigid dressing including fitting alignment and | | | |
| | | |suspension of components, and one cast change, shoulder | | | |
| | | |disarticulation or interscapular thoracic | | | |
|L6386 |NU | |Immediate post-surgical or early fitting, each additional |All |N |Purchase |
| |EP | |cast change and realignment | | | |
|L6388 |NU | |Immediate post-surgical or early fitting, application of |All |N |Purchase |
| |EP | |rigid dressing only | | | |
|L6400 |NU | |Below elbow, molded socket, endoskeletal system, including |All |Y |Purchase |
| |EP | |soft prosthetic tissue shaping | | | |
|L6450 |NU | |Elbow disarticulation, molded socket, endoskeletal system, |All |Y |Purchase |
| |EP | |including soft prosthetic tissue shaping | | | |
|L6500 |NU | |Above elbow, molded socket, endoskeletal system, including |All |Y |Purchase |
| |EP | |soft prosthetic tissue shaping | | | |
|L6550 |NU | |Shoulder disarticulation, molded socket, endoskeletal |All |Y |Purchase |
| |EP | |system, including soft prosthetic tissue shaping | | | |
|L6570 |NU | |Interscapular thoracic, molded socket, endoskeletal system |All |Y |Purchase |
| |EP | |including soft prosthetic tissue shaping | | | |
|L6580 |NU | |Preparatory, wrist disarticulation or below elbow, single |All |Y |Purchase |
| |EP | |wall plastic socket, friction wrist, flexible elbow hinges,| | | |
| | | |figure of eight harness, humeral cuff, Bowden cable | | | |
| | | |control, “USMC” or equal pylon, no cover, molded to patient| | | |
| | | |model | | | |
|L6582 |NU | |Preparatory, wrist disarticulation or below elbow, single |All |N |Purchase |
| |EP | |wall socket, friction wrist, flexible elbow hinges, figure | | | |
| | | |of eight harness, humeral cuff, Bowden cable control, | | | |
| | | |“USMC” or equal pylon, no cover, direct formed | | | |
|L6584 |NU | |Preparatory, elbow disarticulation or above elbow, single |All |Y |Purchase |
| |EP | |wall plastic socket, friction wrist, locking elbow, figure | | | |
| | | |of eight harness, fair lead cable control, “USMC” or equal | | | |
| | | |pylon, no cover, molded to patient model | | | |
|L6586 |NU | |Preparatory, elbow disarticulation or above elbow, single |All |Y |Purchase |
| |EP | |wall socket, friction wrist, locking elbow, figure of eight| | | |
| | | |harness, fair lead cable control, “USMC” or equal pylon, no| | | |
| | | |cover, direct formed | | | |
|L6588 |NU | |Preparatory, shoulder disarticulation or interscapular |All |Y |Purchase |
| |EP | |thoracic, single wall plastic socket, shoulder joint, | | | |
| | | |locking elbow, friction wrist, chest strap, fair lead cable| | | |
| | | |control, “USMC” or equal pylon, no cover, molded to patient| | | |
| | | |model | | | |
|L6590 |NU | |Preparatory, shoulder disarticulation or interscapular |All |Y |Purchase |
| |EP | |thoracic, single wall socket, shoulder joint, locking | | | |
| | | |elbow, friction wrist, chest strap, fair lead cable | | | |
| | | |control, “USMC” or equal pylon, no cover, direct formed | | | |
|L6600 |NU | |Upper extremity additions, polycentric hinge, pair |All |N |Purchase |
| |EP | | | | | |
|L6605 |NU | |Upper extremity additions, single pivot hinge, pair |All |N |Purchase |
| |EP | | | | | |
|L6610 |NU | |Upper extremity additions, flexible metal hinge, pair |All |N |Purchase |
| |EP | | | | | |
|L6615 |NU | |Upper extremity addition, disconnect locking wrist unit |All |N |Purchase |
| |EP | | | | | |
|L6616 |NU | |Upper extremity addition, additional disconnect insert for |All |N |Purchase |
| |EP | |locking wrist unit, each | | | |
|L6620 |NU | |Upper extremity addition, flexion/extension wrist unit, |All |N |Purchase |
| |EP | |with or without friction | | | |
|L6623 |NU | |Upper extremity addition, spring assisted rotational wrist |All |N |Purchase |
| |EP | |unit with latch release | | | |
|L6624 |NU | |Upper extremity addition, flexion/extension and rotation |All |Y |Purchase |
| |EP | |wrist unit | | | |
|L6625 |NU | |Upper extremity addition, rotation wrist unit with cable |All |N |Purchase |
| |EP | |lock | | | |
|L6628 |NU | |Upper extremity addition, quick disconnect hook adapter, |All |N |Purchase |
| |EP | |Otto Bock or equal | | | |
|L6629 |NU | |Upper extremity addition, quick disconnect lamination |All |N |Purchase |
| |EP | |collar with coupling piece, Otto Bock or equal | | | |
|L6630 |NU | |Upper extremity addition, stainless steel, any wrist |All |N |Purchase |
| |EP | | | | | |
|L6632 |NU | |Upper extremity addition, latex suspension sleeve, each |All |N |Purchase |
| |EP | | | | | |
|L6635 |NU | |Upper extremity additions, lift assist for elbow |All |N |Purchase |
| |EP | | | | | |
|L6637 |NU | |Upper extremity addition, nudge control elbow lock |All |N |Purchase |
| |EP | | | | | |
|L6640 |NU | |Upper extremity additions, shoulder abduction joint, pair |All |N |Purchase |
| |EP | | | | | |
|L6641 |NU | |Upper extremity addition, excursion amplifier, pulley type |All |N |Purchase |
| |EP | | | | | |
|L6642 |NU | |Upper extremity addition, excursion amplifier, lever type |All |N |Purchase |
| |EP | | | | | |
|L6645 |NU | |Upper extremity addition, shoulder flexion-abduction joint,|All |N |Purchase |
| |EP | |each | | | |
|L6650 |NU | |Upper extremity addition, shoulder universal joint, each |All |N |Purchase |
| |EP | | | | | |
|L6655 |NU | |Upper extremity addition, standard control cable, extra |All |N |Purchase |
| |EP | | | | | |
|L6660 |NU | |Upper extremity addition, heavy-duty control cable |All |N |Purchase |
| |EP | | | | | |
|L6665 |NU | |Upper extremity addition, Teflon, or equal, cable lining |All |N |Purchase |
| |EP | | | | | |
|L6670 |NU | |Upper extremity addition, hook to hand cable adapter |All |N |Purchase |
| |EP | | | | | |
|L6672 |NU | |Upper extremity addition, harness, chest or shoulder, |All |N |Purchase |
| |EP | |saddle type | | | |
|L6675 |NU | |Upper extremity addition, harness, (e.g., figure of eight |All |N |Purchase |
| |EP | |type), single cable design | | | |
|L6676 |NU | |Upper extremity additions, harness, (e.g., figure of eight |All |N |Purchase |
| |EP | |type), dual cable design | | | |
|L6680 |NU | |Upper extremity addition, test socket, wrist |All |N |Purchase |
| |EP | |disarticulation or below elbow | | | |
|L6682 |NU | |Upper extremity addition, test socket, elbow |All |N |Purchase |
| |EP | |disarticulation or above elbow | | | |
|L6684 |NU | |Upper extremity addition, test socket, shoulder |All |N |Purchase |
| |EP | |disarticulation or interscapular thoracic | | | |
|L6686 |NU | |Upper extremity addition, suction socket |All |N |Purchase |
| |EP | | | | | |
|L6687 |NU | |Upper extremity addition, frame type socket, below elbow or|All |N |Purchase |
| |EP | |wrist disarticulation | | | |
|L6688 |NU | |Upper extremity addition, frame type socket, above elbow or|All |N |Purchase |
| |EP | |elbow disarticulation | | | |
|L6689 |NU | |Upper extremity addition, frame type socket, shoulder |All |N |Purchase |
| |EP | |disarticulation | | | |
|L6690 |NU | |Upper extremity addition, frame type socket, |All |N |Purchase |
| |EP | |interscapular-thoracic | | | |
|L6691 |NU | |Upper extremity addition, removable insert, each |All |N |Purchase |
| |EP | | | | | |
|L6692 |NU | |Upper extremity addition, silicone gel insert or equal, |All |N |Purchase |
| |EP | |each | | | |
|L6693 |NU | |Upper extremity addition, locking elbow, forearm |21+ |Y |Purchase |
| | | |counterbalance | | | |
|L67031 |NU | |Terminal device, passive hand/mitt, any material, any size |All |N |Purchase |
| |EP | | | | | |
|L67041 |NU | |Terminal device, sport/recreational/work attachment, any |All |N |Purchase |
| |EP | |material, any size | | | |
|L67061 |NU | |Terminal device, hook, mechanical, voluntary opening, any |All |N |Purchase |
| |EP | |material, any size, lined or unlined | | | |
|L67071 |NU | |Terminal device, hook, mechanical, voluntary closing, any |All |N |Purchase |
| |EP | |material, any size, lined or unlined | | | |
|L67081 |NU | |Terminal device, hand, mechanical, voluntary opening, any |All |N |Purchase |
| |EP | |material, any size | | | |
|L67091 |NU | |Terminal device, hand, mechanical, voluntary closing, any |All |N |Purchase |
| |EP | |material, any size | | | |
|L6711 |EP | |Terminal device, hook, mechanical, voluntary opening, any |U21 |Y |Purchase |
| | | |material, any size, lined or unlined, pediatric | | | |
|L6712 |EP | |Terminal device, hook, mechanical, voluntary closing, any |U21 |Y |Purchase |
| | | |material, any size, lined or unlined, pediatric | | | |
|L6713 |EP | |Terminal device, hand, mechanical, voluntary opening, any |U21 |Y |Purchase |
| | | |material, any size, pediatric | | | |
|L6714 |EP | |Terminal device, hand, mechanical, voluntary closing, any |U21 |N/A |Purchase |
| | | |material, any size, pediatric | | | |
|L6721 |NU | |Terminal device, hook or hand, heavy-duty, mechanical, |21+ |Y |Purchase |
| | | |voluntary opening, any material, any size, lined or unlined| | | |
|L6722 |NU | |Terminal device, hook or hand, heavy-duty, mechanical, |21+ |Y |Purchase |
| | | |voluntary closing, any material, any size, lined or unlined| | | |
|L6805 |NU | |Terminal device, modifier wrist flexion unit |All |N |Purchase |
| |EP | | | | | |
|L6810 |NU | |Terminal device, pincher tool, Otto Bock or equal |All |N |Purchase |
| |EP | | | | | |
|L6880 |NU | |Electric hand, switch or myoelectric controlled, |All |Y |Purchase |
| |EP | |independently articulating digits, any grasp pattern or | | | |
| | | |combination of grasp patterns, includes motor(s) | | | |
|L6890 |NU | |Terminal device, gloves for above hands, production glove |All |N |Purchase |
| |EP | | | | | |
|L6895 |NU | |Terminal device, glove for above hands, custom glove |All |N |Purchase |
| |EP | | | | | |
|L6900 |NU | |Hand restoration (casts, shading and measurements |All |N |Purchase |
| |EP | |included), partial hand, with glove, thumb or one finger | | | |
| | | |remaining | | | |
|L6905 |NU | |Hand restoration (casts, shading and measurements |All |N |Purchase |
| |EP | |included), partial hand, with glove, multiple fingers | | | |
| | | |remaining | | | |
|L6910 |NU | |Hand restoration (casts, shading and measurements |All |N |Purchase |
| |EP | |included), partial hand, with glove, no fingers remaining | | | |
|L6915 |NU | |Hand restoration (shading and measurements included), |All |N |Purchase |
| |EP | |replacement glove for above | | | |
|L6920* |NU | |Wrist disarticulation, external power, self-suspended inner|All |Y |Purchase |
| |EP | |socket, removable forearm shell, Otto Bock or equal, | | | |
| | | |switch, cables, two batteries and one charger, switch | | | |
| | | |control of terminal device | | | |
|L6925* |NU | |Wrist disarticulation, external power, self-suspended inner|All |Y |Purchase |
| |EP | |socket, removable forearm shell, Otto Bock or equal | | | |
| | | |electrodes, cables, two batteries and one charger, | | | |
| | | |myoelectronic control of terminal device | | | |
|L6930* |NU | |Below elbow, external power, self-suspended inner socket, |All |Y |Purchase |
| |EP | |removable forearm shell, Otto Bock or equal switch, cables,| | | |
| | | |two batteries and one charger, switch control of terminal | | | |
| | | |device | | | |
|L6935* |NU | |Below elbow, external power, self-suspended inner socket, |All |Y |Purchase |
| |EP | |removable forearm shell, Otto Bock or equal electrodes, | | | |
| | | |cables, two batteries and one charger, myoelectronic | | | |
| | | |control of terminal device | | | |
|L6940* |NU | |Elbow disarticulation, external power, molded inner socket,|All |Y |Purchase |
| |EP | |removable humeral shell, outside locking hinges, forearm, | | | |
| | | |Otto Bock or equal switch, cables, two batteries and one | | | |
| | | |charger, switch control of terminal device | | | |
|L6945* |NU | |Elbow disarticulation, external power, molded inner socket,|All |Y |Purchase |
| |EP | |removable humeral shell, outside locking hinges, forearm, | | | |
| | | |Otto Bock or equal electrodes, cables, two batteries and | | | |
| | | |one charger, myoelectronic control of terminal device | | | |
|L6950* |NU | |Above elbow, external power, molded inner socket, removable|All |Y |Purchase |
| |EP | |humeral shell, internal locking elbow, forearm, Otto Bock | | | |
| | | |or equal switch, cables, two batteries and one charger, | | | |
| | | |switch control of terminal device | | | |
|L6955* |NU | |Above elbow, external power, molded inner socket, removable|All |Y |Purchase |
| |EP | |humeral shell, internal locking elbow, forearm, Otto Bock | | | |
| | | |or equal electrodes, cables, two batteries and one charger,| | | |
| | | |myoelectronic control of terminal device | | | |
|L6960* |NU | |Shoulder disarticulation, external power, molded inner |All |Y |Purchase |
| |EP | |socket, removable shoulder shell, shoulder bulkhead, | | | |
| | | |humeral section, mechanical elbow, forearm, Otto Bock or | | | |
| | | |equal switch, cables, two batteries and one charger, switch| | | |
| | | |control of terminal device | | | |
|L6965* |NU | |Shoulder disarticulation, external power, molded inner |All |Y |Purchase |
| |EP | |socket, removable shoulder shell, shoulder bulkhead, | | | |
| | | |humeral section, mechanical elbow, forearm, Otto Bock or | | | |
| | | |equal electrodes, cables, two batteries and one charger, | | | |
| | | |myoelectronic control of terminal device | | | |
|L6970* |NU | |Interscapular-thoracic, external power, molded inner |All |Y |Purchase |
| |EP | |socket, removable shoulder shell, shoulder bulkhead, | | | |
| | | |humeral section, mechanical elbow, forearm, Otto Bock or | | | |
| | | |equal switch, cables, two batteries and one charger, switch| | | |
| | | |control of terminal device | | | |
|L6975* |NU | |Interscapular-thoracic, external power, molded inner |All |Y |Purchase |
| |EP | |socket, removable shoulder shell, shoulder bulkhead, | | | |
| | | |humeral section, mechanical elbow, forearm, Otto Bock or | | | |
| | | |equal electrodes, cables, two batteries and one charger, | | | |
| | | |myoelectronic control of terminal device | | | |
|L70071* |NU | |Electric hand, switch or myoelectric controlled, adult |All |Y |Purchase |
| |EP | | | | | |
|L70081* |NU | |Electric hand, switch or myoelectric, controlled, pediatric|All |Y |Purchase |
| |EP | | | | | |
|L7009 |NU | |Electric hook, switch or myoelectric controlled, adult |All |Y |Purchase |
| |EP | | | | | |
|L7040* |NU | |Prehensile actuator, Hosmer or equal, switch controlled |All |Y |Purchase |
| |EP | | | | | |
|L7045* |NU | |Electronic hook, child, Michigan or equal, switch |All |Y |Purchase |
| |EP | |controlled | | | |
|L7170* |NU | |Electronic elbow, Hosmer or equal, switch controlled |All |Y |Purchase |
| |EP | | | | | |
|L7180* |NU | |Electronic elbow, Utah or equal, myoelectronically |All |Y |Purchase |
| |EP | |controlled | | | |
|L7185 |EP | |Electronic elbow, adolescent, Variety Village or equal, |U21 |N/A |Purchase |
| | | |switch controlled | | | |
|L7186 |EP | |Electronic elbow, child, Variety Village or equal, switch |U21 |N/A |Purchase |
| | | |controlled | | | |
|L7190 |EP | |Electronic elbow, adolescent, Variety Village or equal, |U21 |N/A |Purchase |
| | | |myoelectronically controlled | | | |
|L7191 |EP | |Electronic elbow, child, Variety Village or equal, |U21 |N/A |Purchase |
| | | |myoelectronically controlled | | | |
|L7260* |NU | |Electronic wrist rotator, Otto Bock or equal |All |Y |Purchase |
| |EP | | | | | |
|L7261* |NU | |Electronic wrist rotator, for Utah arm |All |Y |Purchase |
| |EP | | | | | |
|L7360* |NU | |Six volt battery, Otto Bock or equal, each |All |N |Purchase |
| |EP | | | | | |
|L7362* |NU | |Battery charger, six volt, Otto Bock or equal |All |N |Purchase |
| |EP | | | | | |
|L7364* |NU | |Twelve volt battery, Utah or equal, each |All |N |Purchase |
| |EP | | | | | |
|L7366* |NU | |Battery charger, twelve volt, Utah or equal |All |N |Purchase |
| |EP | | | | | |
|L7499 |NU | |((Unlisted Prosthetic Devices or Orthotic Appliances; the |All |Y |Manually Priced |
| | | |manufacturer’s invoice must be attached to all claims.) | | |Manually Priced |
| |EP | |Upper extremity prosthesis, NOS | | | |
|L7510 |NU | |((Orthotics and Prosthetics Repairs) Repair of prosthetic |All |Y |Manually Priced |
| | | |device, repair or replace minor parts | | |Purchase |
| |EP |UB | | | | |
|L7510 |NU | |((Twister cables - repair/replace) Repair of prosthetic |All |N |Manually Priced |
| | | |device, repair or replace minor parts | | |Purchase |
| |EP | | | | | |
|L7520 |NU | |((Orthotics and Prosthetics Repairs) Repair prosthetic |All |Y |Manually Priced |
| | | |device, labor component, per 15 minutes | | |Purchase |
| |EP | | | | | |
|L8000 |NU | |Breast prosthesis, mastectomy bra |All |N |Purchase |
| |EP | | | | | |
|L8010 |NU | |Breast prosthesis, mastectomy sleeve |All |N |Purchase |
| |EP | | | | | |
|L8015 |NU | |External breast prosthesis garment, with mastectomy form, |21+ |N |Purchase |
| | | |post-mastectomy | | | |
|L8020 |NU | |Breast prosthesis, mastectomy form |All |N |Purchase |
| |EP | | | | | |
|L8030 |NU | |Breast prosthesis, silicone or equal |All |N |Purchase |
| |EP | | | | | |
|L8031 |NU | |Breast prosthesis, silicone or equal, with integral |All |N |Purchase |
| |EP | |adhesive | | | |
|L8032 |NU | |Nipple prosthesis, reusable, any type, each |All |N |Purchase |
| |EP | | | | | |
|L8300 |NU | |Truss, single with standard pad |All |N |Purchase |
| |EP | | | | | |
|L8310 |NU | |Truss, double with standard pads |All |N |Purchase |
| |EP | | | | | |
|L8320 |NU | |Truss, addition to standard pad, water pad |All |N |Purchase |
| |EP | | | | | |
|L8330 |NU | |Truss, addition to standard pad, scrotal pad |All |N |Purchase |
| |EP | | | | | |
|L8400 |NU | |Prosthetic sheath, below knee, each |All |N |Purchase |
| |EP | | | | | |
|L8410 |NU | |Prosthetic sheath, above knee, each |All |N |Purchase |
| |EP | | | | | |
|L8415 |NU | |Prosthetic sheath, upper limb, each |All |N |Purchase |
| |EP | | | | | |
|L8417 |NU | |Prosthetic sheath/sock, including a gel cushion layer, |21+ |N |Purchase |
| | | |below knee or above knee, each | | | |
|L8420 |NU | |Prosthetic sock, multiple ply, below knee, each |All |N |Purchase |
| |EP | | | | | |
|L8430 |NU | |Prosthetic sock, multiple ply, above knee, each |All |N |Purchase |
| |EP | | | | | |
|L8435 |NU | |Prosthetic sock, multiple ply upper limb, each |All |N |Purchase |
| |EP | | | | | |
|L8440 |NU | |Prosthetic shrinker, below knee, each |All |N |Purchase |
| |EP | | | | | |
|L8460 |NU | |Prosthetic shrinker, above knee, each |All |N |Purchase |
| |EP | | | | | |
|L8465 |NU | |Prosthetic shrinker, upper limb, each |All |N |Purchase |
| |EP | | | | | |
|L8470 |NU | |Prosthetic sock, single ply, fitting below knee, each |All |N |Purchase |
| |EP | | | | | |
|L8480 |NU | |Prosthetic sock, single ply fitting, above knee, each |All |N |Purchase |
| |EP | | | | | |
|L8485 |NU | |Prosthetic sock, single ply, fitting, upper limb, each |21+ |N |Purchase |
|L8499 |NU | |((Unlisted Prosthetic Devices or Orthotic Appliances; the |All |Y |Manually Priced |
| | | |manufacturer’s invoice must be attached to all claims.) | | |Manually Priced |
| |EP | |Unlisted procedure for miscellaneous prosthetic services | | | |
|L8500 |NU | |Artificial larynx, any type |All |N |Purchase |
| |EP | | | | | |
|L8501 |NU | |Tracheostomy speaking valve |All |N |Purchase |
| |EP | | | | | |
|L8600 |EP | |Implantable breast prosthesis, silicone or equal |U21 |N |Manually Priced |
|L8605 |NU | |Injectable bulking agent, dextranomer/hyaluronic acid |18+ |N |Manually Priced |
| | | |copolymer implant, anal canal, 1ml, includes shipping and | | | |
| | | |necessary supplies (covered only for ages 18 and over) | | | |
|L8693 |EP | |Auditory osseointegrated device abutment, any length, |U21 |Y |Manually Priced |
| | | |replacement only | | | |
|V2623 |NU | |Prosthetic eye, plastic, custom |21+ |N |Purchase |
|V2624 |NU | |Polishing/resurfacing of ocular prosthesis |21+ |N |Purchase |
|V2625 |NU | |Enlargement of ocular prosthesis |21+ |N |Purchase |
|V2626 |NU | |Reduction of ocular prosthesis |21+ |N |Purchase |
|V2628 |NU | |Fabrication and fitting of ocular conformer |21+ |N |Purchase |
|242.191 Specialized Wheelchairs and Wheelchair Seating Systems |5-22-19 |
|for Individuals Age Two Through Adult | |
Arkansas Medicaid covers wheelchairs and wheelchair seating systems for individuals ages two through adult.
For any item to be covered by Arkansas Medicaid, the beneficiary must be eligible for a defined Medicaid Aid Category. Coverage is subject to the requirement that the equipment must be medically necessary for the diagnosis or treatment of an illness or injury to improve the functioning of an affected body part, and must meet all other Medicaid statutory and regulatory requirements and established criteria.
The beneficiary’s diagnosis must warrant the type of equipment being purchased. Items may not be covered in every instance.
Providers are cautioned that an approved prior authorization does not guarantee payment. Reimbursement is contingent upon eligibility of both the beneficiary and the provider at the time service is provided and submission of an accurate and complete request. The DME provider is responsible for verifying the eligibility of the beneficiary at the time service is provided.
Specialized wheelchairs and wheelchair seating systems must be ordered by a physician.
For those services that are not included in the Arkansas Medicaid State Plan, (e.g., highly technological wheelchairs and rehab equipment), the PCP must complete form DMS-693, titled Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Prescription/Referral for Medically Necessary Services/Items Not Specifically Included in the Medicaid State Plan. View or print form DMS-679 and instructions for completion.
NOTE: If the service or item(s) are specifically included in the Arkansas Medicaid State Plan, the completion of form DMS-693 is not required.
When a request is submitted for a power wheelchair, Power-Operated Vehicle (POV) or specialized manual wheelchair, the following Medicaid requirements must be met:
A. A Prescription & Prior Authorization Request for Medical Equipment form (DMS-679) must be completed and submitted. This form must not be altered by the provider. View or print form DMS-679 and instructions for completion.
B. The DMS-679 must be signed and dated by the beneficiary’s PCP, APRN or the ordering physician. The signature must be original. Stamp signatures are not acceptable. Medicaid will accept electronic signatures provided the electronic signatures comply with Arkansas Code § 25-31-103 et seq.
C. Correct Medicaid procedure codes and modifiers must be utilized. Requested items will be denied if correct procedures codes and modifiers are not used.
D. All requests for prior authorization must be legible (felt pens must not be used).
E. Medicaid requires the submission of the original request.
F. Medical documentation from the beneficiary’s PCP, APRN or ordering physician which included a detailed face-to-face medical examination must be submitted to establish medical necessity.
G. An Evaluation for Wheelchair and Wheelchair Seating form (DMS-0843) must be submitted. This evaluation will be completed in three parts:
1. Part A—to be completed by the DME provider.
2. Part B—to be completed by the assistive technology practitioner or can be completed by a physical therapist or occupational therapist or seating specialist for Group 1 (one) and Group 2 (two) power wheelchairs with no power options.
3. Part C—to be completed by the beneficiary’s PCP, APRN or the ordering physician.
4. An Evaluation for Wheelchair and Wheelchair Seating form (DMS-0843) must be completed for all specialized wheelchairs except for rental wheelchairs. View or print form DMS-0843 and instructions for completion.
H. A manufacturer’s order form documenting the suggested retail price for the brand and model wheelchair and accessories and a manufacturer’s quote must be submitted with the DMS 679.
I. A DMS-693, Early and Periodic Screening, Diagnosis and Treatment (EPSDT) form, must be submitted for all pediatric wheelchairs and include detailed PCP or APRN medical documentation that clearly demonstrates medical necessity and clearly identifies the medical condition and the specific equipment that will meet the beneficiary’s medical needs. Form DMS-693 and the supporting documentation must be submitted as an attachment to the request for prior authorization. It will then be reviewed for medical necessity. View or print form DMS-693.
J. If requirements A through I are not completed correctly, the request could be denied.
K. Arkansas Medicaid requires a Durable Medical Equipment (DME) provider to employ a RESNA (Rehabilitation Engineering and Assistive Technology Society of North America) certified ATP (Assistive Technology Practitioner) who specializes in wheelchair seating. The ATP will provide direct in-person recommendations for evaluation of the beneficiary’s wheelchair selection, and is employed by the supplier. This applies for specialized manual wheelchair and power wheelchair in the category of Group 2 (single power option) and above.
The ATP’s involvement in the wheelchair selection must be documented. Documentation of the ATP’s involvement does not qualify as a face-to-face examination and may not be cosigned by a physician.
Procedure codes found in this section must be billed either electronically or on paper with modifier EP for beneficiaries under 21 years of age or modifier NU for beneficiaries age 21 and older. When a second modifier is listed, that modifier must be used in conjunction with either EP or NU.
Modifiers in this section are indicated by the headings M1 and M2. Prior authorization requirements are shown under the heading PA. If prior authorization is needed, that information is indicated with a “Y” in the column; if not, an “N” is shown.
Other coding information found in the chart:
1 The purchase of this component for beneficiaries age 21 and older is limited to one per five-year period.
2 The purchase of this wheelchair component for beneficiaries under age 21 is limited to one per two-year period.
* The purchase of wheelchairs for beneficiaries age 21 and older is limited to one per five-year period.
** Bill only for beneficiaries under age 21.
# This procedure code is payable for beneficiaries ages 2 through 20. Prior authorization is required through Utilization Review.
**** Items listed require prior authorization (PA) when used in combination with other items listed and the total combined value exceeds the $1,000.00 Medicaid maximum allowable reimbursement limit.
( Prior authorization is not required when other insurance pays at least 50% of the Medicaid maximum allowable reimbursement amount.
Note: W/C or w/c indicates wheelchair.
((…) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product. When using a procedure code with this symbol, the product must meet the indicated Arkansas Medicaid description.
|Specialized Wheelchairs and Wheelchair Seating Systems for Individuals |
|Age Two Through Adult (Section 242.191) |
|National Procedure |M1 |M2 |Description |PA |Payment Method |
|Code | | | | | |
|E0700 |NU |U1 |Safety equipment, e.g., belt, harness or vest |N**** |Purchase |
| |EP |U1 | | | |
|E0700 |NU |U2 |((Travel restraint auto safe harness, E-Z on vest, no known |N**** |Purchase |
| |EP |U2 |comparable product) Safety equipment, e.g., belt, harness or| | |
| | | |vest | | |
|E0950 |NU | |((Tray for W/C) W/C accessory, tray, each |Y |Purchase |
| |EP | | | | |
| |UE | | | | |
|E0950 |NU |U2 |((ABS tray, 4-SM 5-LG) W/C accessory, tray, each |Y |Purchase |
| |EP |U2 | | | |
|E0950 |NU |U3 |((W/C Tray, Custom) W/C accessory, tray, each |Y |Purchase |
| |EP |U3 | | | |
|E0950 |NU |U4 |((Tray, customized) W/C accessory, tray, each |N |Purchase |
| |EP |U4 | | | |
|E0950 |NU |U5U5 |((Clear upper Ex support system) W/C accessory, tray, each |Y |Purchase |
| |EP | | | | |
|E0950 |NU |U6 |((Lap Tray Switch Array) Wheelchair accessory, tray, each |Y |Purchase |
| |EP |U6 | | | |
|E0950 |NU |U7 |((Removable Hinged Overlay for Tray) W/C accessory, tray, |Y**** |Purchase |
| |EP |U7 |each | | |
| |UE | | | | |
|E0950 |NU |U8U8 |((Lap Tray for Switch Array) Wheelchair accessory, tray, |Y |Purchase |
| |EP | |each | | |
|E0951 |NU | |Heel loop/holder, with or without ankle strap, each |N**** |Purchase |
| |EP | | | | |
|E0952 |NU | |Toe loop/holder, each |N**** |Purchase |
| |EP | | | | |
|E0955 |NU | |Wheelchair accessory, headrest, cushioned, any type, |N |Purchase |
| |EP | |including fixed mounting hardware, each | | |
|E0956 |NU | |((Trunk supports for any W/C, other than travel, with |N**** |Purchase |
| |EP | |hardware) Wheelchair accessory, lateral trunk or hip | | |
| | | |support, any type, including fixed mounting hardware, each | | |
|E0956 |NU |U1 |((Lateral trunk supports, swing away, each) Wheelchair |N**** |Purchase |
| |EP |U1 |accessory, lateral trunk or hip support, any type, including| | |
| | | |fixed mounting hardware, each | | |
|E0956 |NU |U2 | ((Med. Chest Panel Support) Wheelchair accessory, lateral |N**** |Purchase |
| |EP |U2 |trunk or hip support, any type, including fixed mounting | | |
| | | |hardware, each | | |
|E0956 |NU |U3 |((Chest/Thoracic Supports) Wheelchair accessory, lateral |N**** |Purchase |
| |EP |U3 |trunk or hip support, any type, including fixed mounting | | |
| | | |hardware, each | | |
|E0957 |NU | |Wheelchair accessory, medial thigh support, ((-flip-up) any |N |Purchase |
| |EP | |type, including fixed mounting hardware, each | | |
|E0958 |NU | |Manual W/C accessory, one-arm drive attachment, each |N**** |Purchase |
| |EP | | | | |
|E0959 |NU | |((Amputee adapters for conventional chair, ea.) Manual W/C |N**** |Purchase |
| |EP | |accessory, adapter for amputee, each | | |
|E0959 |NU | | ((Amputee axle plate for high performance manual W/C, ea.) |N**** |Purchase |
| |EP | |Manual wheelchair accessory, adapter for amputee, each | | |
|E0959 |NU |U1 |Manual W/C accessory, adapter for amputee, each |N |Purchase |
| |EP |U1 | | | |
|E0960 |NU | |W/C accessory, shoulder harness/straps or chest strap |N |Purchase |
| |EP | |including any type mounting hardware | | |
|E0961 |NU | |Manual W/C accessory, wheel lock brake extension (handle), |N**** |Purchase |
| |EP | |each | | |
|E0966 |NU | |Manual wheelchair accessory, headrest extension, each |N**** |Purchase |
| |EP | | | | |
|E0967 |NU | |((Hand rim, any type) Manual W/C accessory, hand rim |N**** |Purchase |
| |EP | |w/projections, any type, replacement only, each | | |
|E0967 |NU |U1 |((Hand rim, any type) Manual W/C accessory, hand rim |N**** |Purchase |
| |EP |U1 |w/projections, any type, replacement only, each | | |
|E0967 |NU |U2 |((Hand rim, any type) Manual W/C accessory, hand rim |N**** |Purchase |
| |EP |U2 |w/projections, any type, replacement only, each | | |
|E0967 |NU |U3 |((Hand rim, any type) Manual W/C accessory, hand rim |N**** |Purchase |
| |EP |U3 |w/projections, any type, replacement only, each | | |
|E0967 |NU |U4 |((Hand rim, any type) Manual W/C accessory, hand rim |N**** |Purchase |
| |EP |U4 |w/projections, any type, replacement only, each | | |
|E0970 |NU | |No. 2 footplates, except for elevating legrest |N**** |Purchase |
| |EP | | | | |
|E0971 |NU | |Anti-tipping device W/C |N**** |Purchase |
| |EP | | | | |
|E0973 |NU | |W/C accessory, adjustable height, detachable armrest, |N**** |Purchase |
| |EP | |complete assembly, each | | |
|E0973 |NU |U1 |((Height Adj. Arms, replacement) W/C accessory, adjustable |N**** |Purchase |
| |EP |U1 |height, detachable armrest, complete assembly, each | | |
|E0974 |NU | |Manual wheelchair accessory, anti-rollback device (( grade |N**** |Purchase |
| |EP | |aids), each | | |
|E0978 |NU | |Wheelchair accessory, positioning belt/safety belt/pelvic |N**** |Purchase |
| |EP | |strap, each | | |
|E0978 |NU |U1 |((Belt, safety or chest, w/pad) Wheelchair accessory, |N**** |Purchase |
| |EP |U1 |positioning belt/safety belt/ pelvic strap, each |N | |
|E0978 |NU |U2 |Wheelchair accessory, positioning belt/safety belt/pelvic |N**** |Purchase |
| |EP |U2 |strap, each | | |
|E0980 |NU | |((Chest panel, 21-SM 22-LG) Safety vest, wheelchair |N**** |Purchase |
| |EP | | | | |
|E0980 |NU |U1 |((Shoulder retractors) Safety vest, W/C |N**** |Purchase |
| |EP |U1 | | | |
|E0981 |NU | |W/C accessory, seat upholstery, replacement only, each |N |Purchase |
| |EP | | | | |
|E0982 |NU | |W/C accessory, back upholstery, replacement only, each |N**** |Purchase |
| |EP | | | | |
|E0982 |NU |U1 |((Standard back upholstery replacement) W/C accessory, back |N**** |Purchase |
| |EP |U1 |upholstery, replacement only, each | | |
|E0990 |NU | |((Elevating foot, leg rest) W/C accessory, elevating leg |N**** |Purchase |
| |EP | |rest, complete assembly, each | | |
|E0990 |NU |U1 |((Elevating Leg Rest 90 Degree, 12" - 16" Width) W/C |N**** |Purchase |
| |EP |U1 |accessory, elevating leg rest, complete assembly, each | | |
|E0992 |NU | |( (Manual wheelchair accessory, solid seat) |N**** |Purchase |
| |EP | | | | |
|E0992 |NU |U1 |(Manual w/c accessory, solid seat insert (Large adjustable |N**** |Purchase |
| |EP |U1 |solid seat w/hardware) | | |
|E0992 |NU |U2 |((Foam and Plywood Flat Side Manual wheelchair accessory, |N**** |Purchase |
| |EP |U2 |solid seat) | | |
|E0992 |NU |U3 |((Foam & Plywood Seat, MPI Like Manual wheelchair accessory,|N**** |Purchase |
| |EP |U3 |solid seat) | | |
|E0992 |NU |U4 |((Adjustable solid standard seat with hardware Manual |N**** |Purchase |
| |EP |U4 |wheelchair accessory, solid seat) | | |
|E0994 |NU | |Armrest, each |N**** |Purchase |
| |EP | | | | |
|E1002 |NU | |W/C accessory power seating system, tilt only |Y( |Purchase |
| |EP | | | | |
|E1004 |NU | |W/C accessory, power seating system, recline only, with |Y( |Purchase |
| |EP | |mechanical shear reduction | | |
|E1006 |NU | |W/C accessory, power seating system, combination tilt and |Y |Purchase |
| |EP | |recline, w/o shear reduction | | |
|E1007 |NU | |Wheelchair accessory, power seating system, combination tilt|Y |Purchase |
| |EP | |and recline, with mechanical shear reduction | | |
|E1010 |NU | |W/C accessory, addition to power seating system, power leg |Y |Purchase |
| |EP | |elevation system, including leg rest, each | | |
|E1020 |NU | |((Adjustable Contour Lateral Thigh Support) Residual limb |N**** |Purchase |
| |EP | |support system for W/C | | |
|E1028 |NU | |Wheelchair accessory, manual swingaway, retractable or |N |Purchase |
| |EP | |removable mounting hardware for joystick, other control | | |
| | | |interface or positioning accessory | | |
|E1029 |NU | |((Ventilator Tray With Battery Tray) Wheelchair accessory, |Y |Purchase |
| |EP | |ventilator tray, fixed | | |
|E1030 |NU | |Wheelchair accessory, ventilator tray, gimbaled |Y |Purchase |
| |EP | | | | |
|E1050* |NU | |Fully reclining W/C, fixed full-length arms, swing-away, |N**** |Purchase |
| |EP | |detachable elevating legrests | | |
|E1060* |NU | |Fully reclining W/C, detachable arms, desk or full-length, |Y( |Purchase |
| |EP | |swing-away detachable, elevating legrests | | |
|E1070# |EP | |((A maximum use of three months only) Fully-reclining |Y |Rental only |
| | | |wheelchair, detachable arms, (desk or full-length) | | |
| | | |swing-away, detachable footrest/elevated legrest | | |
|E1084* |NU | |Hemi-W/C; detachable arms, desk or full-length, swing-away, |N**** |Purchase |
| |EP | |detachable, elevating leg rests | | |
|E1086* |NU | |Hemi W/C; detachable arms, desk or full-length, swing-away, |N**** |Purchase |
| |EP | |detachable footrests | | |
|E1086* |NU |U1 |Hemi W/C, detachable arms, desk or full-length, swing-away |Y |Purchase |
| |EP |U1 |detachable footrests | | |
|E1088* |NU | |High strength lightweight W/C; detachable arms, desk or |Y( |Purchase |
| |EP | |full-length, swing-away, detachable, elevating legrests | | |
|E1090 |NU | |High-strength lightweight W/C; detachable arms, desk or |N**** |Purchase |
| |EP | |full-length, swing-away, detachable footrests | | |
|E1092* |NU | |Wide, heavy-duty W/C; detachable arms, desk or full-length, |Y( |Purchase |
| |EP | |swing-away, detachable, elevating legrests | | |
|E1093* |NU | |Wide, heavy-duty W/C; detachable arms, desk or full-length |Y( |Purchase |
| |EP | |arms, swing-away, detachable footrests | | |
|E1110* |NU | |Semi-reclining W/C; detachable arms, desk or full-length, |Y( |Purchase |
| |EP | |elevating legrest | | |
|E1161 |NU | |Manual adult size W/C, includes tilt in space |Y( |Purchase |
| |EP | | | | |
|E1170* |NU | |Amputee W/C; fixed full-length arms, swing-away, detachable,|N**** |Purchase |
| |EP | |elevating legrests | | |
|E1172* |NU | |Amputee W/C; detachable arms, desk or full-length, without |Y( |Purchase |
| |EP | |footrests or legrests | | |
|E1180* |NU | |Amputee W/C; detachable arms, desk or full-length, |Y( |Purchase |
| |EP | |swing-away, detachable footrests | | |
|E1200* |NU | |Amputee W/C; fixed full-length arms, swing-away, detachable |N**** |Purchase |
| |EP | |footrests | | |
|E1220* |NU | |W/C, specially sized or constructed (indicate brand name, |Y |Manually Priced |
| |EP | |model number, if any, and justification) | | |
|E1225 |NU | |((Folding Backrest, 8 Degree Bend, Low, 15" - 16") Manual |N**** |Purchase |
| |EP | |W/C accessory, semi-reclining back, (recline greater than 15| | |
| | | |degrees, but less than 80 degrees), each | | |
|E1228 |NU | |((Folding Backrest, Tall, 19" - 20") Special back height for|N**** |Purchase |
| |EP | |W/C | | |
|E1228 |NU | |((Folding Straight Backrest, Low, (15" - 16") Special back |N**** |Purchase |
| |EP | |height for W/C | | |
|E1228 |NU | |((Folding Straight Backrest, Tall, 19" - 20") Special back |N**** |Purchase |
| |EP | |height for W/C | | |
|E1228 |NU |U1 |((High back contour seat) Special back height for W/C |N**** |Purchase |
| |EP |U1 | | | |
|E1228 |NU |U2 |((Positioning tall back) Special back height for W/C |N**** |Purchase |
| |EP |U2 | | | |
|E1230* |NU | |Power operated vehicle (three- or four-wheel nonhighway), |Y( |Purchase |
| |EP | |specify brand name and model number | | |
|E1230 |EP |U1 |Power operated vehicle (three- or four-wheel nonhighway), |Y( |Purchase |
| |NU |U1 |specify brand name and model number | | |
|E1232* |EP | |W/C, pediatric size, tilt-in-space, folding, adjustable, |Y( |Purchase |
| | | |with seating system | | |
|E1233* |EP | |W/C, pediatric size, tilt-in-space, rigid, adjustable, |Y( |Purchase |
| | | |without seating system | | |
|E1234* |EP | |W/C, pediatric size, tilt-in-space, folding, adjustable, |Y( |Purchase |
| | | |without seating system | | |
|E1235* |NU | |Wheelchair, pediatric size, rigid, adjustable, with seating |Y( |Purchase |
| |EP | |system | | |
|E12352 |EP |U1 |((Rigid W/C Frame) W/C, pediatric size, rigid, adjustable |Y |Purchase |
| | | |with seating system | | |
|E1236 |EP | |Wheelchair, pediatric size, folding, adjustable, with |Y |Purchase |
| | | |seating system | | |
|E1237* |EP | |W/C, pediatric size, rigid, adjustable, without seating |Y( |Purchase |
| | | |system | | |
|E1238* |EP | |W/C, pediatric size, folding, adjustable, without seating |Y( |Purchase |
| | | |system | | |
|E1240* |NU | |Lightweight W/C; detachable arms, desk or full-length, |Y( |Purchase |
| |EP | |swing-away, detachable, elevating legrest | | |
|E1260* |NU | |Lightweight W/C; detachable arms, desk or full-length, |N**** |Purchase |
| |EP | |swing-away, detachable footrests | | |
|E1280* |NU | |Heavy-duty W/C; detachable arms, desk or full-length, |Y( |Purchase |
| |EP | |elevating legrests | | |
|E1290* |NU | |Heavy-duty W/C; detachable arms, swing-away, detachable |Y( |Purchase |
| |EP | |footrests | | |
|E2201 |NU | |((Seat Width 20") Manual w/c accessory, nonstandard seat |N**** |Purchase |
| |EP | |frame width > than or equal to 20 inches and < 24 inches | | |
|E2201 |NU |U1 |((Frame Width 14"-15") Manual w/c accessory, nonstandard |N**** |Purchase |
| |EP |U1 |seat frame width>than or equal to 20 inches and than or equal to 20 inches and than or|N**** |Manually Priced |
| |EP |U3 |equal to 20 inches and ................
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