|
ORTHOTICS
SERVICE FEE MEMORANDUM
MS-JT-00-01-14
-
- DATE: April 11, 2001
-
- RE: Orthotics Fee Schedule
-
-
- All
procedures in the Orthotics Fee Schedule have been updated effective
immediately. Most procedures were updated several months ago.
Recently procedures not covered by Medicare were also updated.
-
This
updated Schedule may be viewed/printed in the Case Management System
and will also be available on the DVR
INTRANET site.
MS/vy
ORTHOTICS
DATE: April 10, 2001
RE: Revised Orthotic Services Fee Schedule
Medicare HCPCS Codes and Descriptions for Orthotic Services are being
utilized on this Schedule.
For any "By Report" item, obtain item description and charge. Then
contact the Central Office for approval to purchase and an allowable fee.
|
Item No. |
Orthotic |
Unit Price |
|
A. |
CERVICAL |
|
|
L0100 |
Cervical, craniostenosis, helmet, non-molded to patient model |
432.50 |
|
L0110 |
Cervical, craniostenosis, helmet, non-molded |
127.60 |
|
L0120 |
Cervical, flexible, non-adjustable (foam collar) |
21.39 |
|
L0130 |
Cervical, flexible, thermoplastic collar, molded to patient |
154.64 |
|
L0140 |
Cervical, semi-rigid, adjustable (plastic collars) |
53.37 |
|
L0150 |
Cervical, semi-rigid, adjustable molded chin cup (plastic collar with
mandibular/occipital piece) |
88.99 |
|
L0160 |
Cervical, semi-rigid, wire frame occipital/mandibular support |
126.69 |
|
L0170 |
Cervical, collar, molded to patient model |
536.13 |
|
L0172 |
Cervical, collar, semi-rigid thermoplastic foam, two
piece |
108.71 |
|
L0174 |
Cervical, collar, semi-rigid, thermoplastic form, two piece with
thoracic extension |
195.29 |
|
L0180 |
Cervical, multiple post collar, occipital/mandibular supports,
adjustable |
265.60 |
|
L0190 |
Cervical, multiple post collar, occipital/mandibular supports,
adjustable cervical bars (Somi, Guilford, Taylor types) |
399.80 |
|
L0200 |
Cervical, multiple post collar, occipital/mandibular supports,
adjustable cervical bars, and thoracic extension |
367.11 |
|
B |
THORACIC AND THORACIC-LUMBAR-SACRAL |
|
|
A |
THORACIC |
|
|
L0210 |
Thoracic, rib belt, custom fitted |
38.10 |
|
L0220 |
Thoracic, rib belt, custom fabricated |
87.07 |
|
B |
THORACIC-LUMBAR-SACRAL |
|
|
L0300 |
Thoracic-Lumbar-Sacral Orthosis (TLSO), flexible (dorso-lumbar surgical
support), custom fitted |
143.73 |
|
L0310 |
Thoracic-Lumbar-Sacral Orthosis (TLSO), flexible dorso surgical
support) custom fabricated |
268.59 |
|
L0315 |
Thoracic-Lumbar-Sacral Orthosis (TLSO), flexible dorso surgical
support, elastic type, with rigid posterior panel |
186.94 |
|
L0317 |
Thoracic-Lumbar-Sacral Orthosis (TLSO), flexible dorso-lumbar surgical
support hyperextension, elastic type, with rigid posterior panel |
253.61 |
|
L0320 |
Thoracic-Lumbar-Sacral Orthosis (TLSO), anterior-posterior control
Taylor type, with apron front |
292.17 |
|
L0330 |
Thoracic-Lumbar-Sacral Orthosis (TLSO), anterior-posterior-lateral
control (Knight-Taylor design) with apron front |
366.31 |
|
L0340 |
Thoracic-Lumbar-Sacral Orthosis (TLSO),
anterior-posterior-lateral-rotary control (Arnold, Magnuson, Steindler
types) with apron front |
583.64 |
|
L0350 |
Thoracic-Lumbar-Sacral Orthosis(TLSO),
anterior-posterior-lateral-rotary control, flexion compression jacket,
custom fitted |
812.84 |
|
L0360 |
Thoracic-Lumbar-Sacral Orthosis (TLSO),
anterior-posterior-lateral-rotary control, flexion compression jacket
molded to patient model |
1,199.37 |
|
L0370 |
Thoracic-Lumbar-Sacral Orthosis (TLSO),
anterior-posterior-lateral-rotary control, hyperextension (Jewett, Lennox,
Baker, Cash types |
327.36 |
|
L0380 |
Thoracic-Lumbar-Sacral Orthosis (TLSO),
anterior-posterior-lateral-rotary control with extensions |
459.42 |
|
L0390 |
Thoracic-Lumbar-Sacral Orthosis (TLSO), anterior-posterior-lateral
control (body jacket) molded to patient model |
1,012.27 |
|
L0400 |
Thoracic-Lumbar-Sacral Orthosis (TLSO), anterior-posterior-lateral
control (body jacket) molded to patient model, with interface material |
1,160.42 |
|
L0410 |
Thoracic-Lumbar-Sacral Orthosis (TLSO), anterior-posterior-lateral
control (body jacket), two piece construction, molded to patient model |
1,353.03 |
|
L0420 |
Thoracic-Lumbar-Sacral Orthosis (TLSO), two piece construction, molded
to patient model, with interface material |
1,340.34 |
|
L0430 |
Thoracic-Lumbar-Sacral Orthosis (TLSO), anterior-posterior-lateral
control (body jacket), with interface material custom fitted |
1,063.26 |
|
L0440 |
Thoracic-Lumbar-Sacral Orthosis (TLSO), anterior-posterior-lateral
control (body Jacket), with overlapping front section, spring steel front,
custom fitted |
867.14 |
|
C |
LUMBAR-SACRAL (LSO) |
|
|
L0500 |
Lumbar-Sacral Orthosis (LSO), flexible (Lumb0-sacral surgical support),
custom fitted |
107.14 |
|
L0510 |
Lumbar-Sacral Orthosis (LSO), flexible (Lumbar-sacral surgical
support), custom fabricated |
218.10 |
|
L0515 |
Lumbar-Sacral-Orthosis (LSO), flexible (lumbar-sacral surgical
support), elastic type, with rigid posterior panel |
130.10 |
|
L0520 |
Lumbar-Sacral Orthosis (LSO), anterior-posterior-lateral control
(Knight, Wilcox types), with apron front |
319.98 |
|
L0530 |
Lumbar-Sacral Orthosis (LSO), anterior-posterior control (Macausland
type), with apron front |
294.51 |
|
L0540 |
Lumbar-Sacral Orthosis (LSO), lumbar flexion(Williams flexion type)
anterior-posterior-lateral control (body jacket) |
317.83 |
|
L0550 |
Lumbar-Sacral Orthosis (LSO), anterior-posterior-lateral control (body
jacket), molded to patient model |
953.75 |
|
L0560 |
Lumbar-Sacral Orthosis (LSO), anterior-posterior-lateral control (body
jacket), molded to patient model, with interface material |
1,043.57 |
|
L0565 |
Lumbar-Sacral Orthosis (LSO), anterior-posterior-lateral control (body
jacket), custom fitted |
1,040.64 |
|
C |
OTHER SPINAL ORTHOSES |
|
|
A |
FLEXIBLE SACROILIAC |
|
|
L0600 |
Sacroiliac, Flexible (sacroiliac surgical support, custom fitted |
68.15 |
|
L0610 |
Sacroiliac, flexible (sacroiliac surgical support), custom fabricated |
184.81 |
|
L0620 |
Sacroiliac, Semi-rigid (Goldthawaite, Osgood types), with apron front |
308.16 |
|
B |
CERVICAL-THORACIC-LUMBAR-SACRAL |
|
|
L0700 |
Cervical-Thoracic-Lumbar-Sacral Orthosis CTLSO),
anterior-posterior-lateral control, molded to patient model, (Minerva
type) |
1,645.77 |
|
L0710 |
Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLSO),
anterior-posterior-lateral control, molded to patient model, with
interface material (Minerva type) |
1,796.47 |
|
C |
HALO PROCEDURE |
|
|
L0810 |
Halo procedure, cervical halo incorporated into jacket vest |
1,908.48 |
|
L0820 |
Halo procedure, cervical halo incorporated into plaster body jacket |
1,543.88 |
|
L0830 |
Halo procedures, cervical halo incorporated into Milwaukee type
orthosis |
2,229.20 |
|
L0860 |
Addition to HALO procedure, magnet reasonance image compatible system |
866.03 |
|
D |
TORSO SUPPORTS |
|
|
L0900 |
Torso support, PTOSIS support, custom fitted |
141.86 |
|
L0910 |
Torso support, PTOSIS support, custom fabricated |
283.37 |
|
L0920 |
Torso support, pedulous abdomen support, custom fitted |
160.87 |
|
L0930 |
Torso support, pedulous abdomen support, custom fabricated |
329.41 |
|
L0940 |
Torso support, post surgical support, custom fitted |
113.65 |
|
L050 |
Torso support, post surgical support, custom fabricated |
291.65 |
|
L0960 |
Torso support, post surgical support, pads for post surgical support |
65.48 |
|
E |
ADDITIONS TO SPINAL ORTHOSES |
|
|
L0970 |
Thoracic-Lumbar-Sacral Orthosis (TLSO), corset front |
81.25 |
|
L0972 |
Lumbar-Sacral Orthosis (LSO), corset front |
83.05 |
|
L0974 |
Thoracic-Lumbar-Sacral Orthosis (TLSO), full corset |
169.70 |
|
L0976 |
Lumbar Sacral Orthosis (LSO), full corset |
151.56 |
|
L0978 |
Axillary crutch extension |
136.84 |
|
L0980 |
Peroneal straps, pair |
12.41 |
|
L0982 |
Stocking supporter grips, set of four (4) |
13.52 |
| L0984 |
Protective
Body Sock, Each |
43.15 |
|
D |
SCOLIOSIS PROCEDURES |
|
|
A |
CERVICAL-THORACIC-LUMBAR-SACRAL |
|
|
L1000 |
Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLSO) (Milwaukee), inclusive
of furnishing initial orthosis, including model |
1,443.28 |
|
L1010 |
Addition to Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLSO) or
Scoliosis Orthosis, axilla sling |
58.12 |
|
L1020 |
Addition to Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLSO)or
Scoliosis Orthosis, kyphosis pad |
79.41 |
|
L1025 |
Addition to Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLSO or
Scoliosis Orthosis, kyphosis pad, floating |
90.25 |
|
L1030 |
Addition to Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLSO) or
Scoliosis Orthosis, lumbar bolster pad |
60.30 |
|
L1040 |
Addition to Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLSO) or
Scoliosis Orthosis, lumbar or lumbar rib pad |
72.58 |
|
L1050 |
Addition to Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLS)) or
Scoliosis Orthosis, sternal pad |
62.85 |
|
L1060 |
Addition to Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLSO) or
Scoliosis Orthosis, thoracic pad |
70.88 |
|
L1070 |
Addition to Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLSO) or
Scoliosis Orthosis, trapezius sling |
72.47 |
|
L1080 |
Addition to Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLS)) or
Scoliosis Orthosis, outrigger |
50.21 |
|
L1085 |
Addition to Cervical -Thoracic-Lumbar-Sacral Orthosis (CTLSO) or
Scoliosis Orthosis, outrigger, bilateral with vertical extension |
139.50 |
|
L1090 |
Addition to Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLSO) or
Scoliosis Orthosis, lumbar sling |
65.17 |
|
L1100 |
Addition to cervical-Thoracic-Lumbar-Sacral Orthosis (CTLSO) or
Scoliosis Orthosis, ring flange, plastic or leather |
115.03 |
|
L1110 |
Addition to Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLSO) or
Scoliosis Orthosis, ring flange, plastic or leather, molded to patient
model |
194.84 |
|
L1120 |
Addition to Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLSO) or
Scoliosis Orthosis, cover for upright each |
31.04 |
|
B |
THORACIC-LUMBAR-SACRAL |
|
|
L1200 |
Thoracic-Lumbar-Sacral Orthosis (TLSO) inclusive of furnishing initial
orthosis only |
1,235.45 |
|
L1210 |
Addition to Addition to Thoracic-Lumbar-Sacral Orthosis (TLSO), (low
profile) lateral thoracic extension |
186.01 |
|
L1220 |
Addition to Thoracic-Lumbar-Sacral Orthosis (TLSO), (low profile),
anterior thoracic extension |
157.49 |
|
L1230 |
Addition to Thoracic-Lumbar-Sacral Orthosis (TLSO), (low profile),
Milwaukee type superstructure |
404.11 |
|
L1240 |
Addition to Thoracic-Lumbar-Sacral Orthosis (TLSO), (low-Profile),
lumbar derotation pad |
69.55 |
|
L1250 |
Addition to Thoracic-Lumbar-Sacral Orthosis (TLSO), (low profile),
anterior ASIS pad |
68.48 |
|
L1260 |
Addition to Thoracic-Lumbar-Sacral Orthosis (TLSO), (low profile),
anterior thoracic derotation pad |
70.37 |
|
L1270 |
Addition to Thoracic-Lumbar-Sacral Orthosis (TLSO), (low profile),
abdominal pad |
70.27 |
|
L1280 |
Addition to Thoracic-Lumbar-Sacral Orthosis (TLSO), (low profile), rib
gusset (elastic) each |
62.65 |
|
L1290 |
Addition to Thoracic-Lumbar-Sacral Orthosis (TLSO), (low profile),
lateral trochanteric pad |
71.03 |
|
C |
OTHER SCOLIOSIS PROCEDURES |
|
|
L1300 |
Other scoliosis procedures, body jacket molded to patient model |
1,187.49 |
|
L1310 |
Other scoliosis procedures, post-operative body jacket |
1,221.94 |
|
L1499 |
Unlisted procedure for spinal orthosis
(BY REPORT PROCEDURE) |
By Report |
|
E |
LOWER LIMB: HIP, LEG PERTHE, AND KNEE |
|
|
A |
THORACIC-HIP-KNEE-ANKLE |
|
|
L1500 |
Thoracic-Hip-Knee-Angle Orthosis (THKAO), mobility frame (Newington,
Parapodium types) |
1,350.32 |
|
L1510 |
Thoracic-Hip-Knee-Angle Orthosis (THKAO), standing frame |
854.27 |
|
L1520 |
Thoracic-Hip-Knee-Angle Orthosis (THKAO), swivel walker |
2,029.03 |
|
B |
HIP |
|
|
L1600 |
Hip Orthosis (HO), abduction control of hip joints, flexible, Frejka
type with cover |
91.61 |
|
L1610 |
Hip Orthosis (HO), abduction control of hip joints,, flexible, Frejka
cover only |
31.21 |
|
L1620 |
Hip Orthosis (HO), abduction control of hip joints, flexible, Pavlik
harness |
102.78 |
|
L1630 |
Hip Orthosis (HO), abduction control of hip joints, semi-flexible (Von
Rossen type) |
122.64 |
|
L1640 |
Hip Orthosis (HO), abduction control of hip joints, static, pelvic band
or spreader bar, thigh cuffs |
328.03 |
|
L1650 |
Hip Orthosis (HO), abduction control of hip joints, static adjustable
custom fitted (Ilfled type) |
173.95 |
|
L1660 |
Hip Orthosis (HO), abduction control of hip joints, static, plastic,
custom fitted |
121.66 |
|
L1680 |
Hip Orthosis (HO), abduction control of hip joints, dynamic, pelvic
control, adjustable hip motion control, thigh cuffs (Rancho hip action
type) |
1,000.22 |
|
L1685 |
Hip Orthosis (HO), abduction control of hip joint, post-operative hip
abduction type, custom fabricated |
1,055.40 |
|
L1686 |
Hip Orthosis (HO), abduction control of hip joint, post-operative hip
abduction type, custom fitted |
708.03 |
| L1690 |
Combination
Bilateral, Lumbo - Sacral, Hip, Femur Orthosis providing
adduction and internal rotation control |
1,478.17 |
|
C |
LOWER LIMB-LEGG PERTHES |
|
|
L1700 |
Legg Perthes Orthosis, Toronto type |
1,229.74 |
|
L1710 |
Legg Perthes Orthosis, Newington type |
1,445.49 |
|
L1720 |
Legg Perthes Orthosis, trilateral, (Tachdijan type) |
1,067.78 |
|
L1730 |
Legg Perthes Orthosis, Scottish rite type |
805.63 |
|
L1750 |
Legg Perthes Orthosis, Legg perthes sling (Sam Brown type) |
139.86 |
|
L1755 |
Legg Perthes Orthosis, patten bottom type |
1,172.58 |
|
D |
KNEE (KO) |
|
|
L1800 |
Knee Orthosis (KO), elastic with stays |
63.05 |
|
L1810 |
Knee Orthosis (KO) elastic with joints |
92.55 |
|
L1815 |
Knee Orthosis (KO), elastic with condylar pads |
84.81 |
|
L1820 |
Knee Orthosis (KO), elastic with condyle pads and joints |
92.17 |
|
L1825 |
Knee Orthosis (KO), elastic knee cap |
41.09 |
|
L1830 |
Knee Orthosis (KO), immobilizer, canvas longitudinal |
77.11 |
|
L1832 |
Knee Orthosis (KO), adjustable knee joints, positional orthosis, rigid
support, custom fitted |
576.27 |
|
L1834 |
Knee Orthosis (KO), without knee joint, rigid, molded to patient model |
677.96 |
|
L1840 |
Knee Orthosis (KO), derotation, medial-lateral, anterior cruciate
ligament, custom fabricated to patient model |
712.65 |
| L1843 |
KO,
Single Upright, Thigh and Calf. with adjustable Flexion and
Extension Joint, Medial-Lateral and Rotation Control, Custom
Fitted |
685.87 |
| L1844 |
KO,
Single Upright, Thigh and Calf. with adjustable Flexion and
Extension Joint, Medial-Lateral and Rotation Control, Molded to
Patient Model |
1,188.46 |
|
L1845 |
Knee Orthosis (KO), double upright, thigh and calf, with adjustable
flexion and extension joint, medial-lateral and rotation control, custom
fitted |
715.99 |
|
L1846 |
Knee Orthosis (KO), double upright, thigh and calf, with adjustable
flexion and extension joint, medial-lateral and rotation control, molded
to patient model |
897.37 |
| L1847 |
Knee
Orthosis, Double Upright with Adjustable Joint, with Inflatable
Air Support Chamber(s) |
439.66 |
|
L1850 |
Knee Orthosis (KO), Swedish type |
204.62 |
|
L1855 |
Knee Orthosis (KO), molded plastic, thigh and calf sections, with
double upright knee joints, molded to patient model |
875.60 |
|
L1858 |
Knee Orthosis (KO), molded plastic, polycentric knee joints, pneumatic
knee pads (CTI) |
962.30 |
|
L1860 |
Knee Orthosis (KO), modification of supracondylar prosthetic socket
molded to patient model (SK) |
793.65 |
|
L1870 |
Knee Orthosis (KO), double upright, thigh and calf lacers, molded to
patient model with knee joints |
815.64 |
|
L1880 |
Knee Orthosis (KO), double upright, non-molded thigh and calf cuss
cuffs/lacers with knee joints |
503.17 |
| L1885 |
Knee
Orthosis (KO), Single or Double Upright, Thigh and Calf, with
Functional Action Resistance Control |
790.99 |
|
F |
LOWER LIMB: ANKLE FOOT (AFO) |
|
|
L1900 |
Ankle-Foot Orthosis (AFO), spring wire, dorsiflexion assist calf band |
215.00 |
|
L1902 |
Ankle-Foot Orthosis (AFO), ankle gauntlet |
58.39 |
|
L1904 |
Ankle-Foot Orthosis (AFO), molded ankle gauntlet molded to patient
model |
334.30 |
|
L1906 |
Ankle-Foot Orthosis (AFO), multiligamentus ankle support |
97.69 |
|
L1910 |
Ankle-Foot Orthosis (AFO), posterior, single bar, clasp attachment, to
shoe counter |
190.11 |
|
L1920 |
Ankle-Foot Orthosis (AFO), single upright with static or adjustable
(Phelps or Perlstein type) |
248.52 |
|
L1930 |
Ankle-Foot Orthosis (AFO), custom fitted, plastic |
168.17 |
|
L1940 |
Ankle-Foot Orthosis (AFO), molded to patient model, plastic |
380.05 |
|
L1945 |
Ankle-Foot Orthosis (AFO), molded to patient model, plastic, rigid
anterior tibial section (floor reaction) |
697.92 |
|
L1950 |
Ankle-Foot Orthosis (AFO), spiral, molded to patient model (Irm type),
plastic |
529.50 |
|
L1960 |
Ankle-Foot Orthosis (AFO), posterior solid ankle, molded to patient
model, plastic |
394.04 |
|
L1970 |
Ankle-Foot Orthosis (AFO), plastic molded to patient model, with ankle
joint |
582.81 |
|
L1980 |
Ankle-Foot Orthosis (AFO), single upright free plantar dorsiflexion,
solid stirrup, calf band/cuff (single bar "BK" orthosis) |
260.90 |
|
L1990 |
Ankle-Foot Orthosis (AFO), double upright free plantar dorsiflexion,
solid stirrup, calf band/cuff (double bar "BK" orthosis) |
335.22 |
|
G |
HIP KNEE ANGLE FOOT |
|
|
A |
KNEE-ANKLE-FOOT |
|
|
L2000 |
Knee-Ankle-Foot Orthosis (KAFO), single upright free knee, free ankle,
solid stirrup, thigh and calf bands/cuffs (single bar "AK"
orthosis) |
721.05 |
|
L2010 |
Knee-Ankle-Foot Orthosis (KAFO), single upright, free knee, free ankle,
solid stirrup, thigh and calf bands/cuffs (single bar "AK"
orthosis) without knee joint |
657.30 |
|
L2020 |
Knee-Ankle-Foot Orthosis (KAFO), double upright, free knee, free ankle,
solid stirrup, thigh and calf bands/cuffs (double bar "AK"
orthosis) |
830.07 |
|
L2030 |
Knee-Ankle-Foot Orthosis (KAFO), double upright, free ankle, solid
stirrup, thigh and calf bands/cuffs, (double bar "AK" orthosis),
without knee joint |
720.16 |
| L2035 |
KAFO.
Full Plastic, Static, Prefabricated (Pediatric Size) |
0.00 |
|
L2036 |
Knee-Ankle-Foot Orthosis (KAFO), full plastic, double upright, free
knee, molded to patient model |
1,318.93 |
|
L2037 |
Knee-Ankle-Foot Orthosis (KAFO, full plastic, single upright, free
knee, molded to patient model |
1,215.49 |
|
L2038 |
Knee-Angle-Foot Orthosis (KAFO), full plastic, without knee joint,
multi-axis angle, molded to patient model (Lively orthosis or equal) |
1,016.38 |
| L2039 |
KAFO, Full Plastic,
Single Upright, Poly-Axial Hinge, Medial Lateral Rotation
Control, Molded to Patient Model |
0.00 |
|
B |
HIP-KNEE-ANKLE-FOOT |
|
|
L2040 |
Hip-Knee-Ankle-Foot Orthosis (HKAFO), torsion control, bilateral
rotation straps, pelvic band/belt |
129.82 |
|
L2050 |
Hip-Knee-Ankle-Foot Orthosis (HKAFO), torsion control, bilateral
torsion cables, hip joint, pelvic band/belt |
345.75 |
|
L2060 |
Hip-Knee-Ankle Foot Orthosis (HKAFO), torsion control, bilateral
torsion cables, ball bearing hip joint, pelvic band/belt |
443.75 |
| L2070 |
Hip-Knee-Ankle-Foot
Orthosis (HKAFO), Torsion Control, Unilateral Rotation Straps,
Pelvic Band/Belt |
127.47 |
|
L2080 |
Hip-Knee-Ankle-Foot Orthosis (HKAFO), torsion control, unilateral
torsion cable, hip joint pelvic band/belt |
271.83 |
|
L2090 |
Hip-Knee-Ankle-Foot Orthosis (HKAFO), torsion control, unilateral
torsion cable, ball bearing hip joint, pelvic band/belt |
335.08 |
|
H |
LOWER LIMB FRACTURE ORTHOSIS AND ADDITIONS |
|
|
L2102 |
Ankle-Foot Orthosis (AFO), fracture Orthosis, tibial fracture cast
orthosis, plaster type casting material, molded to patient |
330.71 |
|
L2104 |
Ankle-Foot Orthosis (AFO), fracture orthosis, tibial fracture cast
orthosis synthetic type casting material, molded to patient |
350.88 |
|
L2106 |
Ankle-Foot Orthosis (AFO), fracture orthosis, tibial fracture cast
orthosis, thermoplastic type casting material, molded to patient |
483.35 |
|
L2108 |
Ankle-Foot Orthosis (AFO), fracture orthosis, tibial fracture cast
orthosis, molded to patient model |
759.56 |
|
L2112 |
Ankle-Foot Orthosis (AFO), fracture orthosis, tibial fracture orthosis
soft custom fitted |
360.65 |
|
L2114 |
Ankle-Foot Orthosis (AFO), fracture orthosis tibial fracture orthosis,
semi-rigid custom fitted |
412.63 |
|
L2116 |
Ankle-Foot Orthosis (AFO), fracture orthosis, tibial fracture orthosis,
rigid custom fitted |
543.65 |
|
L2122 |
Knee-Ankle-Foot Orthosis (KAFO), fracture orthosis, femoral fracture
cast orthosis, plaster type casting material, molded to patient |
583.04 |
|
L2124 |
Knee-Ankle-Foot Orthosis (KAFO), fracture orthosis, femoral fracture
cast orthosis, synthetic type casting material, molded to patient |
723.81 |
|
L2126 |
Knee-Ankle-Foot Orthosis (KAFO), fracture orthosis, femoral fracture
cast orthosis, thermoplastic type casting, molded to patient |
967.28 |
|
L2128 |
Knee-Ankle-Foot Orthosis (KAFO), fracture orthosis, femoral fracture
cast orthosis, molded to patient model |
1,218.99 |
|
L2132 |
Knee-Ankle-Foot Orthosis (KAFO), fracture orthosis, femoral fracture
cast orthosis, soft custom fitted |
573.46 |
|
L2134 |
Knee-Ankle-Foot Orthosis (KAFO), fracture orthosis, femoral fracture
cast orthosis, semi-rigid custom fitted |
687.56 |
|
L2136 |
Knee-Ankle-Foot Orthosis (KAFO), fracture orthosis, femoral fracture
cast orthosis, rigid custom fitted |
840.70 |
|
L2180 |
Addition to lower extremity fracture orthosis, plastic shoe insert with
ankle joints |
83.25 |
|
L2182 |
Addition to lower extremity fracture orthosis, drop knee joint |
65.16 |
|
L2184 |
Addition to lower extremity fracture orthosis, limited motion knee
joint |
117.42 |
|
L2186 |
Addition to lower extremity fracture orthosis, adjustable motion knee
joint, lerman type |
130.11 |
|
L2188 |
Addition to lower extremity fracture orthosis, quadrilateral brim |
283.88 |
|
L2190 |
Addition to lower extremity fracture orthosis, waist belt |
73.73 |
|
L2192 |
Addition to lower extremity fracture orthosis, hip joint, pelvic band,
thigh flange, and pelvic belt |
253.48 |
|
I |
LOWER LIMB ADDITIONS |
|
|
A |
SHOE-ANKLE-SHIN |
|
|
L2200 |
Addition to lower extremity, limited ankle motion, each joint |
33.80 |
|
L2210 |
Addition to lower extremity, dorsiflexion assist (plantar flexion
resist), each joint |
54.85 |
|
L2220 |
Addition to lower extremity, dorsiflexion and plantar flexion
assist/resist, each joint |
62.97 |
|
L2230 |
Addition to lower extremity, spit flat caliper stirrups and plate
attachment |
54.55 |
|
L2240 |
Addition to lower extremity, round caliper and plate attachment |
59.45 |
|
L2250 |
Addition to lower extremity, foot plate, molded to patient model,
stirrup attachment |
252.60 |
|
L2260 |
Additions to lower extremity, reinforced solid stirrup (Scott-Craig
type) |
142.51 |
|
L2265 |
Addition to lower extremity, long tongue stirrup |
83.72 |
|
L2270 |
Additions to lower extremity, varus/valgus correction ("T")
strap, padded/lined or malleolus pad |
38.18 |
| L2275 |
Addition
to Lower Extremity, Varus/Vulgas Correction, Plastic
Modification, Padded/Lined |
92.89 |
|
L2280 |
Additions to lower extremity, molded inner
boot |
345.10 |
|
L2300 |
Additions to lower extremity, abduction bar (bilateral hip
involvement), jointed, adjustable |
194.80 |
|
L2310 |
Additions to lower extremity, abduction bar-straight |
87.46 |
|
L2320 |
Additions to lower extremity, non-molded lacer |
146.26 |
|
L2330 |
Additions to lower extremity, lacer molded to patient model |
279.14 |
|
L2335 |
Addition to lower extremity, anterior swing band |
164.21 |
|
L2340 |
Addition to lower extremity, pre-tibial shell, molded to patient model |
387.50 |
|
L2350 |
Addition to lower extremity, prosthetic type, (BK) socket, molded to
patient model, (used for 'PTB' 'AFO' orthoses) |
633.44 |
|
L2360 |
Addition to lower extremity, extended steel shank |
36.78 |
|
L2370 |
Addition to lower extremity, patten bottom |
182.49 |
|
L2375 |
Addition to lower extremity, torsion control, ankle joint and half
solid stirrup |
80.32 |
|
L2380 |
Addition to lower extremity, torsion control, straight knee joint, each
joint |
87.52 |
|
L2385 |
Addition to lower extremity, straight knee joint, heavy duty, each
joint |
95.22 |
|
L2390 |
Addition to lower extremity, offset knee joint, each joint |
77.82 |
|
L2395 |
Addition to lower extremity, offset knee joint, heavy duty, each joint |
118.81 |
| L2397 |
Addition to Lower
Extremity, Orthosis, Suspension Sleeve |
83.33 |
|
B |
KNEE |
|
|
L2405 |
Addition to knee joint, drop lock, each joint |
37.94 |
|
L2415 |
Addition to knee joint, cam lock (Swiss, French, Bail types), each
joint |
174.07 |
|
L2425 |
Addition to knee joint, disc or dial lock for adjustable knee flexion,
each joint |
129.44 |
| L2430 |
Addition
to Knee Joint, Ratchet Lock for Active and Progressive Knee
Extension, each Joint |
75.15 |
|
L2435 |
Addition to knee joint, polycentric joint, each joint |
129.23 |
|
L2492 |
Addition to knee joint, lift loop for drop lock ring |
72.49 |
|
C |
THIGH/WEIGHT BEARING |
|
|
L2500 |
Addition to lower extremity, thigh/weight bearing, gluteal/ischial
weight bearing, ring |
224.27 |
|
L2510 |
Addition to lower extremity, thigh/weight
bearing, quadrilateral
brim, molded to patient model |
600.45 |
|
L2520 |
Addition to lower extremity, thigh/weight bearing, quadrilateral brim,
custom fitted |
327.49 |
|
L2525 |
Addition to lower extremity, thigh/weight bearing, ischial
containment/narrow M-L brim molded to patient model |
1,123.57 |
|
L2526 |
Addition to lower extremity, thigh/weight bearing, ischial
containment/narrow M-L, custom fitted |
605.60 |
|
L2530 |
Addition to lower extremity, thigh/weight bearing, lacer, non-molded |
167.03 |
|
L2540 |
Addition to lower extremity, thigh/weight bearing, Lacer molded to
patient model |
300.55 |
|
L2550 |
Addition to lower extremity, thigh/weight bearing, high roll cuff |
204.17 |
|
D |
PELVIC AND THORACIC CONTROL |
|
|
L2570 |
Addition to lower extremity, pelvic control, hip joint, Clevis type two
position joint, each |
451.47 |
|
L2580 |
Addition to lower extremity, pelvic control, pelvic sling |
427.97 |
|
L2600 |
Addition to lower extremity, pelvic control, hip joint, Clevis type, or
thrust bearing, free, each |
146.00 |
|
L2610 |
Addition to lower extremity, pelvic control, hip joint, Clevis or
thrust bearing, lock each |
172.64 |
|
L2620 |
Addition to lower extremity, pelvic control, hip joint, heavy duty,
each |
190.08 |
|
L2622 |
Addition to lower extremity, pelvic control, hip joint, adjustable
flexion each |
218.00 |
|
L2624 |
Addition to lower extremity, pelvic control, hip joint adjustable
flexion, extension, abduction control, each |
296.37 |
|
L2627 |
Addition to lower extremity, pelvic control, plastic, molded to patient
model, reciprocating High joint and cables |
1,221.00 |
|
L2628 |
Addition to lower extremity, pelvic control, metal frame, reciprocating
hip joint and cables |
1,434.31 |
|
L2630 |
Addition to lower extremity, pelvic control, band and belt, unilateral |
176.03 |
|
L2640 |
Addition to lower extremity, pelvic control, band and belt, bilateral |
238.90 |
|
L2650 |
Addition to lower extremity, pelvic and thoracic control, gluteal pad,
each |
85.31 |
|
L2660 |
Addition to lower extremity, thoracic control, thoracic band |
132.49 |
|
L2670 |
Addition to lower extremity, thoracic control, paraspinal uprights |
121.26 |
|
L2680 |
Addition to lower extremity, thoracic control, lateral support uprights |
111.25 |
|
E |
ADDITIONS-GENERAL |
|
|
L2750 |
Addition to lower extremity orthosis, plating chrome or nickel, per bar |
59.42 |
| L2755 |
Addition
to lower extremity orthosis, carbon graphite lamination |
99.89 |
|
L2760 |
Addition to lower extremity orthosis, extension, per extension, per bar
(for lineal adjustment for growth) |
43.19 |
|
L2770 |
Addition to lower extremity orthosis, stainless steel-per bar or joint |
43.89 |
|
L2780 |
Addition to lower extremity, non-corrosive finish, per bar |
51.09 |
|
L2785 |
Addition to lower extremity orthosis, drop lock retainer, each |
30.04 |
|
L2795 |
Addition to lower extremity orthosis, knee control, full kneecap |
60.40 |
|
L2800 |
Addition to lower extremity orthosis, knee control, knee cap, medial or
lateral pull |
75.83 |
|
L2810 |
Addition to lower extremity orthosis, knee control, condylar pad |
55.52 |
|
L2820 |
Addition to lower extremity orthosis, soft interface for molded
plastic, below-knee section |
61.73 |
|
L2830 |
Addition to lower extremity orthosis, soft interface for molded
plastic, above-knee section |
69.42 |
|
L2840 |
Addition to lower extremity orthosis, tibal length socks, fracture or
equal, each |
38.74 |
|
L2850 |
Addition to lower extremity orthosis, femoral length sock, fracture or
equal, each |
44.02 |
|
L2999 |
Unlisted procedures for lower extremity orthosis
(BY REPORT PROCEDURE) |
By Report |
|
J |
FOOT |
|
|
A |
INSERT, REMOVABLE, MOLDED TO PATIENT/PATIENT MODEL |
|
|
L3000 |
Foot, insert, removable, molded to patient model, "UCB" type,
Berkeley shell, each |
106.00 |
|
L3001 |
Foot, insert, removable, molded to patient model, Spenco, each |
87.00 |
|
L3002 |
Foot, insert, removable, molded to patient model, Plasazota or equal,
each |
37.00 |
|
L3003 |
Foot, insert, removable, molded to patient model, silicone gel, each |
135.00 |
|
L3010 |
Foot, insert, removable, molded to patient model, longitudinal arch
support, each |
87.00 |
|
L3020 |
Foot, insert, removable, molded to patient model,
longitudinal/metatarsal support, each |
142.00 |
|
L3030 |
Foot, insert, removable, formed to patient foot, each |
101.00 |
|
B |
ARCH SUPPORT, REMOVABLE, PRE-MOLDED |
|
|
L3040 |
Foot, arch support, removable, pre-molded, longitudinal each |
34.00 |
|
L3050 |
Foot, arch support, removable, pre-molded, metatarsal, each |
34.00 |
|
L3060 |
Foot, arch support, removable, pre-molded, longitudinal/metatarsal,
each |
39.00 |
|
C |
ARCH SUPPORT, NON-REMOVABLE, ATTACHED TO SHOE |
|
|
L3070 |
Foot, arch support, non-removable attached to shoe, longitudinal, each |
13.00 |
|
L3080 |
Foot, arch support, non-removable attached to shoe, metatarsal, each |
13.00 |
|
L3090 |
Foot, arch support, non-removable attached to shoe,
longitudinal/metatarsal, each |
15.00 |
|
L3100 |
Hallus-valgus night dynamic splint |
27.00 |
|
D |
ABDUCTION AND ROTATION BARS |
|
|
L3140 |
Foot, abduction rotation bars (Dennis Browne type), attached to shoe |
68.00 |
|
L3150 |
Foot, abduction rotation bars (Denis Browne type), clamped to shoe |
68.00 |
|
L3170 |
Foot-plastic heel stabilizer |
21.00 |
|
K |
ORTHOPEDIC FOOTWEAR |
|
|
L3215 |
Orthopedic footwear, Ladies shoes, Oxford, pair |
83.00 |
|
L3216 |
Orthopedic footwear, Ladies shoes, depth inlay, pair |
153.00 |
|
L3217 |
Orthopedic footwear, Ladies shoes, hightop depth inlay, pair |
156.00 |
|
L3218 |
Orthopedic footwear, Ladies surgical boot, each |
65.00 |
|
L3219 |
Orthopedic footwear, Mens shoes, oxford, pair |
96.00 |
|
L3221 |
Orthopedic footwear, Mens shoes, depth inlay, pair |
174.00 |
|
L3222 |
Orthopedic footwear, Mens shoes, hightop, depth, inlay pair |
102.00 |
|
L3223 |
Orthopedic footwear, Mens surgical boot, each |
110.00 |
| L3224 |
Orthopedic
footwear, Woman's shoe, oxford, used as an integral part of a
brace (Orthosis) |
41.80 |
| L3225 |
Orthopedic
footwear, Man's shoe, oxford, used as an integral part of a
brace (Orthosis) |
48.09 |
|
L3230 |
Orthopedic footwear, custom shoes, depth inlay, pair |
218.00 |
|
L3250 |
Orthopedic footwear, custom molded shoe, removable inner mold,
prosthetic shoe, each |
206.00 |
|
E3251 |
Foot, shoe molded to patient model, silicone shoe, each |
89.00 |
|
L3252 |
Foot, shoe molded to patient model - Plastazote (or similar), custom
fabricated, each |
52.00 |
|
L3253 |
Foot, molded shoe Plastozote (or similar) custom fitted each |
162.00 |
|
L3254 |
Non-standard size or width |
47.00 |
|
L3255 |
Non-standard size or length |
47.00 |
|
L3257 |
Orthopedic footwear, additional charge for split size |
105.00 |
|
L3260 |
Ambulatory surgical boot, each |
24.00 |
|
L3265 |
Plastazote sandal, each |
27.00 |
|
L |
SHOE MODIFICATIONS |
|
|
A. |
LIFTS |
|
|
L3310 |
Lift, elevation, heel and sole, neoprene
(USE LLL3311-L3316) |
|
|
L3311 |
Lift, elevation, heel and sole, neoprene, 0" to 5/8" |
43.00 |
|
L3312 |
Lift, elevation, heel and sole, neoprene, 3/4" to 1 1/2" |
66.00 |
|
L3313 |
Lift, elevation, heel and sole, neoprene, 1 5/8" to 2" |
72.00 |
|
L3314 |
Lift, elevation, heel and sole, neoprene, 2 1/8" to 2 5/8" |
83.00 |
|
L3315 |
Lift, elevation, heel and sole, neoprene, 2 3/4" to 3 1/4" |
101.00 |
|
L3316 |
Lift, elevation, heel and sole, neoprene, Over 3 1/4", add to
above |
75.00 |
|
L3320 |
Lift, elevation, heel and sole, cork, (USE L3221-L3326) |
69.00 |
|
L3321 |
Lift, elevation, heel and sole, cork, 0" to 5/8" |
124.00 |
|
L3322 |
Lift, elevation, heel and sole, cork, 3/4" to 1 1/2" |
148.00 |
|
L3323 |
Lift, elevation, heel and sole, cork, 1 5/8" to 2" |
154.00 |
|
L3324 |
Lift, elevation, heel and sole, cork 2 1/8" to 2 5/8" |
165.00 |
|
L3325 |
Lift, elevation, heel and sole, cork, 2 3/4" to 3 1/4" |
183.00 |
|
L3326 |
Over 3 1/4", add to above |
82.00 |
|
L3330 |
Lift, elevation, metal extension, "skate"
(BY REPORT PROCEDURE) |
By report |
|
B |
WEDGES |
|
|
L3340 |
Heel wedge, Sach |
40.00 |
|
L3350 |
Heel wedge |
8.00 |
|
L3360 |
Sole wedge, outside sole |
11.00 |
|
L3370 |
Sole wedge, between sole |
14.00 |
|
L3380 |
Clubfoot wedge |
14.00 |
|
L3390 |
Outflare wedge |
11.00 |
|
L3400 |
Metatarsal bar wedge, rocker |
21.00 |
|
L3410 |
Metatarsal bar wedge, between sole |
33.00 |
|
L3420 |
Full sole and heel wedge "between sole" |
23.00 |
|
C |
HEELS |
|
|
L3430 |
Heel, counter, plastic reinforced |
23.00 |
|
L3440 |
Heel, counter, leather reinforced |
23.00 |
|
L3450 |
Heel, sach cushion type |
16.00 |
|
L3455 |
Heel, new leather, standard |
7.00 |
|
L3460 |
Heel, new rubber, standard |
5.50 |
|
L3465 |
Heel, Thomas with wedge |
7.00 |
|
L3470 |
Heel, Thomas extended to ball |
16.00 |
|
L3480 |
Heel, pad and depression for spur |
12.00 |
|
L3485 |
Heel, pad, removable for spur |
12.00 |
|
D |
MISCELLANEOUS SHOE ADDITIONS |
|
|
L3500 |
Miscellaneous shoe addition, insole, leather |
10.00 |
|
L3510 |
Miscellaneous shoe addition, insole, rubber |
10.00 |
|
L3520 |
Miscellaneous shoe addition, insole, felt covered with leather |
10.00 |
|
L3530 |
Miscellaneous shoe addition, sole, half |
23.00 |
|
L3540 |
Miscellaneous shoe addition, sole, full |
17.00 |
|
L3550 |
Miscellaneous shoe addition, toe--tap, standard |
3.25 |
|
L3560 |
Miscellaneous shoe addition, toe-tap, horseshoe |
5.50 |
|
L3570 |
Miscellaneous shoe addition, special extension to instep (leather with
eyelets |
40.00 |
|
L3580 |
Miscellaneous shoe addition covert instep to Velcro closure |
26.00 |
|
L3590 |
Miscellaneous shoe addition, covert firm shoe counter to soft counter |
38.00 |
|
L3595 |
Miscellaneous shoe addition, march bar |
14.00 |
|
M |
TRANSFERS |
|
|
L3600 |
Transfers of an orthosis from one she to another, caliper plate
existing |
26.00 |
|
L3610 |
Transfers of an orthosis from one shoe to another, caliper plate new |
60.00 |
|
L3620 |
Transfer of an orthosis from one shoe to another, solid stirrup,
existing |
32.00 |
|
L3630 |
Transfer of an orthosis from one shoe to another, solid stirrup, new |
60.00 |
|
L3640 |
Transfer of an orthosis from one shoe to another, Dennis Browne splint
(Riveton), both shoes |
24.00 |
|
L3649 |
Unlisted procedures for foot orthopedic shoes, shoe modifications and
transfers
(BY REPORT PROCEDURE) |
By Report |
|
N |
UPPER LIMB: SHOULDER |
|
|
L3650 |
Shoulder Orthosis (SO), figure of "8" design abduction
restrainer |
41.64 |
|
L3660 |
Shoulder Orthosis (SO), figure of "8" design abduction
restrainer |
71.50 |
| L3675 |
Shoulder
Orthosis (SO), vest type abduction restrainer, canvas webbing
type, or equal |
122.08 |
|
L3670 |
Shoulder Orthosis (SO), acromio/clavicalar (canvas and webbing type) |
99.66 |
|
O |
UPPER LIMB: ELBOW |
|
|
L3700 |
Elbow Orthosis (EO), elastic with stays |
48.56 |
|
L3710 |
Elbow Orthosis (EO), elastic with metal joints |
100.86 |
|
L3720 |
Elbow Orthosis (EO), double upright with forearm/arm cuffs, free motion |
503.20 |
|
L3730 |
Elbow Orthosis (EO), double upright with forearm/arm cuffs,
extension/flexion assist |
662.42 |
|
L3740 |
Elbow Orthosis (EO), double upright with forearm/arm cuffs, adjustable
position lock with active control |
744.44 |
|
P |
WRIST-HAND-FINGER |
|
|
A |
WRIST-HAND-FINGER |
|
|
L3800 |
Wrist-Hand-Finger Orthosis (WHFO), short opponens, no attachments |
139.10 |
|
L3805 |
Wrist-Hand-Finger Orthosis (WHFO), short opponens, no attachments |
222.56 |
|
L3810 |
Wrist-Hand-Finger Orthosis (WHFO), addition to short and long opponens,
thumb abduction ("C") bar |
45.08 |
|
L3815 |
Wrist-Hand-Finger Orthosis (WHFO), addition to short and long opponens,
second M.P. abduction assist |
41.85 |
|
L3820 |
Wrist-Hand-Finger Orthosis (WHFO), addition to short and long opponens,
I.P. extension assist with M.O. extension stop |
71.89 |
|
L3825 |
Wrist-Hand-Finger Orthosis (WHFO), addition to short and long opponens,
M.P. extension stop |
51.04 |
|
L3830 |
Wrist-Hand-Finger Orthosis (WHFO), addition to short and long opponens,
M.P. extension assist |
58.89 |
|
L3835 |
Wrist-Hand-Finger Orthosis (WHFO), addition to short and long opponens,
M.P. spring extension assist |
63.85 |
|
L3840 |
Wrist-Hand-Finger Orthosis (WHFO), addition to short and long opponens,
spring swivel thumb |
43.73 |
|
L3845 |
Wrist-Hand-Finger Orthosis (WHFO), addition to short and long opponens,
thumb I.P. extension assist, with M.P. stop |
56.47 |
|
L3850 |
Wrist-Hand-Finger Orthosis (WHFO), addition to short and long opponens,
action wrist with dorsiflexion assist |
80.67 |
|
L3855 |
Wrist-Hand-Finger Orthosis (WHFO), addition to short and long opponens,
adjustable M.P. Flexion control |
87.18 |
|
L3860 |
Wrist-Hand-Finger Orthosis (WHFO), addition to short and long opponens,
adjustable M.P. flexion control and I.P. |
118.53 |
|
B |
FINGER FLEXION/EXTENSION |
|
|
L3900 |
Wrist-Hand-Finger Orthosis (WHFO), dynamic flexor hinge; reciprocal
wrist extension/flexion, finger flexion/extension, wrist or finger driven |
1086.76 |
|
L3901 |
Wrist-Hand-Finger Orthosis (WHFO), dynamic flexor hinge; reciprocal
wrist extension/flexion, finger flexion/extension, cable driven external
power |
1218.54 |
|
C |
EXTERNAL POWER |
|
|
L3902 |
Wrist-Hand-Finger Orthosis (WHFO), external powered, compressed gas |
1,875.21 |
|
L3904 |
Wrist-Hand-Finger Orthosis (WHFO), external powered, electric |
2,480.63 |
|
D |
OTHER WRIST-HAND-FINGER ORTHOSES |
|
|
L3906 |
Writs-Hand-Finger Orthosis (WHFO), molded to patient model |
293.48 |
|
L3907 |
Wrist-Hand-Finger Orthosis (WHFO), Wrist gauntlet with thumb spica,
molded to patient model |
394.95 |
|
L3908 |
Wrist-Hand-Finger Orthosis (WHFO), wrist extension control cock-up,
canvas or leather design, non-molded |
41.68 |
|
L3910 |
Wrist-Hand-Finger Orthosis (WHFO), Swanson design |
307.92 |
|
L3912 |
Wrist-Hand-Finger Orthosis (WHFO), flexion glove with elastic finger
control |
66.88 |
|
L3914 |
Wrist-Hand-Finger Orthosis (WHFO), wrist extension cock-up |
67.34 |
|
L3916 |
Wrist-Hand-Finger Orthosis (WHFO), wrist extension cock-up, with
outrigger |
88.35 |
|
L3918 |
Wrist-Hand-Finger Orthosis (WHFO), knuckle bender |
59.74 |
|
L3920 |
Wrist-Hand Finder Orthosis (WHFO), knuckle bender, with outrigger |
71.23 |
|
L3922 |
Wrist-Hand-Finger Orthosis (WHFO), knuckle bender, two segment to flex
joints |
81.71 |
|
L3924 |
Wrist-Hand-Finger Orthosis (WHFO), Oppenheimer |
87.33 |
|
L3926 |
Wrist-Hand-Finger Orthosis (WHFO), Thomas suspension |
71.81 |
|
L3928 |
Wrist-Hand-Finger Orthosis (WHFO), finger extension, with clock spring |
42.41 |
|
L3930 |
Wrist-Hand-Finger Orthosis (WHFO), finger extension, with wrist support |
43.80 |
|
L3932 |
Wrist-Hand-Finger Orthosis (WHFO), safety pin, spring wire |
37.98 |
|
L3934 |
Wrist-Hand-Finger Orthosis (WHFO), safety pin, modified |
33.52 |
|
L3936 |
Wrist-Hand-Finger Orthosis (WHFO), palmer |
61.97 |
|
L3938 |
Wrist-Hand-finger Orthosis (WHFO), dorsal wrist |
65.18 |
|
L3940 |
Wrist-Hand-Finger Orthosis (WHFO), dorsal, wrist, with outrigger
attachment |
74.78 |
|
L3942 |
Wrist Hand-Finger Orthosis (WHFO), reverse knuckle bender |
51.72 |
|
L3944 |
Wrist-Hand-Finger Orthosis (WHFO), reverse knuckle bender with
outrigger attachment |
85.18 |
|
L3946 |
Wrist-Hand-Finger Orthosis (WHFO), composite electric |
69.90 |
|
3948 |
Wrist-Hand-Finger Orthosis (WHFO), finger knuckle bender |
46.80 |
|
L3950 |
Wrist-Hand-Finger Orthosis (WHFO), combination Oppenheimer, with
knuckle bender and two attachments |
110.20 |
|
L3952 |
Wrist-Hand-Finger Orthosis (WHFO), combination Oppenheimer, with
reverse knuckle and two attachments |
122.13 |
|
L3954 |
Wrist-Hand-Finger Orthosis (WHFO), spreading hand |
76.82 |
|
Q |
UPPER LIMB: SHOULDER-ELBOW-WRIST-HAND |
|
|
A |
ABDUCTION POSITIONING-CUSTOM FITTED |
|
|
L3960 |
Shoulder-Elbow-Wrist-Hand Orthosis (SEWHO), abduction positioning,
airplane design |
573.42 |
|
L3962 |
Shoulder-Elbow-Wrist-Hand Orthosis (SEWHO), abduction positioning ,
ERBS palsey design |
597.07 |
|
L3963 |
Shoulder-Elbow-Wrist-Hand Orthosis (SEWHO), molded shoulder, arm,
forearm, and wrist, with articulating elbow joint |
1510.43 |
|
L3964 |
Shoulder-Elbow-Wrist-Hand Orthosis (SEWHO), mobile arm support attached
to wheelchair, balanced and fitted to patient, adjustable |
592.43 |
|
L3965 |
Shoulder-Elbow-Wrist-Hand Orthosis (SEWHO), radial arm support,
attached to wheelchair balanced and fitted to patient, adjustable Rancho
type |
945.35 |
|
L3966 |
Shoulder-Elbow-Wrist-Hand Orthosis (SEWHO), mobile arm support attached
to wheelchair, balanced and fitted to patient, reclining |
630.23 |
|
L3968 |
Shoulder-Elbow-Wrist-Hand Orthosis (SEWHO), mobile arm support attached
to wheelchair, balanced and fitted to patient, friction arm support
(friction dampening to proximal and distal joints |
876.02 |
|
L3969 |
Shoulder-Elbow-Wrist-Hand Orthosis (SEWHO), mobile arm support,
monsuspension arm and hand support, overhead elbow forearm hand sling
support, yoke type arm suspension support |
630.23 |
|
B |
ADDITIONS TO MOBILE ARM SUPPORTS |
|
|
L3970 |
Shoulder-Elbow-Wrist-Hand Orthosis (SEWHO), addition to mobile arm
support, elevating proximal arm |
252.10 |
|
L3972 |
Shoulder-Elbow-Wrist-Hand Orthosis (SEWHO), addition to mobile arm
support, offset or lateral rocker arm with elastic balance control |
160.31 |
|
L39.74 |
Shoulder-Elbow-Wrist-Hand Orthosis (SEWHO), addition to mobile arm
support, supinator |
128.21 |
|
C |
FRACTURE ORTHOSES |
|
|
L3980 |
Upper extremity fracture orthosis, humeral |
215.06 |
|
L3982 |
Upper extremity fracture orthosis, radius/ulner |
265.70 |
|
L3984 |
Upper extremity fracture orthosis, wrist |
283.62 |
|
L3985 |
Upper extremity fracture orthosis, forearm, hand with wrist hinge |
420.91 |
|
L3986 |
Upper extremity fracture orthosis, combination of humeral,
radius/ulnar, wrists (example-colles fracture) |
486.79 |
|
L3995 |
Addition to upper extremity orthosis, sock, fracture or equal, each |
23.81 |
|
L3999 |
Unlisted procedures for upper limb orthosis
(BY REPORT PROCEDURE) |
By Report |
|
R |
SPECIFIC REPAIR |
|
|
A. |
REPLACEMENTS |
|
|
L4000 |
Replace girdle for Milwaukee orthosis |
927.39 |
|
L4010 |
Replace Trilateral socket brim |
521.88 |
|
L4020 |
Replace quadrilateral socket brim, molded to patient model |
651.87 |
|
L4030 |
Replace quadrilateral socket brim, custom fitted |
358.92 |
|
L4040 |
Replace molded thigh lacer |
290.18 |
|
L4045 |
Replace non-molded thigh lacer |
233.19 |
|
L4050 |
Replace molded calf lacer |
293.49 |
|
L4055 |
Replace non-molded calf later |
190.04 |
|
L4060 |
Replace high roll cuff |
225.92 |
|
L4070 |
Replace proximal and distal upright for KAFO |
215.55 |
|
L4080 |
Replace metal bands KAFO, proximal thigh |
75.98 |
|
L4090 |
Replace metal bands KAFO-AFO, calf or distal thigh |
67.26 |
|
L4100 |
Replace leather cuff KAFO, proximal thigh |
75.86 |
|
L4110 |
Replace leather cuff KAFO-AFO, calf or distal thigh |
60.29 |
|
L4130 |
Replace pretibial shell |
414.92 |
|
B |
ORTHOTIC REPAIRS |
|
|
L4200 |
Repair of orthotic device, hourly rate |
27.00 |
|
L4210 |
Repair of orthotic device, repair or replace minor parts |
37.00 |
|
S |
ANCILLARY ORTHOTIC SERVICES |
|
|
L4310 |
Multi-Podus or equal orthotic preparatory management system for lower
extremities |
408.00 |
|
L4320 |
Addition to AFO, multi-podus (or equal) orthotic preparatory management
system for lower extremities, flexible foot positioner with soft interface
for AFO, with velcro closure custom fitted |
127.00 |
|
L4350 |
Pneumatic ankle control splint (aircast or equal) |
74.75 |
|
L4360 |
Pneumatic walking splint (aircast or equal) |
209.13 |
|
L4370 |
Pneumatic full leg splint (aircast or equal) |
134.20 |
|
L4380 |
Pneumatic knee splint (aircast or equal) |
82.29 |
|
|
|
ORTHOTICS
SERVICE FEE MEMORANDUM
MS-93-94-10
DATE: December 10, 1993
RE: Orthotic Services Fee Schedule
You will find attached an updated Orthotic services Fee Scheduled effective
December 10, 1993.
Medicare HCPCS Codes and Descriptions for Orthotic Services are being
utilized on this Schedule.
For any "By Report" item, obtain item description and charge. Then
contact the Central Office for approval to purchase and an allowable fee.
|
Item No. |
Orthotic |
Unit Price |
|
A. |
CERVICAL |
|
|
L0100 |
Cervical, craniostenosis, helmet, non-molded to patient model |
415.05 |
|
L0110 |
Cervical, craniostenosis, helmet, non-molded |
124.70 |
|
L0120 |
Cervical, flexible, non-adjustable(from collar) |
17.47 |
|
L0130 |
Cervical, flexible, thermoplastic collar, molded to patient |
140.59 |
|
L0140 |
Cervical, semi-rigid, adjustable (plastic collars) |
56.41 |
|
L0150 |
Cervical, semi-rigid, adjustable molded chin cup (plastic collar with
mandibular/occipital piece) |
95.61 |
|
L0160 |
Cervical, semi-rigid, wire frame occipital/mandibular support |
118.46 |
|
L0170 |
Cervical, collar, molded to patient model |
520.33 |
|
L0172 |
Cervical, collar, semi-rigid thermoplastic foam, two pieces |
101.07 |
|
L0174 |
Cervical, collar, semi-rigid, thermoplastic form, two piece with
thoracic extension |
177.43 |
|
L0180 |
Cervical, multiple post collar, occipital/mandibular supports,
adjustable |
269.35 |
|
L0190 |
Cervical, multiple post collar, occipital/mandibular supports,
adjustable cervical bars (Somi, Guilford, Taylor types) |
339.68 |
|
L0200 |
Cervical, multiple post collar, occipital/mandibular supports,
adjustable cervical bars, and thoracic extension |
339.15 |
|
B |
THORACIC AND THORACIC-LUMBAR-SACRAL |
|
|
A |
THORACIC |
|
|
L0210 |
Thoracic, rib belt, custom fitted |
32.95 |
|
L0220 |
Thoracic, rib belt, custom fabricated |
77.44 |
|
B |
THORACIC-LUMBAR-SACRAL |
|
|
L0300 |
Thoracic-Lumbar-Sacral Orthosis (TLSO), flexible (dorso-lumbar surgical
support), custom fitted |
138.83 |
|
L0310 |
Thoracic-Lumbar-Sacral Orthosis (TLSO), flexible dorso surgical
support) custom fabricated |
218.01 |
|
L0315 |
Thoracic-Lumbar-Sacral Orthosis (TLSO), flexible dorso surgical
support, elastic type, with rigid posterior panel |
172.49 |
|
L0317 |
Thoracic-Lumbar-Sacral Orthosis (TLSO), flexible dorso-lumbar surgical
support hyperextension, elastic type, with rigid posterior panel |
273.70 |
|
L0320 |
Thoracic-Lumbar-Sacral Orthosis (TLSO), anterior-posterior control
Taylor type, with apron front |
246.15 |
|
L0330 |
Thoracic-Lumbar-Sacral Orthosis (TLSO), anterior-posterior-lateral
control (Knight-Taylor design) with apron front |
350.38 |
|
L0340 |
Thoracic-Lumbar-Sacral Orthosis (TLSO),
anterior-posterior-lateral-rotary control (Arnold, Magnuson, Steindler
types) with apron front |
527.38 |
|
L0350 |
Thoracic-Lumbar-Sacral Orthosis(TLSO),
anterior-posterior-lateral-rotary control, flexion compression jacket,
custom fitted |
780.34 |
|
L0360 |
Thoracic-Lumbar-Sacral Orthosis (TLSO),
anterior-posterior-lateral-rotary control, flexion compression jacket
molded to patient model |
994.32 |
|
L0370 |
Thoracic-Lumbar-Sacral Orthosis (TLSO),
anterior-posterior-lateral-rotary control, hyperextension (Jewett, Lennox,
Baker, Cash types |
270.76 |
|
L0380 |
Thoracic-Lumbar-Sacral Orthosis (TLSO),
anterior-posterior-lateral-rotary control with extensions |
455.07 |
|
L0390 |
Thoracic-Lumbar-Sacral Orthosis (TLSO), anterior-posterior-lateral
control (body jacket) molded to patient model |
933.40 |
|
L0400 |
Thoracic-Lumbar-Sacral Orthosis (TLSO), anterior-posterior-lateral
control (body jacket) molded to patient model, with interface material |
1,169.20 |
|
L0410 |
Thoracic-Lumbar-Sacral Orthosis (TLSO), anterior-posterior-lateral
control (body jacket), two piece construction, molded to patient model |
1,223.93 |
|
L0420 |
Thoracic-Lumbar-Sacral Orthosis (TLSO), two piece construction, molded
to patient model, with interface material |
1,227.69 |
|
L0430 |
Thoracic-Lumbar-Sacral Orthosis (TLSO), anterior-posterior-lateral
control (body jacket), with interface material custom fitted |
982.75 |
|
L0440 |
Thoracic-Lumbar-Sacral Orthosis (TLSO), anterior-posterior-lateral
control (body Jacket), with overlapping front section, spring steel front,
custom fitted |
795.39 |
|
C |
LUMBAR-SACRAL (LSO) |
|
|
L0500 |
Lumbar-Sacral Orthosis (LSO), flexible (Lumb0-sacral surgical support),
custom fitted |
91.18 |
|
L0510 |
Lumbar-Sacral Orthosis (LSO), flexible (Lumbar-sacral surgical
support), custom fabricated |
196.02 |
|
L0515 |
Lumbar-Sacral-Orthosis (LSO), flexible (lumbar-sacral surgical
support), elastic type, with rigid posterior panel |
118.82 |
|
L0520 |
Lumbar-Sacral Orthosis (LSO), anterior-posterior-lateral control
(Knight, Wilcox types), with apron front |
306.86 |
|
L0530 |
Lumbar-Sacral Orthosis (LSO), anterior-posterior control (Macausland
type), with apron front |
267.51 |
|
L0540 |
Lumbar-Sacral Orthosis (LSO), lumbar flexion(Williams flexion type)
anterior-posterior-lateral control (body jacket) |
314.74 |
|
L0550 |
Lumbar-Sacral Orthosis (LSO), anterior-posterior-lateral control (body
jacket), molded to patient model |
881.74 |
|
L0560 |
Lumbar-Sacral Orthosis (LSO), anterior-posterior-lateral control (body
jacket), molded to patient model, with interface material |
947.61 |
|
L0565 |
Lumbar-Sacral Orthosis (LSO), anterior-posterior-lateral control (body
jacket), custom fitted |
965.11 |
|
C |
OTHER SPINAL ORTHOSES |
|
|
A |
FLEXIBLE SACROILIAC |
|
|
L0600 |
Sacroiliac, Flexible (sacroiliac surgical support, custom fitted |
82.66 |
|
L0610 |
Sacroiliac, flexible (sacroiliac surgical support), custom fabricated |
169.79 |
|
L0620 |
Sacroiliac, Semi-rigid (Goldthawaite, Osgood types), with apron front |
274.75 |
|
B |
CERVICAL-THORACIC-LUMBAR-SACRAL |
|
|
L0700 |
Cervical-Thoracic-Lumbar-Sacral Orthosis CTLSO),
anterior-posterior-lateral control, molded to patient model, (Minerva
type) |
1,323.25 |
|
L0710 |
Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLSO),
anterior-posterior-lateral control, molded to patient model, with
interface material (Minerva type) |
1,427.17 |
|
C |
HALO PROCEDURE |
|
|
L0810 |
Halo procedure, cervical halo incorporated into jacket vest |
1,781.49 |
|
L0820 |
Halo procedure, cervical halo incorporated into plaster body jacket |
1,417.47 |
|
L0830 |
Halo procedures, cervical halo incorporated into Milwaukee type
orthosis |
2,084.10 |
|
L0860 |
Addition to HALO procedure, magnet reasonance image compatible system |
819.82 |
|
D |
TORSO SUPPORTS |
|
|
L0900 |
Torso support, PTOSIS support, custom fitted |
117.18 |
|
L0910 |
Torso support, PTOSIS support, custom fabricated |
220.45 |
|
L0920 |
Torso support, pedulous abdomen support, custom fitted |
122.00 |
|
L0930 |
Torso support, pedulous abdomen support, custom fabricated |
246.04 |
|
L0940 |
Torso support, post surgical support, custom fitted |
101.33 |
|
L050 |
Torso support, post surgical support, custom fabricated |
277.77 |
|
L0960 |
Torso support, post surgical support, pads for post surgical support |
59.93 |
|
E |
ADDITIONS TO SPINAL ORTHOSES |
|
|
L0970 |
Thoracic-Lumbar-Sacral Orthosis (TLSO), corset front |
74.70 |
|
L0972 |
Lumbar-Sacral Orthosis (LSO), corset front |
67.44 |
|
L0974 |
Thoracic-Lumbar-Sacral Orthosis (TLSO), full corset |
133.8 |
|
L0976 |
Lumbar Sacral Orthosis (LSO), full corset |
112.86 |
|
L0978 |
Axillary crutch extension |
125.66 |
|
L0980 |
Peroneal straps, pair |
11.72 |
|
L0982 |
Stocking supporter grips, set of four (4) |
13.69 |
|
D |
SCOLIOSIS PROCEDURES |
|
|
A |
CERVICAL-THORACIC-LUMBAR-SACRAL |
|
|
L1000 |
Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLSO) (Milwaukee), inclusive
of furnishing initial orthosis, including model |
1,328.37 |
|
L1010 |
Addition to Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLSO) or
Scoliosis Orthosis, axilla sling |
44.88 |
|
L1020 |
Addition to Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLSO)or
Scoliosis Orthosis, kyphosis pad |
69.33 |
|
L1025 |
Addition to Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLSO or
Scoliosis Orthosis, kyphosis pad, floating |
83.72 |
|
L1030 |
Addition to Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLSO) or
Scoliosis Orthosis, lumbar bolster pad |
52.71 |
|
L1040 |
Addition to Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLSO) or
Scoliosis Orthosis, lumbar or lumbar rib pad |
52.48 |
|
L1050 |
Addition to Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLS)) or
Scoliosis Orthosis, sternal pad |
61.74 |
|
L1060 |
Addition to Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLSO) or
Scoliosis Orthosis, thoracic pad |
73.66 |
|
L1070 |
Addition to Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLSO) or
Scoliosis Orthosis, trapezius sling |
74.39 |
|
L1080 |
Addition to Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLS)) or
Scoliosis Orthosis, outrigger |
42.43 |
|
L1085 |
Addition to Cervical -Thoracic-Lumbar-Sacral Orthosis (CTLSO) or
Scoliosis Orthosis, outrigger, bilateral with vertical extension |
126.87 |
|
L1090 |
Addition to Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLSO) or
Scoliosis Orthosis, lumbar sling |
60.53 |
|
L1100 |
Addition to cervical-Thoracic-Lumbar-Sacral Orthosis (CTLSO) or
Scoliosis Orthosis, ring flange, plastic or leather |
113.11 |
|
L1110 |
Addition to Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLSO) or
Scoliosis Orthosis, ring flange, plastic or leather, molded to patient
model |
196.34 |
|
L1120 |
Addition to Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLSO) or
Scoliosis Orthosis, cover for upright each |
31.37 |
|
B |
THORACIC-LUMBAR-SACRAL |
|
|
L1200 |
Thoracic-Lumbar-Sacral Orthosis (TLSO) inclusive of furnishing initial
orthosis only |
1,101.43 |
|
L1210 |
Addition to Addition to Thoracic-Lumbar-Sacral Orthosis (TLSO), (low
profile) lateral thoracic extension |
180.44 |
|
L1220 |
Addition to Thoracic-Lumbar-Sacral Orthosis (TLSO), (low profile),
anterior thoracic extension |
145.24 |
|
L1230 |
Addition to Thoracic-Lumbar-Sacral Orthosis (TLSO), (low profile),
Milwaukee type superstructure |
366.42 |
|
L1240 |
Addition to Thoracic-Lumbar-Sacral Orthosis (TLSO), (low-Profile),
lumbar derotation pad |
64.61 |
|
L1250 |
Addition to Thoracic-Lumbar-Sacral Orthosis (TLSO), (low profile),
anterior ASIS pad |
61.71 |
|
L1260 |
Addition to Thoracic-Lumbar-Sacral Orthosis (TLSO), (low profile),
anterior thoracic derotation pad |
64.75 |
|
L1270 |
Addition to Thoracic-Lumbar-Sacral Orthosis (TLSO), (low profile),
abdominal pad |
64.72 |
|
L1280 |
Addition to Thoracic-Lumbar-Sacral Orthosis (TLSO), (low profile), rib
gusset (elastic) each |
58.69 |
|
L1290 |
Addition to Thoracic-Lumbar-Sacral Orthosis (TLSO), (low profile),
lateral trochanteric pad |
65.07 |
|
C |
OTHER SCOLIOSIS PROCEDURES |
|
|
L1300 |
Other scoliosis procedures, body jacket molded to patient model |
1,083.08 |
|
L1310 |
Other scoliosis procedures, post-operative body jacket |
1,118.02 |
|
L1499 |
Unlisted procedure for spinal orthosis
(BY REPORT PROCEDURE) |
By Report |
|
E |
LOWER LIMB: HIP, LEG PERTHE, AND KNEE |
|
|
A |
THORACIC-HIP-KNEE-ANKLE |
|
|
L1500 |
Thoracic-Hip-Knee-Angle Orthosis (THKAO), mobility frame (Newington,
Parapodium types) |
1,243.33 |
|
L1510 |
Thoracic-Hip-Knee-Angle Orthosis (THKAO), standing frame |
784.14 |
|
L1520 |
Thoracic-Hip-Knee-Angle Orthosis (THKAO), swivel walker |
1,833.17 |
|
B |
HIP |
|
|
L1600 |
Hip Orthosis (HO), abduction control of hip joints, flexible, Frejka
type with cover |
81.97 |
|
L1610 |
Hip Orthosis (HO), abduction control of hip joints,, flexible, Frejka
cover only |
30.33 |
|
L1620 |
Hip Orthosis (HO), abduction control of hip joints, flexible, Pavlik
harness |
88.07 |
|
L1630 |
Hip Orthosis (HO), abduction control of hip joints, semi-flexible (Von
Rossen type) |
111.31 |
|
L1640 |
Hip Orthosis (HO), abduction control of hip joints, static, pelvic band
or spreader bar, thigh cuffs |
296.93 |
|
L1650 |
Hip Orthosis (HO), abduction control of hip joints, static adjustable
custom fitted (Ilfled type) |
152.26 |
|
L1660 |
Hip Orthosis (HO), abduction control of hip joints, static, plastic,
custom fitted |
109.70 |
|
L1680 |
Hip Orthosis (HO), abduction control of hip joints, dynamic, pelvic
control, adjustable hip motion control, thigh cuffs (Rancho hip action
type) |
963.26 |
|
L1685 |
Hip Orthosis (HO), abduction control of hip joint, post-operative hip
abduction type, custom fabricated |
997.73 |
|
L1686 |
Hip Orthosis (HO), abduction control of hip joint, post-operative hip
abduction type, custom fitted |
615.71 |
|
C |
LOWER LIMB-LEGG PERTHES |
|
|
L1700 |
Legg Perthes Orthosis, Toronto type |
1,150.81 |
|
L1710 |
Legg Perthes Orthosis, Newington type |
1,283.20 |
|
L1720 |
Legg Perthes Orthosis, trilateral, (Tachdijan type) |
999.63 |
|
L1730 |
Legg Perthes Orthosis, Scottish rite type |
816.71 |
|
L1750 |
Legg Perthes Orthosis, Legg perthes sling (Sam Brown type) |
127.42 |
|
L1755 |
Legg Perthes Orthosis, patten bottom type |
1,161.28 |
|
D |
KNEE (KO) |
|
|
L1800 |
Knee Orthosis (KO), elastic with stays |
55.57 |
|
L1810 |
Knee Orthosis (KO) elastic with joints |
72.60 |
|
L1815 |
Knee Orthosis (KO), elastic with condylar pads |
84.25 |
|
L1820 |
Knee Orthosis (KO), elastic with condyle pads and joints |
91.25 |
|
L1825 |
Knee Orthosis (KO), elastic knee cap |
35.78 |
|
L1830 |
Knee Orthosis (KO), immobilizer, canvas longitudinal |
70.14 |
|
L1832 |
Knee Orthosis (KO), adjustable knee joints, positional orthosis, rigid
support, custom fitted |
516.66 |
|
L1834 |
Knee Orthosis (KO), without knee joint, rigid, molded to patient model |
599,06 |
|
L1840 |
Knee Orthosis (KO), derotation, medial-lateral, anterior cruciate
ligament, custom fabricated to patient model |
614.80 |
|
L1845 |
Knee Orthosis (KO), double upright, thigh and calf, with adjustable
flexion and extension joint, medial-lateral and rotation control, custom
fitted |
620.00 |
|
L1846 |
Knee Orthosis (KO), double upright, thigh and calf, with adjustable
flexion and extension joint, medial-lateral and rotation control, molded
to patient model |
739.81 |
|
L1850 |
Knee Orthosis (KO), Swedish type |
187.26 |
|
L1855 |
Knee Orthosis (KO), molded plastic, thigh and calf sections, with
double upright knee joints, molded to patient model |
800.14 |
|
L1858 |
Knee Orthosis (KO), molded plastic, polycentric knee joints, pneumatic
knee pads (CTI) |
866.07 |
|
L1860 |
Knee Orthosis (KO), modification of supracondylar prosthetic socket
molded to patient model (SK) |
771.82 |
|
L1870 |
Knee Orthosis (KO), double upright, thigh and calf lacers, molded to
patient model with knee joints |
687.45 |
|
L1880 |
Knee Orthosis (KO), double upright, non-molded thigh and calf cuss
cuffs/lacers with knee joints |
471.95 |
|
F |
LOWER LIMB: ANKLE FOOT (AFO) |
|
|
L1900 |
Ankle-Foot Orthosis (AFO), spring wire, dorsiflexion assist calf band |
196.77 |
|
L1902 |
Ankle-Foot Orthosis (AFO), ankle gauntlet |
51.82 |
|
L1904 |
Ankle-Foot Orthosis (AFO), molded ankle gauntlet molded to patient
model |
313.18 |
|
L1906 |
Ankle-Foot Orthosis (AFO), multiligamentus ankle support |
80.08 |
|
L1910 |
Ankle-Foot Orthosis (AFO), posterior, single bar, clasp attachment, to
shoe counter |
190.66 |
|
L1920 |
Ankle-Foot Orthosis (AFO), single upright with static or adjustable
(Phelps or Perlstein type) |
234.65 |
|
L1930 |
Ankle-Foot Orthosis (AFO), custom fitted, plastic |
156.80 |
|
L1940 |
Ankle-Foot Orthosis (AFO), molded to patient model, plastic |
358.10 |
|
L1945 |
Ankle-Foot Orthosis (AFO), molded to patient model, plastic, rigid
anterior tibial section (floor reaction) |
601.54 |
|
L1950 |
Ankle-Foot Orthosis (AFO), spiral, molded to patient model (Irm type),
plastic |
498.01 |
|
L1960 |
Ankle-Foot Orthosis (AFO), posterior solid ankle, molded to patient
model, plastic |
377.63 |
|
L1970 |
Ankle-Foot Orthosis (AFO), plastic molded to patient model, with ankle
joint |
489.42 |
|
L1980 |
Ankle-Foot Orthosis (AFO), single upright free plantar dorsiflexion,
solid stirrup, calf band/cuff (single bar "BK" orthosis) |
240.61 |
|
L1990 |
Ankle-Foot Orthosis (AFO), double upright free plantar dorsiflexion,
solid stirrup, calf band/cuff (double bar "BK" orthosis |
319.59 |
|
G |
HIP KNEE ANGLE FOOT |
|
|
A |
KNEE-ANKLE-FOOT |
|
|
L2000 |
Knee-Ankle-Foot Orthosis (KAFO), single upright free knee, free ankle,
solid stirrup, thigh and calf bands/cuffs (single bar "AK"
orthosis |
654.57 |
|
L2010 |
Knee-Ankle-Foot Orthosis (KAFO), single upright, free knee, free ankle,
solid stirrup, thigh and calf bands/cuffs (single bar "AK"
orthosis) without knee joint |
597.61 |
|
L2020 |
Knee-Ankle-Foot Orthosis (KAFO), double upright, free knee, free ankle,
solid stirrup, thigh and calf bands/cuffs (double bar "AK"
orthosis) |
754.91 |
|
L2030 |
Knee-Ankle-Foot Orthosis (KAFO), double upright, free ankle, solid
stirrup, thigh and calf bands/cuffs, (double bar "AK" orthosis),
without knee joint |
665.13 |
|
L2036 |
Knee-Ankle-Foot Orthosis (KAFO), full plastic, double upright, free
knee, molded to patient model |
1,189.17 |
|
L2037 |
Knee-Ankle-Foot Orthosis (KAFO, full plastic, single upright, free
knee, molded to patient model |
1,078.23 |
|
L2038 |
Knee-Angle-Foot Orthosis (KAFO), full plastic, without knee joint,
multi-axis angle, molded to patient model (Lively orthosis or equal) |
939.78 |
|
B |
HIP-KNEE-ANKLE-FOOT |
|
|
L2040 |
Hip-Knee-Ankle-Foot Orthosis (HKAFO), torsion control, bilateral
rotation straps, pelvic band/belt |
114.30 |
|
L2050 |
Hip-Knee-Ankle-Foot Orthosis (HKAFO), torsion control, bilateral
torsion cables, hip joint, pelvic band/belt |
348.54 |
|
L2060 |
Hip-Knee-Ankle Foot Orthosis (HKAFO), torsion control, bilateral
torsion cables, ball bearing hip joint, pelvic band/belt |
401.00 |
|
L2080 |
Hip-Knee-Ankle-Foot Orthosis (HKAFO), torsion control, unilateral
torsion cable, hip joint pelvic band/belt |
265.38 |
|
L2090 |
Hip-Knee-Ankle-Foot Orthosis (HKAFO), torsion control, unilateral
torsion cable, ball bearing hip joint, pelvic band/belt |
330.29 |
|
H |
LOWER LIMB FRACTURE ORTHOSIS AND ADDITIONS |
|
|
L2102 |
Ankle-Foot Orthosis (AFO), fracture Orthosis, tibial fracture cast
orthosis, plaster type casting material, molded to patient |
354.96 |
|
L2104 |
Ankle-Foot Orthosis (AFO), fracture orthosis, tibial fracture cast
orthosis synthetic type casting material, molded to patient |
327.12 |
|
L2106 |
Ankle-Foot Orthosis (AFO), fracture orthosis, tibial fracture cast
orthosis, thermoplastic type casting material, molded to patient |
437.27 |
|
L2108 |
Ankle-Foot Orthosis (AFO), fracture orthosis, tibial fracture cast
orthosis, molded to patient model |
692.07 |
|
L2112 |
Ankle-Foot Orthosis (AFO), fracture orthosis, tibial fracture orthosis
soft custom fitted |
299.87 |
|
L2114 |
Ankle-Foot Orthosis (AFO), fracture orthosis tibial fracture orthosis,
semi-rigid custom fitted |
374.74 |
|
L2116 |
Ankle-Foot Orthosis (AFO), fracture orthosis, tibial fracture orthosis,
rigid custom fitted |
474.01 |
|
L2122 |
Knee-Ankle-Foot Orthosis (KAFO), fracture orthosis, femoral fracture
cast orthosis, plaster type casting material, molded to patient |
596.71 |
|
L2124 |
Knee-Ankle-Foot Orthosis (KAFO), fracture orthosis, femoral fracture
cast orthosis, synthetic type casting material, molded to patient |
624.36 |
|
L2126 |
Knee-Ankle-Foot Orthosis (KAFO), fracture orthosis, femoral fracture
cast orthosis, thermoplastic type casting, molded to patient |
881.18 |
|
L2128 |
Knee-Ankle-Foot Orthosis (KAFO), fracture orthosis, femoral fracture
cast orthosis, molded to patient model |
1,094.42 |
|
L2132 |
Knee-Ankle-Foot Orthosis (KAFO), fracture orthosis, femoral fracture
cast orthosis, soft custom fitted |
523.66 |
|
L2134 |
Knee-Ankle-Foot Orthosis (KAFO), fracture orthosis, femoral fracture
cast orthosis, semi-rigid custom fitted |
621.93 |
|
L2136 |
Knee-Ankle-Foot Orthosis (KAFO), fracture orthosis, femoral fracture
cast orthosis, rigid custom fitted |
764.27 |
|
L2180 |
Addition to lower extremity fracture orthosis, plastic shoe insert with
ankle joints |
78.04 |
|
L2182 |
Addition to lower extremity fracture orthosis, drop knee joint |
60.62 |
|
L2184 |
Addition to lower extremity fracture orthosis, limited motion knee
joint |
109.14 |
|
L2186 |
Addition to lower extremity fracture orthosis, adjustable motion knee
joint, lerman type |
132.71 |
|
L2188 |
Addition to lower extremity fracture orthosis, quadrilateral brim |
255.23 |
|
L2190 |
Addition to lower extremity fracture orthosis, waist belt |
69.46 |
|
L2192 |
Addition to lower extremity fracture orthosis, hip joint, pelvic band,
thigh flange, and pelvic belt |
252.24 |
|
I |
LOWER LIMB ADDITIONS |
|
|
A |
SHOE-ANKLE-SHIN |
|
|
L2200 |
Addition to lower extremity, limited ankle motion, each joint |
30.80 |
|
L2210 |
Addition to lower extremity, dorsiflexion assist (plantar flexion
resist), each joint |
42.70 |
|
L2220 |
Addition to lower extremity, dorsiflexion and plantar flexion
assist/resist, each joint |
52.42 |
|
L2230 |
Addition to lower extremity, spit flat caliper stirrups and plate
attachment |
49.95 |
|
L2240 |
Addition to lower extremity, round caliper and plate attachment |
54.10 |
|
L2250 |
Addition to lower extremity, foot plate, molded to patient model,
stirrup attachment |
231.77 |
|
L2260 |
Additions to lower extremity, reinforced solid stirrup (Scott-Craig
type) |
127.38 |
|
L2265 |
Addition to lower extremity, long tongue stirrup |
78.57 |
|
L2270 |
Additions to lower extremity, varus/valgus correction ("T")
strap, padded/lined or malleolus pad |
34.75 |
|
L2280 |
Additions to lower extremity, molded inner bot |
291.95 |
|
L2300 |
Additions to lower extremity, abduction bar (bilateral hip
involvement), jointed, adjustable |
179.47 |
|
L2310 |
Additions to lower extremity, abduction bar-straight |
77.71 |
|
L2320 |
Additions to lower extremity, non-molded lacer |
138.05 |
|
L2330 |
Additions to lower extremity, lacer molded to patient model |
253.14 |
|
L2335 |
Addition to lower extremity, anterior swing band |
173.61 |
|
L2340 |
Addition to lower extremity, pre-tibial shell, molded to patient model |
381.53 |
|
L2350 |
Addition to lower extremity, prosthetic type, (BK) socket, molded to
patient model, (used for 'PTB' 'AFO' orthoses) |
581.67 |
|
L2360 |
Addition to lower extremity, extended steel shank |
33.69 |
|
L2370 |
Addition to lower extremity, patten bottom |
167.25 |
|
L2375 |
Addition to lower extremity, torsion control, ankle joint and half
solid stirrup |
72.58 |
|
L2380 |
Addition to lower extremity, torsion control, straight knee joint, each
joint |
98.48 |
|
L2385 |
Addition to lower extremity, straight knee joint, heavy duty, each
joint |
89.70 |
|
L2390 |
Addition to lower extremity, offset knee joint, each joint |
70.93 |
|
L2395 |
Addition to lower extremity, offset knee joint, heavy duty, each joint |
119.23 |
|
B |
KNEE |
|
|
L2405 |
Addition to knee joint, drop lock, each joint |
43.07 |
|
L2415 |
Addition to knee joint, cam lock (Swiss, French, Bail types), each
joint |
141.37 |
|
L2425 |
Addition to knee joint, disc or dial lock for adjustable knee flexion,
each joint |
119.74 |
|
L2435 |
Addition to knee joint, polycentric joint, each joint |
108.03 |
|
L2492 |
Addition to knee joint, lift loop for drop lock ring |
65.89 |
|
C |
THIGH/WEIGHT BEARING |
|
|
L2500 |
Addition to lower extremity, thigh/weight bearing, gluteal/ischial
weight bearing, ring |
203.68 |
|
L2510 |
Addition to lower extremity, thigh/weight bearing, , quadrilateral
brim, molded to patient model |
476.91 |
|
L2520 |
Addition to lower extremity, thigh/weight bearing, quadrilateral brim,
custom fitted |
301.21 |
|
L2525 |
Addition to lower extremity, thigh/weight bearing, ischial
containment/narrow M-L brim molded to patient model |
1,075.93 |
|
L2526 |
Addition to lower extremity, thigh/weight bearing, ischial
containment/narrow M-L, custom fitted |
536.11 |
|
L2530 |
Addition to lower extremity, thigh/weight bearing, lacer, non-molded |
155.87 |
|
L2540 |
Addition to lower extremity, thigh/weight bearing, Lacer molded to
patient model |
278.88 |
|
L2550 |
Addition to lower extremity, thigh/weight bearing, high roll cuff |
191.73 |
|
D |
PELVIC AND THORACIC CONTROL |
|
|
L2570 |
Addition to lower extremity, pelvic control, hip joint, Clevis type two
position joint, each |
332.71 |
|
L2580 |
Addition to lower extremity, pelvic control, pelvic sling |
323.34 |
|
L2600 |
Addition to lower extremity, pelvic control, hip joint, Clevis type, or
thrust bearing, free, each |
131.92 |
|
L2610 |
Addition to lower extremity, pelvic control, hip joint, Clevis or
thrust bearing, lock each |
157.50 |
|
L2620 |
Addition to lower extremity, pelvic control, hip joint, heavy duty,
each |
173.44 |
|
L2622 |
Addition to lower extremity, pelvic control, hip joint, adjustable
flexion each |
198.65 |
|
L2624 |
Addition to lower extremity, pelvic control, hip joint adjustable
flexion, extension, abduction control, each |
249.30 |
|
L2627 |
Addition to lower extremity, pelvic control, plastic, molded to patient
model, reciprocating High joint and cables |
1,146.99 |
|
L2628 |
Addition to lower extremity, pelvic control, metal frame, reciprocating
hip joint and cables |
1,138.79 |
|
L2630 |
Addition to lower extremity, pelvic control, band and belt, unilateral |
163.42 |
|
L2640 |
Addition to lower extremity, pelvic control, band and belt, bilateral |
218.64 |
|
L2650 |
Addition to lower extremity, pelvic and thoracic control, gluteal pad,
each |
78.57 |
|
L2660 |
Addition to lower extremity, thoracic control, thoracic band |
116.31 |
|
L2670 |
Addition to lower extremity, thoracic control, paraspinal uprights |
108.83 |
|
L2680 |
Addition to lower extremity, thoracic control, lateral support uprights |
103.00 |
|
E |
ADDITIONS-GENERAL |
|
|
L2750 |
Addition to lower extremity orthosis, plating chrome or nickel, per bar |
58.12 |
|
L2760 |
Addition to lower extremity orthosis, extension, per extension, per bar
(for lineal adjustment for growth) |
39.25 |
|
L2770 |
Addition to lower extremity orthosis, stainless steel-per bar or joint |
40.07 |
|
L2780 |
Addition to lower extremity, non-corrosive finish, per bar |
44.05 |
|
L2785 |
Addition to lower extremity orthosis, drop lock retainer, each |
27.48 |
|
L2795 |
Addition to lower extremity orthosis, knee control, full kneecap |
55.47 |
|
L2800 |
Addition to lower extremity orthosis, knee control, knee cap, medial or
lateral pull |
69.88 |
|
L2810 |
Addition to lower extremity orthosis, knee control, condylar pad |
49.53 |
|
L2820 |
Addition to lower extremity orthosis, soft interface for molded
plastic, below-knee section |
56.32 |
|
L2830 |
Addition to lower extremity orthosis, soft interface for molded
plastic, above-knee section |
61.70 |
|
L2840 |
Addition to lower extremity orthosis, tibal length socks, fracture or
equal, each |
28.04 |
|
L2850 |
Addition to lower extremity orthosis, femoral length sock, fracture or
equal, each |
40.35 |
|
L2999 |
Unlisted procedures for lower extremity orthosis
(BY REPORT PROCEDURE) |
By Report |
|
J |
FOOT |
|
|
A |
INSERT, REMOVABLE, MOLDED TO PATIENT/PATIENT MODEL |
|
|
L3000 |
Foot, insert, removable, molded to patient model, "UCB" type,
Berkeley shell, each |
97.00 |
|
L3001 |
Foot, insert, removable, molded to patient model, Spenco, each |
80.00 |
|
L3002 |
Foot, insert, removable, molded to patient model, Plasazota or equal,
each |
34.00 |
|
L3003 |
Foot, insert, removable, molded to patient model, silicone gel, each |
124.00 |
|
L3010 |
Foot, insert, removable, molded to patient model, longitudinal arch
support, each |
80.00 |
|
L3020 |
Foot, insert, removable, molded to patient model,
longitudinal/metatarsal support, each |
130.00 |
|
L3030 |
Foot, insert, removable, formed to patient foot, each |
93.00 |
|
B |
ARCH SUPPORT, REMOVABLE, PRE-MOLDED |
|
|
L3040 |
Foot, arch support, removable, pre-molded, longitudinal each |
31.00 |
|
L3050 |
Foot, arch support, removable, pre-molded, metatarsal, each |
31.00 |
|
L3060 |
Foot, arch support, removable, pre-molded, longitudinal/metatarsal,
each |
36.00 |
|
C |
ARCH SUPPORT, NON-REMOVABLE, ATTACHED TO SHOE |
|
|
L3070 |
Foot, arch support, non-removable attached to shoe, longitudinal, each |
12.00 |
|
L3080 |
Foot, arch support, non-removable attached to shoe, metatarsal, each |
12.00 |
|
L3090 |
Foot, arch support, non-removable attached to shoe,
longitudinal/metatarsal, each |
14.00 |
|
L3100 |
Hallus-valgus night dynamic splint |
25.00 |
|
D |
ABDUCTION AND ROTATION BARS |
|
|
L3140 |
Foot, abduction rotation bars (Dennis Browne type), attached to shoe |
62.00 |
|
L3150 |
Foot, abduction rotation bars (Denis Browne type), clamped to shoe |
62.00 |
|
L3170 |
Foot-plastic heel stabilizer |
19.00 |
|
K |
ORTHOPEDIC FOOTWEAR |
|
|
L3215 |
Orthopedic footwear, Ladies shoes, Oxford, pair |
75.99 |
|
L3216 |
Orthopedic footwear, Ladies shoes, depth inlay, pair |
140.00 |
|
L3217 |
Orthopedic footwear, Ladies shoes, hightop depth inlay, pair |
143.00 |
|
L3218 |
Orthopedic footwear, Ladies surgical boot, each |
60.00 |
|
L3219 |
Orthopedic footwear, Mens shoes, oxford, pair |
88.44 |
|
L3221 |
Orthopedic footwear, Mens shoes, depth inlay, pair |
160.00 |
|
L3222 |
Orthopedic footwear, Mens shoes, hightop, depth, inlay pair |
94.00 |
|
L3223 |
Orthopedic footwear, Mens surgical boot, each |
101.00 |
|
L3230 |
Orthopedic footwear, custom shoes, depth inlay, pair |
200.00 |
|
L3250 |
Orthopedic footwear, custom molded shoe, removable inner mold,
prosthetic shoe, each |
189.00 |
|
E3251 |
Foot, shoe molded to patient model, silicone shoe, each |
82.00 |
|
L3252 |
Foot, shoe molded to patient model - Plastazote (or similar), custom
fabricated, each |
48.00 |
|
L3253 |
Foot, molded shoe Plastozote (or similar) custom fitted each |
149.00 |
|
L3254 |
Non-standard size or width |
43.00 |
|
L3255 |
Non-standard size or length |
43.00 |
|
L3257 |
Orthopedic footwear, additional charge for split size |
96.00 |
|
L3260 |
Ambulatory surgical boot, each |
22.00 |
|
L3265 |
Plastazote sandal, each |
25.00 |
|
L |
SHOE MODIFICATIONS |
|
|
A. |
LIFTS |
|
|
L3310 |
Lift, elevation, heel and sole, neoprene
(USE LLL3311-L3316) |
|
|
L3311 |
Lift, elevation, heel and sole, neoprene, 0" to 5/8" |
39.00 |
|
L3312 |
Lift, elevation, heel and sole, neoprene, 3/4" to 1 1/2" |
61.00 |
|
L3313 |
Lift, elevation, heel and sole, neoprene, 1 5/8" to 2" |
66.00 |
|
L3314 |
Lift, elevation, heel and sole, neoprene, 2 1/8" to 2 5/8" |
76.00 |
|
L3315 |
Lift, elevation, heel and sole, neoprene, 2 3/4" to 3 1/4" |
93.00 |
|
L3316 |
Lift, elevation, heel and sole, neoprene, Over 3 1/4", add to
above |
69.00 |
|
L3320 |
Lift, elevation, heel and sole, cork, (USE L3221-L3326) |
|
|
L3321 |
Lift, elevation, heel and sole, cork, 0" to 5/8" |
114.00 |
|
L3322 |
Lift, elevation, heel and sole, cork, 3/4" to 1 1/2" |
136.00 |
|
L3323 |
Lift, elevation, heel and sole, cork, 1 5/8" to 2" |
141.00 |
|
L3324 |
Lift, elevation, heel and sole, cork 2 1/8" to 2 5/8" |
151.00 |
|
L3325 |
Lift, elevation, heel and sole, cork, 2 3/4" to 3 1/4" |
168.00 |
|
L3326 |
Over 3 1/4", add to above |
75.00 |
|
L3330 |
Lift, elevation, metal extension, "skate"
(BY REPORT PROCEDURE) |
By report |
|
B |
WEDGES |
|
|
L3340 |
Heel wedge, Sach |
37.00 |
|
L3350 |
Heel wedge |
7.00 |
|
L3360 |
Sole wedge, outside sole |
10.00 |
|
L3370 |
Sole wedge, between sole |
13.00 |
|
L3380 |
Clubfoot wedge |
13.00 |
|
L3390 |
Outflare wedge |
10.00 |
|
L3400 |
Metatarsal bar wedge, rocker |
19.00 |
|
L3410 |
Metatarsal bar wedge, between sole |
30.00 |
|
L3420 |
Full sole and heel wedge "between sole" |
23.00 |
|
C |
HEELS |
|
|
L3430 |
Heel, counter, plastic reinforced |
21.00 |
|
L3440 |
Heel, counter, leather reinforced |
21.00 |
|
L3450 |
Heel, sach cushion type |
15.00 |
|
L3455 |
Heel, new leather, standard |
6.00 |
|
L3460 |
Heel, new rubber, standard |
5.00 |
|
L3465 |
Heel, Thomas with wedge |
6.00 |
|
L3470 |
Heel, Thomas extended to ball |
15.00 |
|
L3480 |
Heel, pad and depression for spur |
11.00 |
|
L3485 |
Heel, pad, removable for spur |
11.00 |
|
D |
MISCELLANEOUS SHOE ADDITIONS |
|
|
L3500 |
Miscellaneous shoe addition, insole, leather |
9.00 |
|
L3510 |
Miscellaneous shoe addition, insole, rubber |
9.00 |
|
L3520 |
Miscellaneous shoe addition, insole, felt covered with leather |
9.00 |
|
L3530 |
Miscellaneous shoe addition, sole, half |
21.00 |
|
L3540 |
Miscellaneous shoe addition, sole, full |
16.00 |
|
L3550 |
Miscellaneous shoe addition, toe--tap, standard |
3.00 |
|
L3560 |
Miscellaneous shoe addition, toe-tap, horseshoe |
5.00 |
|
L3570 |
Miscellaneous shoe addition, special extension to instep (leather with
eyelets |
37.00 |
|
L3580 |
Miscellaneous shoe addition covert instep to Velcro closure |
24.00 |
|
L3590 |
Miscellaneous shoe addition, covert firm shoe counter to soft counter |
35.00 |
|
L3595 |
Miscellaneous shoe addition, march bar |
13.00 |
|
M |
TRANSFERS |
|
|
L3600 |
Transfers of an orthosis from one she to another, caliper plate
existing |
24.00 |
|
L3610 |
Transfers of an orthosis from one shoe to another, caliper plate new |
55.00 |
|
L3620 |
Transfer of an orthosis from one shoe to another, solid stirrup,
existing |
29.00 |
|
L3630 |
Transfer of an orthosis from one shoe to another, solid stirrup, new |
55.00 |
|
L3640 |
Transfer of an orthosis from one shoe to another, Dennis Browne splint
(Riveton), both shoes |
22.00 |
|
L3649 |
Unlisted procedures for foot orthopedic shoes, shoe modifications and
transfers
(BY REPORT PROCEDURE) |
By Report |
|
N |
UPPER LIMB: SHOULDER |
|
|
L3650 |
Shoulder Orthosis (SO), figure of "8" design abduction
restrainer |
45.16 |
|
L3660 |
Shoulder Orthosis (SO), figure of "8" design abduction
restrainer |
68.68 |
|
L3670 |
Shoulder Orthosis (SO), acromio/clavicalar (canvas and webbing type) |
72.68 |
|
O |
UPPER LIMB: ELBOW |
|
|
L3700 |
Elbow Orthosis (EO), elastic with stays |
43.87 |
|
L3710 |
Elbow Orthosis (EO), elastic with metal joints |
95.08 |
|
L3720 |
Elbow Orthosis (EO), double upright with forearm/arm cuffs, free motion |
478.74 |
|
L3730 |
Elbow Orthosis (EO), double upright with forearm/arm cuffs,
extension/flexion assistant |
580.80 |
|
L3740 |
Elbow Orthosis (EO), double upright with forearm/arm cuffs, adjustable
position lock with active control |
676.38 |
|
P |
WRIST-HAND-FINGER |
|
|
A |
WRIST-HAND-FINGER |
|
|
L3800 |
Wrist-Hand-Finger Orthosis (WHFO), short opponens, no attachments |
124.28 |
|
L3805 |
Wrist-Hand-Finger Orthosis (WHFO), short opponens, no attachments |
201.36 |
|
L3810 |
Wrist-Hand-Finger Orthosis (WHFO), addition to short and long opponens,
thumb abduction ("C") bar |
41.83 |
|
L3815 |
Wrist-Hand-Finger Orthosis (WHFO), addition to short and long opponens,
second M.P. abduction assist |
40.98 |
|
L3820 |
Wrist-Hand-Finger Orthosis (WHFO), addition to short and long opponens,
I.P. extension assist with M.O. extension stop |
73.94 |
|
L3825 |
Wrist-Hand-Finger Orthosis (WHFO), addition to short and long opponens,
M.P. extension stop |
46.72 |
|
L3830 |
Wrist-Hand-Finger Orthosis (WHFO), addition to short and long opponens,
M.P. extension assist |
55.06 |
|
L3835 |
Wrist-Hand-Finger Orthosis (WHFO), addition to short and long opponens,
M.P. spring extension assist |
58.83 |
|
L3840 |
Wrist-Hand-Finger Orthosis (WHFO), addition to short and long opponens,
spring swivel thumb |
41.65 |
|
L3845 |
Wrist-Hand-Finger Orthosis (WHFO), addition to short and long opponens,
thumb I.P. extension assist, with M.P. stop |
54.12 |
|
L3850 |
Wrist-Hand-Finger Orthosis (WHFO), addition to short and long opponens,
action wrist with dorsiflexion assist |
78.28 |
|
L3855 |
Wrist-Hand-Finger Orthosis (WHFO), addition to short and long opponens,
adjustable M.P. Flexion control |
97.60 |
|
L3860 |
Wrist-Hand-Finger Orthosis (WHFO), addition to short and long opponens,
adjustable M.P. flexion control and I.P. |
114.71 |
|
B |
FINGER FLEXION/EXTENSION |
|
|
L3900 |
Wrist-Hand-Finger Orthosis (WHFO), dynamic flexor hinge; reciprocal
wrist extension/flexion, finger flexion/extension, wrist or finer driven |
1,047.00 |
|
L3901 |
Wrist-Hand-Finger Orthosis (WHFO), dynamic flexor hinge; reciprocal
wrist extension/flexion, finger flexion/extension, cable driven external
power |
1,189.72 |
|
C |
EXTERNAL POWER |
|
|
L3902 |
Wrist-Hand-Finger Orthosis (WHFO), external powered, compressed gas |
1,765.16 |
|
L3904 |
Wrist-Hand-Finger Orthosis (WHFO), external powered, electric |
2,062.96 |
|
D |
OTHER WRIST-HAND-FINGER ORTHOSES |
|
|
L3906 |
Writs-Hand-Finger Orthosis (WHFO), molded to patient model |
253.80 |
|
L3907 |
Wrist-Hand-Finger Orthosis (WHFO), Wrist gauntlet with thumb spica,
molded to patient model |
392.35 |
|
L3908 |
Wrist-Hand-Finger Orthosis (WHFO), wrist extension control cock-up,
canvas or leather design, non-molded |
38.80 |
|
L3910 |
Wrist-Hand-Finger Orthosis (WHFO), Swanson design |
269.81 |
|
L3912 |
Wrist-Hand-Finger Orthosis (WHFO), flexion glove with elastic finger
control |
67.98 |
|
L3914 |
Wrist-Hand-Finger Orthosis (WHFO), wrist extension cock-up |
63.80 |
|
L3916 |
Wrist-Hand-Finger Orthosis (WHFO), wrist extension cock-up, with
outrigger |
89.40 |
|
L3918 |
Wrist-Hand-Finger Orthosis (WHFO), knuckle bender |
67.27 |
|
L3920 |
Wrist-Hand Finder Orthosis (WHFO), knuckle bender, with outrigger |
79.31 |
|
L3922 |
Wrist-Hand-Finger Orthosis (WHFO), knuckle bender, two segment to flex
joints |
84.72 |
|
L3924 |
Wrist-Hand-Finger Orthosis (WHFO), Oppenheimer |
92.02 |
|
L3926 |
Wrist-Hand-Finger Orthosis (WHFO), Thomas suspension |
80.12 |
|
L3928 |
Wrist-Hand-Finger Orthosis (WHFO), finger extension, with clock spring |
41.39 |
|
L3930 |
Wrist-Hand-Finger Orthosis (WHFO), finger extension, with wrist support |
53.91 |
|
L3932 |
Wrist-Hand-Finger Orthosis (WHFO), safety pin, spring wire |
38.82 |
|
L3934 |
Wrist-Hand-Finger Orthosis (WHFO), safety pin, modified |
36.53 |
|
L3936 |
Wrist-Hand-Finger Orthosis (WHFO), palmer |
76.63 |
|
L3938 |
Wrist-Hand-finger Orthosis (WHFO), dorsal wrist |
71.05 |
|
L3940 |
Wrist-Hand-Finger Orthosis (WHFO), dorsal, wrist, with outrigger
attachment |
84.26 |
|
L3942 |
Wrist Hand-Finger Orthosis (WHFO), reverse knuckle bender |
63.03 |
|
L3944 |
Wrist-Hand-Finger Orthosis (WHFO), reverse knuckle bender with
outrigger attachment |
84.69 |
|
L3946 |
Wrist-Hand-Finger Orthosis (WHFO), composite electric |
75.95 |
|
3948 |
Wrist-Hand-Finger Orthosis (WHFO), finger knuckle bender |
43.40 |
|
L3950 |
Wrist-Hand-Finger Orthosis (WHFO), combination Oppenheimer, with
knuckle bender and two attachments |
108.73 |
|
L3952 |
Wrist-Hand-Finger Orthosis (WHFO), combination Oppenheimer, with
reverse knuckle and two attachments |
116.76 |
|
L3954 |
Wrist-Hand-Finger Orthosis (WHFO), spreading hand |
67.81 |
|
Q |
UPPER LIMB: SHOULDER-ELBOW-WRIST-HAND |
|
|
A |
ABDUCTION POSITIONING-CUSTOM FITTED |
|
|
L3960 |
Shoulder-Elbow-Wrist-Hand Orthosis (SEWHO), abduction positioning,
airplane design |
468.66 |
|
L3962 |
Shoulder-Elbow-Wrist-Hand Orthosis (SEWHO), abduction positioning ,
ERBS palsey design |
495.96 |
|
L3963 |
Shoulder-Elbow-Wrist-Hand Orthosis (SEWHO), molded shoulder, arm,
forearm, and wrist, with articulating elbow joint |
1,412.83 |
|
L3964 |
Shoulder-Elbow-Wrist-Hand Orthosis (SEWHO), mobile arm support attached
to wheelchair, balanced and fitted to patient, adjustable |
612.92 |
|
L3965 |
Shoulder-Elbow-Wrist-Hand Orthosis (SEWHO), radial arm support,
attached to wheelchair balanced and fitted to patient, adjustable Rancho
type |
1,012.88 |
|
L3966 |
Shoulder-Elbow-Wrist-Hand Orthosis (SEWHO), mobile arm support attached
to wheelchair, balanced and fitted to patient, reclining |
596.37 |
|
L3968 |
Shoulder-Elbow-Wrist-Hand Orthosis (SEWHO), mobile arm support attached
to wheelchair, balanced and fitted to patient, friction arm support
(friction dampening to proximal and distal joints |
778.77 |
|
L3969 |
Shoulder-Elbow-Wrist-Hand Orthosis (SEWHO), mobile arm support,
monsuspension arm and hand support, overhead elbow forearm hand sling
support, yoke type arm suspension support |
658.22 |
|
B |
ADDITIONS TO MOBILE ARM SUPPORTS |
|
|
L3970 |
Shoulder-Elbow-Wrist-Hand Orthosis (SEWHO), addition to mobile arm
support, elevating proximal arm |
251.03 |
|
L3972 |
Shoulder-Elbow-Wrist-Hand Orthosis (SEWHO), addition to mobile arm
support, offset or lateral rocker arm with elastic balance control |
167.42 |
|
L39.74 |
Shoulder-Elbow-Wrist-Hand Orthosis (SEWHO), addition to mobile arm
support, supinator |
109.55 |
|
C |
FRACTURE ORTHOSES |
|
|
L3980 |
Upper extremity fracture orthosis, humeral |
197.36 |
|
L3982 |
Upper extremity fracture orthosis, radius/ulner |
253.26 |
|
L3984 |
Upper extremity fracture orthosis, wrist |
272.63 |
|
L3985 |
Upper extremity fracture orthosis, forearm, hand with wrist hinge |
422.40 |
|
L3986 |
Upper extremity fracture orthosis, combination of humeral,
radius/ulnar, wrists (example-colles fracture) |
398.41 |
|
L3995 |
Addition to upper extremity orthosis, sock, fracture or equal, each |
28.09 |
|
L3999 |
Unlisted procedures for upper limb orthosis
(BY REPORT PROCEDURE) |
By Report |
|
R |
SPECIFIC REPAIR |
|
|
A. |
REPLACEMENTS |
|
|
L4000 |
Replace girdle for Milwaukee orthosis |
946.51 |
|
L4010 |
Replace Trilateral socket brim |
444.59 |
|
L4020 |
Replace quadrilateral socket brim, molded to patient model |
602.78 |
|
L4030 |
Replace quadrilateral socket brim, custom fitted |
330.99 |
|
L4040 |
Replace molded thigh lacer |
271.40 |
|
L4045 |
Replace non-molded thigh lacer |
213.40 |
|
L4050 |
Replace molded calf lacer |
274.39 |
|
L4055 |
Replace non-molded calf later |
171.49 |
|
L4060 |
Replace high roll cuff |
212.40 |
|
L4070 |
Replace proximal and distal upright for KAFO |
190.70 |
|
L4080 |
Replace metal bands KAFO, proximal thigh |
89.75 |
|
L4090 |
Replace metal bands KAFO-AFO, calf or distal thigh |
78.64 |
|
L4100 |
Replace leather cuff KAFO, proximal thigh |
92.62 |
|
L4110 |
Replace leather cuff KAFO-AFO, calf or distal thigh |
74.31 |
|
L4130 |
Replace pretibial shell |
354.84 |
|
B |
ORTHOTIC REPAIRS |
|
|
L4200 |
Repair of orthotic device, hourly rate |
25.00 |
|
L4210 |
Repair of orthotic device, repair or replace minor parts |
34.00 |
|
S |
ANCILLARY ORTHOTIC SERVICES |
|
|
L4310 |
Multi-Podus or equal orthotic preparatory management system for lower
extremities |
374.61 |
|
L4320 |
Addition to AFO, multi-podus (or equal) orthotic preparatory management
system for lower extremities, flexible foot positioner with soft interface
for AFO, with velcro closure custom fitted |
116.89 |
|
L4350 |
Pneumatic ankle control splint (aircast or equal) |
69.98 |
|
L4360 |
Pneumatic walking splint (aircast or equal) |
192.89 |
|
L4370 |
Pneumatic full leg splint (aircast or equal) |
124.48 |
|
L4380 |
Pneumatic knee splint (aircast or equal) |
76.79 |
SERVICE FEE MEMORANDUM
MS-93-94-10
DATE: December 10, 1993
RE: Orthotic Services Fee Schedule
You will find attached an updated Orthotic services Fee Scheduled effective
December 10, 1993.
Medicare HCPCS Codes and Descriptions for Orthotic Services are being
utilized on this Schedule.
For any "By Report" item, obtain item description and charge. Then
contact the Central Office for approval to purchase and an allowable fee.
|
Item No. |
Orthotic |
Unit Price |
|
A. |
CERVICAL |
|
|
L0100 |
Cervical, craniostenosis, helmet, non-molded to patient model |
415.05 |
|
L0110 |
Cervical, craniostenosis, helmet, non-molded |
124.70 |
|
L0120 |
Cervical, flexible, non-adjustable(from collar) |
17.47 |
|
L0130 |
Cervical, flexible, thermoplastic collar, molded to patient |
140.59 |
|
L0140 |
Cervical, semi-rigid, adjustable (plastic collars) |
56.41 |
|
L0150 |
Cervical, semi-rigid, adjustable molded chin cup (plastic collar with
mandibular/occipital piece) |
95.61 |
|
L0160 |
Cervical, semi-rigid, wire frame occipital/mandibular support |
118.46 |
|
L0170 |
Cervical, collar, molded to patient model |
520.33 |
|
L0172 |
Cervical, collar, semi-rigid thermoplastic foam, two pieces |
101.07 |
|
L0174 |
Cervical, collar, semi-rigid, thermoplastic form, two piece with
thoracic extension |
177.43 |
|
L0180 |
Cervical, multiple post collar, occipital/mandibular supports,
adjustable |
269.35 |
|
L0190 |
Cervical, multiple post collar, occipital/mandibular supports,
adjustable cervical bars (Somi, Guilford, Taylor types) |
339.68 |
|
L0200 |
Cervical, multiple post collar, occipital/mandibular supports,
adjustable cervical bars, and thoracic extension |
339.15 |
|
B |
THORACIC AND THORACIC-LUMBAR-SACRAL |
|
|
A |
THORACIC |
|
|
L0210 |
Thoracic, rib belt, custom fitted |
32.95 |
|
L0220 |
Thoracic, rib belt, custom fabricated |
77.44 |
|
B |
THORACIC-LUMBAR-SACRAL |
|
|
L0300 |
Thoracic-Lumbar-Sacral Orthosis (TLSO), flexible (dorso-lumbar surgical
support), custom fitted |
138.83 |
|
L0310 |
Thoracic-Lumbar-Sacral Orthosis (TLSO), flexible dorso surgical
support) custom fabricated |
218.01 |
|
L0315 |
Thoracic-Lumbar-Sacral Orthosis (TLSO), flexible dorso surgical
support, elastic type, with rigid posterior panel |
172.49 |
|
L0317 |
Thoracic-Lumbar-Sacral Orthosis (TLSO), flexible dorso-lumbar surgical
support hyperextension, elastic type, with rigid posterior panel |
273.70 |
|
L0320 |
Thoracic-Lumbar-Sacral Orthosis (TLSO), anterior-posterior control
Taylor type, with apron front |
246.15 |
|
L0330 |
Thoracic-Lumbar-Sacral Orthosis (TLSO), anterior-posterior-lateral
control (Knight-Taylor design) with apron front |
350.38 |
|
L0340 |
Thoracic-Lumbar-Sacral Orthosis (TLSO),
anterior-posterior-lateral-rotary control (Arnold, Magnuson, Steindler
types) with apron front |
527.38 |
|
L0350 |
Thoracic-Lumbar-Sacral Orthosis(TLSO),
anterior-posterior-lateral-rotary control, flexion compression jacket,
custom fitted |
780.34 |
|
L0360 |
Thoracic-Lumbar-Sacral Orthosis (TLSO),
anterior-posterior-lateral-rotary control, flexion compression jacket
molded to patient model |
994.32 |
|
L0370 |
Thoracic-Lumbar-Sacral Orthosis (TLSO),
anterior-posterior-lateral-rotary control, hyperextension (Jewett, Lennox,
Baker, Cash types |
270.76 |
|
L0380 |
Thoracic-Lumbar-Sacral Orthosis (TLSO),
anterior-posterior-lateral-rotary control with extensions |
455.07 |
|
L0390 |
Thoracic-Lumbar-Sacral Orthosis (TLSO), anterior-posterior-lateral
control (body jacket) molded to patient model |
933.40 |
|
L0400 |
Thoracic-Lumbar-Sacral Orthosis (TLSO), anterior-posterior-lateral
control (body jacket) molded to patient model, with interface material |
1,169.20 |
|
L0410 |
Thoracic-Lumbar-Sacral Orthosis (TLSO), anterior-posterior-lateral
control (body jacket), two piece construction, molded to patient model |
1,223.93 |
|
L0420 |
Thoracic-Lumbar-Sacral Orthosis (TLSO), two piece construction, molded
to patient model, with interface material |
1,227.69 |
|
L0430 |
Thoracic-Lumbar-Sacral Orthosis (TLSO), anterior-posterior-lateral
control (body jacket), with interface material custom fitted |
982.75 |
|
L0440 |
Thoracic-Lumbar-Sacral Orthosis (TLSO), anterior-posterior-lateral
control (body Jacket), with overlapping front section, spring steel front,
custom fitted |
795.39 |
|
C |
LUMBAR-SACRAL (LSO) |
|
|
L0500 |
Lumbar-Sacral Orthosis (LSO), flexible (Lumb0-sacral surgical support),
custom fitted |
91.18 |
|
L0510 |
Lumbar-Sacral Orthosis (LSO), flexible (Lumbar-sacral surgical
support), custom fabricated |
196.02 |
|
L0515 |
Lumbar-Sacral-Orthosis (LSO), flexible (lumbar-sacral surgical
support), elastic type, with rigid posterior panel |
118.82 |
|
L0520 |
Lumbar-Sacral Orthosis (LSO), anterior-posterior-lateral control
(Knight, Wilcox types), with apron front |
306.86 |
|
L0530 |
Lumbar-Sacral Orthosis (LSO), anterior-posterior control (Macausland
type), with apron front |
267.51 |
|
L0540 |
Lumbar-Sacral Orthosis (LSO), lumbar flexion(Williams flexion type)
anterior-posterior-lateral control (body jacket) |
314.74 |
|
L0550 |
Lumbar-Sacral Orthosis (LSO), anterior-posterior-lateral control (body
jacket), molded to patient model |
881.74 |
|
L0560 |
Lumbar-Sacral Orthosis (LSO), anterior-posterior-lateral control (body
jacket), molded to patient model, with interface material |
947.61 |
|
L0565 |
Lumbar-Sacral Orthosis (LSO), anterior-posterior-lateral control (body
jacket), custom fitted |
965.11 |
|
C |
OTHER SPINAL ORTHOSES |
|
|
A |
FLEXIBLE SACROILIAC |
|
|
L0600 |
Sacroiliac, Flexible (sacroiliac surgical support, custom fitted |
82.66 |
|
L0610 |
Sacroiliac, flexible (sacroiliac surgical support), custom fabricated |
169.79 |
|
L0620 |
Sacroiliac, Semi-rigid (Goldthawaite, Osgood types), with apron front |
274.75 |
|
B |
CERVICAL-THORACIC-LUMBAR-SACRAL |
|
|
L0700 |
Cervical-Thoracic-Lumbar-Sacral Orthosis CTLSO),
anterior-posterior-lateral control, molded to patient model, (Minerva
type) |
1,323.25 |
|
L0710 |
Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLSO),
anterior-posterior-lateral control, molded to patient model, with
interface material (Minerva type) |
1,427.17 |
|
C |
HALO PROCEDURE |
|
|
L0810 |
Halo procedure, cervical halo incorporated into jacket vest |
1,781.49 |
|
L0820 |
Halo procedure, cervical halo incorporated into plaster body jacket |
1,417.47 |
|
L0830 |
Halo procedures, cervical halo incorporated into Milwaukee type
orthosis |
2,084.10 |
|
L0860 |
Addition to HALO procedure, magnet reasonance image compatible system |
819.82 |
|
D |
TORSO SUPPORTS |
|
|
L0900 |
Torso support, PTOSIS support, custom fitted |
117.18 |
|
L0910 |
Torso support, PTOSIS support, custom fabricated |
220.45 |
|
L0920 |
Torso support, pedulous abdomen support, custom fitted |
122.00 |
|
L0930 |
Torso support, pedulous abdomen support, custom fabricated |
246.04 |
|
L0940 |
Torso support, post surgical support, custom fitted |
101.33 |
|
L050 |
Torso support, post surgical support, custom fabricated |
277.77 |
|
L0960 |
Torso support, post surgical support, pads for post surgical support |
59.93 |
|
E |
ADDITIONS TO SPINAL ORTHOSES |
|
|
L0970 |
Thoracic-Lumbar-Sacral Orthosis (TLSO), corset front |
74.70 |
|
L0972 |
Lumbar-Sacral Orthosis (LSO), corset front |
67.44 |
|
L0974 |
Thoracic-Lumbar-Sacral Orthosis (TLSO), full corset |
133.8 |
|
L0976 |
Lumbar Sacral Orthosis (LSO), full corset |
112.86 |
|
L0978 |
Axillary crutch extension |
125.66 |
|
L0980 |
Peroneal straps, pair |
11.72 |
|
L0982 |
Stocking supporter grips, set of four (4) |
13.69 |
|
D |
SCOLIOSIS PROCEDURES |
|
|
A |
CERVICAL-THORACIC-LUMBAR-SACRAL |
|
|
L1000 |
Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLSO) (Milwaukee), inclusive
of furnishing initial orthosis, including model |
1,328.37 |
|
L1010 |
Addition to Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLSO) or
Scoliosis Orthosis, axilla sling |
44.88 |
|
L1020 |
Addition to Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLSO)or
Scoliosis Orthosis, kyphosis pad |
69.33 |
|
L1025 |
Addition to Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLSO or
Scoliosis Orthosis, kyphosis pad, floating |
83.72 |
|
L1030 |
Addition to Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLSO) or
Scoliosis Orthosis, lumbar bolster pad |
52.71 |
|
L1040 |
Addition to Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLSO) or
Scoliosis Orthosis, lumbar or lumbar rib pad |
52.48 |
|
L1050 |
Addition to Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLS)) or
Scoliosis Orthosis, sternal pad |
61.74 |
|
L1060 |
Addition to Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLSO) or
Scoliosis Orthosis, thoracic pad |
73.66 |
|
L1070 |
Addition to Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLSO) or
Scoliosis Orthosis, trapezius sling |
74.39 |
|
L1080 |
Addition to Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLS)) or
Scoliosis Orthosis, outrigger |
42.43 |
|
L1085 |
Addition to Cervical -Thoracic-Lumbar-Sacral Orthosis (CTLSO) or
Scoliosis Orthosis, outrigger, bilateral with vertical extension |
126.87 |
|
L1090 |
Addition to Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLSO) or
Scoliosis Orthosis, lumbar sling |
60.53 |
|
L1100 |
Addition to cervical-Thoracic-Lumbar-Sacral Orthosis (CTLSO) or
Scoliosis Orthosis, ring flange, plastic or leather |
113.11 |
|
L1110 |
Addition to Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLSO) or
Scoliosis Orthosis, ring flange, plastic or leather, molded to patient
model |
196.34 |
|
L1120 |
Addition to Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLSO) or
Scoliosis Orthosis, cover for upright each |
31.37 |
|
B |
THORACIC-LUMBAR-SACRAL |
|
|
L1200 |
Thoracic-Lumbar-Sacral Orthosis (TLSO) inclusive of furnishing initial
orthosis only |
1,101.43 |
|
L1210 |
Addition to Addition to Thoracic-Lumbar-Sacral Orthosis (TLSO), (low
profile) lateral thoracic extension |
180.44 |
|
L1220 |
Addition to Thoracic-Lumbar-Sacral Orthosis (TLSO), (low profile),
anterior thoracic extension |
145.24 |
|
L1230 |
Addition to Thoracic-Lumbar-Sacral Orthosis (TLSO), (low profile),
Milwaukee type superstructure |
366.42 |
|
L1240 |
Addition to Thoracic-Lumbar-Sacral Orthosis (TLSO), (low-Profile),
lumbar derotation pad |
64.61 |
|
L1250 |
Addition to Thoracic-Lumbar-Sacral Orthosis (TLSO), (low profile),
anterior ASIS pad |
61.71 |
|
L1260 |
Addition to Thoracic-Lumbar-Sacral Orthosis (TLSO), (low profile),
anterior thoracic derotation pad |
64.75 |
|
L1270 |
Addition to Thoracic-Lumbar-Sacral Orthosis (TLSO), (low profile),
abdominal pad |
64.72 |
|
L1280 |
Addition to Thoracic-Lumbar-Sacral Orthosis (TLSO), (low profile), rib
gusset (elastic) each |
58.69 |
|
L1290 |
Addition to Thoracic-Lumbar-Sacral Orthosis (TLSO), (low profile),
lateral trochanteric pad |
65.07 |
|
C |
OTHER SCOLIOSIS PROCEDURES |
|
|
L1300 |
Other scoliosis procedures, body jacket molded to patient model |
1,083.08 |
|
L1310 |
Other scoliosis procedures, post-operative body jacket |
1,118.02 |
|
L1499 |
Unlisted procedure for spinal orthosis
(BY REPORT PROCEDURE) |
By Report |
|
E |
LOWER LIMB: HIP, LEG PERTHE, AND KNEE |
|
|
A |
THORACIC-HIP-KNEE-ANKLE |
|
|
L1500 |
Thoracic-Hip-Knee-Angle Orthosis (THKAO), mobility frame (Newington,
Parapodium types) |
1,243.33 |
|
L1510 |
Thoracic-Hip-Knee-Angle Orthosis (THKAO), standing frame |
784.14 |
|
L1520 |
Thoracic-Hip-Knee-Angle Orthosis (THKAO), swivel walker |
1,833.17 |
|
B |
HIP |
|
|
L1600 |
Hip Orthosis (HO), abduction control of hip joints, flexible, Frejka
type with cover |
81.97 |
|
L1610 |
Hip Orthosis (HO), abduction control of hip joints,, flexible, Frejka
cover only |
30.33 |
|
L1620 |
Hip Orthosis (HO), abduction control of hip joints, flexible, Pavlik
harness |
88.07 |
|
L1630 |
Hip Orthosis (HO), abduction control of hip joints, semi-flexible (Von
Rossen type) |
111.31 |
|
L1640 |
Hip Orthosis (HO), abduction control of hip joints, static, pelvic band
or spreader bar, thigh cuffs |
296.93 |
|
L1650 |
Hip Orthosis (HO), abduction control of hip joints, static adjustable
custom fitted (Ilfled type) |
152.26 |
|
L1660 |
Hip Orthosis (HO), abduction control of hip joints, static, plastic,
custom fitted |
109.70 |
|
L1680 |
Hip Orthosis (HO), abduction control of hip joints, dynamic, pelvic
control, adjustable hip motion control, thigh cuffs (Rancho hip action
type) |
963.26 |
|
L1685 |
Hip Orthosis (HO), abduction control of hip joint, post-operative hip
abduction type, custom fabricated |
997.73 |
|
L1686 |
Hip Orthosis (HO), abduction control of hip joint, post-operative hip
abduction type, custom fitted |
615.71 |
|
C |
LOWER LIMB-LEGG PERTHES |
|
|
L1700 |
Legg Perthes Orthosis, Toronto type |
1,150.81 |
|
L1710 |
Legg Perthes Orthosis, Newington type |
1,283.20 |
|
L1720 |
Legg Perthes Orthosis, trilateral, (Tachdijan type) |
999.63 |
|
L1730 |
Legg Perthes Orthosis, Scottish rite type |
816.71 |
|
L1750 |
Legg Perthes Orthosis, Legg perthes sling (Sam Brown type) |
127.42 |
|
L1755 |
Legg Perthes Orthosis, patten bottom type |
1,161.28 |
|
D |
KNEE (KO) |
|
|
L1800 |
Knee Orthosis (KO), elastic with stays |
55.57 |
|
L1810 |
Knee Orthosis (KO) elastic with joints |
72.60 |
|
L1815 |
Knee Orthosis (KO), elastic with condylar pads |
84.25 |
|
L1820 |
Knee Orthosis (KO), elastic with condyle pads and joints |
91.25 |
|
L1825 |
Knee Orthosis (KO), elastic knee cap |
35.78 |
|
L1830 |
Knee Orthosis (KO), immobilizer, canvas longitudinal |
70.14 |
|
L1832 |
Knee Orthosis (KO), adjustable knee joints, positional orthosis, rigid
support, custom fitted |
516.66 |
|
L1834 |
Knee Orthosis (KO), without knee joint, rigid, molded to patient model |
599,06 |
|
L1840 |
Knee Orthosis (KO), derotation, medial-lateral, anterior cruciate
ligament, custom fabricated to patient model |
614.80 |
|
L1845 |
Knee Orthosis (KO), double upright, thigh and calf, with adjustable
flexion and extension joint, medial-lateral and rotation control, custom
fitted |
620.00 |
|
L1846 |
Knee Orthosis (KO), double upright, thigh and calf, with adjustable
flexion and extension joint, medial-lateral and rotation control, molded
to patient model |
739.81 |
|
L1850 |
Knee Orthosis (KO), Swedish type |
187.26 |
|
L1855 |
Knee Orthosis (KO), molded plastic, thigh and calf sections, with
double upright knee joints, molded to patient model |
800.14 |
|
L1858 |
Knee Orthosis (KO), molded plastic, polycentric knee joints, pneumatic
knee pads (CTI) |
866.07 |
|
L1860 |
Knee Orthosis (KO), modification of supracondylar prosthetic socket
molded to patient model (SK) |
771.82 |
|
L1870 |
Knee Orthosis (KO), double upright, thigh and calf lacers, molded to
patient model with knee joints |
687.45 |
|
L1880 |
Knee Orthosis (KO), double upright, non-molded thigh and calf cuss
cuffs/lacers with knee joints |
471.95 |
|
F |
LOWER LIMB: ANKLE FOOT (AFO) |
|
|
L1900 |
Ankle-Foot Orthosis (AFO), spring wire, dorsiflexion assist calf band |
196.77 |
|
L1902 |
Ankle-Foot Orthosis (AFO), ankle gauntlet |
51.82 |
|
L1904 |
Ankle-Foot Orthosis (AFO), molded ankle gauntlet molded to patient
model |
313.18 |
|
L1906 |
Ankle-Foot Orthosis (AFO), multiligamentus ankle support |
80.08 |
|
L1910 |
Ankle-Foot Orthosis (AFO), posterior, single bar, clasp attachment, to
shoe counter |
190.66 |
|
L1920 |
Ankle-Foot Orthosis (AFO), single upright with static or adjustable
(Phelps or Perlstein type) |
234.65 |
|
L1930 |
Ankle-Foot Orthosis (AFO), custom fitted, plastic |
156.80 |
|
L1940 |
Ankle-Foot Orthosis (AFO), molded to patient model, plastic |
358.10 |
|
L1945 |
Ankle-Foot Orthosis (AFO), molded to patient model, plastic, rigid
anterior tibial section (floor reaction) |
601.54 |
|
L1950 |
Ankle-Foot Orthosis (AFO), spiral, molded to patient model (Irm type),
plastic |
498.01 |
|
L1960 |
Ankle-Foot Orthosis (AFO), posterior solid ankle, molded to patient
model, plastic |
377.63 |
|
L1970 |
Ankle-Foot Orthosis (AFO), plastic molded to patient model, with ankle
joint |
489.42 |
|
L1980 |
Ankle-Foot Orthosis (AFO), single upright free plantar dorsiflexion,
solid stirrup, calf band/cuff (single bar "BK" orthosis) |
240.61 |
|
L1990 |
Ankle-Foot Orthosis (AFO), double upright free plantar dorsiflexion,
solid stirrup, calf band/cuff (double bar "BK" orthosis |
319.59 |
|
G |
HIP KNEE ANGLE FOOT |
|
|
A |
KNEE-ANKLE-FOOT |
|
|
L2000 |
Knee-Ankle-Foot Orthosis (KAFO), single upright free knee, free ankle,
solid stirrup, thigh and calf bands/cuffs (single bar "AK"
orthosis |
654.57 |
|
L2010 |
Knee-Ankle-Foot Orthosis (KAFO), single upright, free knee, free ankle,
solid stirrup, thigh and calf bands/cuffs (single bar "AK"
orthosis) without knee joint |
597.61 |
|
L2020 |
Knee-Ankle-Foot Orthosis (KAFO), double upright, free knee, free ankle,
solid stirrup, thigh and calf bands/cuffs (double bar "AK"
orthosis) |
754.91 |
|
L2030 |
Knee-Ankle-Foot Orthosis (KAFO), double upright, free ankle, solid
stirrup, thigh and calf bands/cuffs, (double bar "AK" orthosis),
without knee joint |
665.13 |
|
L2036 |
Knee-Ankle-Foot Orthosis (KAFO), full plastic, double upright, free
knee, molded to patient model |
1,189.17 |
|
L2037 |
Knee-Ankle-Foot Orthosis (KAFO, full plastic, single upright, free
knee, molded to patient model |
1,078.23 |
|
L2038 |
Knee-Angle-Foot Orthosis (KAFO), full plastic, without knee joint,
multi-axis angle, molded to patient model (Lively orthosis or equal) |
939.78 |
|
B |
HIP-KNEE-ANKLE-FOOT |
|
|
L2040 |
Hip-Knee-Ankle-Foot Orthosis (HKAFO), torsion control, bilateral
rotation straps, pelvic band/belt |
114.30 |
|
L2050 |
Hip-Knee-Ankle-Foot Orthosis (HKAFO), torsion control, bilateral
torsion cables, hip joint, pelvic band/belt |
348.54 |
|
L2060 |
Hip-Knee-Ankle Foot Orthosis (HKAFO), torsion control, bilateral
torsion cables, ball bearing hip joint, pelvic band/belt |
401.00 |
|
L2080 |
Hip-Knee-Ankle-Foot Orthosis (HKAFO), torsion control, unilateral
torsion cable, hip joint pelvic band/belt |
265.38 |
|
L2090 |
Hip-Knee-Ankle-Foot Orthosis (HKAFO), torsion control, unilateral
torsion cable, ball bearing hip joint, pelvic band/belt |
330.29 |
|
H |
LOWER LIMB FRACTURE ORTHOSIS AND ADDITIONS |
|
|
L2102 |
Ankle-Foot Orthosis (AFO), fracture Orthosis, tibial fracture cast
orthosis, plaster type casting material, molded to patient |
354.96 |
|
L2104 |
Ankle-Foot Orthosis (AFO), fracture orthosis, tibial fracture cast
orthosis synthetic type casting material, molded to patient |
327.12 |
|
L2106 |
Ankle-Foot Orthosis (AFO), fracture orthosis, tibial fracture cast
orthosis, thermoplastic type casting material, molded to patient |
437.27 |
|
L2108 |
Ankle-Foot Orthosis (AFO), fracture orthosis, tibial fracture cast
orthosis, molded to patient model |
692.07 |
|
L2112 |
Ankle-Foot Orthosis (AFO), fracture orthosis, tibial fracture orthosis
soft custom fitted |
299.87 |
|
L2114 |
Ankle-Foot Orthosis (AFO), fracture orthosis tibial fracture orthosis,
semi-rigid custom fitted |
374.74 |
|
L2116 |
Ankle-Foot Orthosis (AFO), fracture orthosis, tibial fracture orthosis,
rigid custom fitted |
474.01 |
|
L2122 |
Knee-Ankle-Foot Orthosis (KAFO), fracture orthosis, femoral fracture
cast orthosis, plaster type casting material, molded to patient |
596.71 |
|
L2124 |
Knee-Ankle-Foot Orthosis (KAFO), fracture orthosis, femoral fracture
cast orthosis, synthetic type casting material, molded to patient |
624.36 |
|
L2126 |
Knee-Ankle-Foot Orthosis (KAFO), fracture orthosis, femoral fracture
cast orthosis, thermoplastic type casting, molded to patient |
881.18 |
|
L2128 |
Knee-Ankle-Foot Orthosis (KAFO), fracture orthosis, femoral fracture
cast orthosis, molded to patient model |
1,094.42 |
|
L2132 |
Knee-Ankle-Foot Orthosis (KAFO), fracture orthosis, femoral fracture
cast orthosis, soft custom fitted |
523.66 |
|
L2134 |
Knee-Ankle-Foot Orthosis (KAFO), fracture orthosis, femoral fracture
cast orthosis, semi-rigid custom fitted |
621.93 |
|
L2136 |
Knee-Ankle-Foot Orthosis (KAFO), fracture orthosis, femoral fracture
cast orthosis, rigid custom fitted |
764.27 |
|
L2180 |
Addition to lower extremity fracture orthosis, plastic shoe insert with
ankle joints |
78.04 |
|
L2182 |
Addition to lower extremity fracture orthosis, drop knee joint |
60.62 |
|
L2184 |
Addition to lower extremity fracture orthosis, limited motion knee
joint |
109.14 |
|
L2186 |
Addition to lower extremity fracture orthosis, adjustable motion knee
joint, lerman type |
132.71 |
|
L2188 |
Addition to lower extremity fracture orthosis, quadrilateral brim |
255.23 |
|
L2190 |
Addition to lower extremity fracture orthosis, waist belt |
69.46 |
|
L2192 |
Addition to lower extremity fracture orthosis, hip joint, pelvic band,
thigh flange, and pelvic belt |
252.24 |
|
I |
LOWER LIMB ADDITIONS |
|
|
A |
SHOE-ANKLE-SHIN |
|
|
L2200 |
Addition to lower extremity, limited ankle motion, each joint |
30.80 |
|
L2210 |
Addition to lower extremity, dorsiflexion assist (plantar flexion
resist), each joint |
42.70 |
|
L2220 |
Addition to lower extremity, dorsiflexion and plantar flexion
assist/resist, each joint |
52.42 |
|
L2230 |
Addition to lower extremity, spit flat caliper stirrups and plate
attachment |
49.95 |
|
L2240 |
Addition to lower extremity, round caliper and plate attachment |
54.10 |
|
L2250 |
Addition to lower extremity, foot plate, molded to patient model,
stirrup attachment |
231.77 |
|
L2260 |
Additions to lower extremity, reinforced solid stirrup (Scott-Craig
type) |
127.38 |
|
L2265 |
Addition to lower extremity, long tongue stirrup |
78.57 |
|
L2270 |
Additions to lower extremity, varus/valgus correction ("T")
strap, padded/lined or malleolus pad |
34.75 |
|
L2280 |
Additions to lower extremity, molded inner bot |
291.95 |
|
L2300 |
Additions to lower extremity, abduction bar (bilateral hip
involvement), jointed, adjustable |
179.47 |
|
L2310 |
Additions to lower extremity, abduction bar-straight |
77.71 |
|
L2320 |
Additions to lower extremity, non-molded lacer |
138.05 |
|
L2330 |
Additions to lower extremity, lacer molded to patient model |
253.14 |
|
L2335 |
Addition to lower extremity, anterior swing band |
173.61 |
|
L2340 |
Addition to lower extremity, pre-tibial shell, molded to patient model |
381.53 |
|
L2350 |
Addition to lower extremity, prosthetic type, (BK) socket, molded to
patient model, (used for 'PTB' 'AFO' orthoses) |
581.67 |
|
L2360 |
Addition to lower extremity, extended steel shank |
33.69 |
|
L2370 |
Addition to lower extremity, patten bottom |
167.25 |
|
L2375 |
Addition to lower extremity, torsion control, ankle joint and half
solid stirrup |
72.58 |
|
L2380 |
Addition to lower extremity, torsion control, straight knee joint, each
joint |
98.48 |
|
L2385 |
Addition to lower extremity, straight knee joint, heavy duty, each
joint |
89.70 |
|
L2390 |
Addition to lower extremity, offset knee joint, each joint |
70.93 |
|
L2395 |
Addition to lower extremity, offset knee joint, heavy duty, each joint |
119.23 |
|
B |
KNEE |
|
|
L2405 |
Addition to knee joint, drop lock, each joint |
43.07 |
|
L2415 |
Addition to knee joint, cam lock (Swiss, French, Bail types), each
joint |
141.37 |
|
L2425 |
Addition to knee joint, disc or dial lock for adjustable knee flexion,
each joint |
119.74 |
|
L2435 |
Addition to knee joint, polycentric joint, each joint |
108.03 |
|
L2492 |
Addition to knee joint, lift loop for drop lock ring |
65.89 |
|
C |
THIGH/WEIGHT BEARING |
|
|
L2500 |
Addition to lower extremity, thigh/weight bearing, gluteal/ischial
weight bearing, ring |
203.68 |
|
L2510 |
Addition to lower extremity, thigh/weight bearing, , quadrilateral
brim, molded to patient model |
476.91 |
|
L2520 |
Addition to lower extremity, thigh/weight bearing, quadrilateral brim,
custom fitted |
301.21 |
|
L2525 |
Addition to lower extremity, thigh/weight bearing, ischial
containment/narrow M-L brim molded to patient model |
1,075.93 |
|
L2526 |
Addition to lower extremity, thigh/weight bearing, ischial
containment/narrow M-L, custom fitted |
536.11 |
|
L2530 |
Addition to lower extremity, thigh/weight bearing, lacer, non-molded |
155.87 |
|
L2540 |
Addition to lower extremity, thigh/weight bearing, Lacer molded to
patient model |
278.88 |
|
L2550 |
Addition to lower extremity, thigh/weight bearing, high roll cuff |
191.73 |
|
D |
PELVIC AND THORACIC CONTROL |
|
|
L2570 |
Addition to lower extremity, pelvic control, hip joint, Clevis type two
position joint, each |
332.71 |
|
L2580 |
Addition to lower extremity, pelvic control, pelvic sling |
323.34 |
|
L2600 |
Addition to lower extremity, pelvic control, hip joint, Clevis type, or
thrust bearing, free, each |
131.92 |
|
L2610 |
Addition to lower extremity, pelvic control, hip joint, Clevis or
thrust bearing, lock each |
157.50 |
|
L2620 |
Addition to lower extremity, pelvic control, hip joint, heavy duty,
each |
173.44 |
|
L2622 |
Addition to lower extremity, pelvic control, hip joint, adjustable
flexion each |
198.65 |
|
L2624 |
Addition to lower extremity, pelvic control, hip joint adjustable
flexion, extension, abduction control, each |
249.30 |
|
L2627 |
Addition to lower extremity, pelvic control, plastic, molded to patient
model, reciprocating High joint and cables |
1,146.99 |
|
L2628 |
Addition to lower extremity, pelvic control, metal frame, reciprocating
hip joint and cables |
1,138.79 |
|
L2630 |
Addition to lower extremity, pelvic control, band and belt, unilateral |
163.42 |
|
L2640 |
Addition to lower extremity, pelvic control, band and belt, bilateral |
218.64 |
|
L2650 |
Addition to lower extremity, pelvic and thoracic control, gluteal pad,
each |
78.57 |
|
L2660 |
Addition to lower extremity, thoracic control, thoracic band |
116.31 |
|
L2670 |
Addition to lower extremity, thoracic control, paraspinal uprights |
108.83 |
|
L2680 |
Addition to lower extremity, thoracic control, lateral support uprights |
103.00 |
|
E |
ADDITIONS-GENERAL |
|
|
L2750 |
Addition to lower extremity orthosis, plating chrome or nickel, per bar |
58.12 |
|
L2760 |
Addition to lower extremity orthosis, extension, per extension, per bar
(for lineal adjustment for growth) |
39.25 |
|
L2770 |
Addition to lower extremity orthosis, stainless steel-per bar or joint |
40.07 |
|
L2780 |
Addition to lower extremity, non-corrosive finish, per bar |
44.05 |
|
L2785 |
Addition to lower extremity orthosis, drop lock retainer, each |
27.48 |
|
L2795 |
Addition to lower extremity orthosis, knee control, full kneecap |
55.47 |
|
L2800 |
Addition to lower extremity orthosis, knee control, knee cap, medial or
lateral pull |
69.88 |
|
L2810 |
Addition to lower extremity orthosis, knee control, condylar pad |
49.53 |
|
L2820 |
Addition to lower extremity orthosis, soft interface for molded
plastic, below-knee section |
56.32 |
|
L2830 |
Addition to lower extremity orthosis, soft interface for molded
plastic, above-knee section |
61.70 |
|
L2840 |
Addition to lower extremity orthosis, tibal length socks, fracture or
equal, each |
28.04 |
|
L2850 |
Addition to lower extremity orthosis, femoral length sock, fracture or
equal, each |
40.35 |
|
L2999 |
Unlisted procedures for lower extremity orthosis
(BY REPORT PROCEDURE) |
By Report |
|
J |
FOOT |
|
|
A |
INSERT, REMOVABLE, MOLDED TO PATIENT/PATIENT MODEL |
|
|
L3000 |
Foot, insert, removable, molded to patient model, "UCB" type,
Berkeley shell, each |
97.00 |
|
L3001 |
Foot, insert, removable, molded to patient model, Spenco, each |
80.00 |
|
L3002 |
Foot, insert, removable, molded to patient model, Plasazota or equal,
each |
34.00 |
|
L3003 |
Foot, insert, removable, molded to patient model, silicone gel, each |
124.00 |
|
L3010 |
Foot, insert, removable, molded to patient model, longitudinal arch
support, each |
80.00 |
|
L3020 |
Foot, insert, removable, molded to patient model,
longitudinal/metatarsal support, each |
130.00 |
|
L3030 |
Foot, insert, removable, formed to patient foot, each |
93.00 |
|
B |
ARCH SUPPORT, REMOVABLE, PRE-MOLDED |
|
|
L3040 |
Foot, arch support, removable, pre-molded, longitudinal each |
31.00 |
|
L3050 |
Foot, arch support, removable, pre-molded, metatarsal, each |
31.00 |
|
L3060 |
Foot, arch support, removable, pre-molded, longitudinal/metatarsal,
each |
36.00 |
|
C |
ARCH SUPPORT, NON-REMOVABLE, ATTACHED TO SHOE |
|
|
L3070 |
Foot, arch support, non-removable attached to shoe, longitudinal, each |
12.00 |
|
L3080 |
Foot, arch support, non-removable attached to shoe, metatarsal, each |
12.00 |
|
L3090 |
Foot, arch support, non-removable attached to shoe,
longitudinal/metatarsal, each |
14.00 |
|
L3100 |
Hallus-valgus night dynamic splint |
25.00 |
|
D |
ABDUCTION AND ROTATION BARS |
|
|
L3140 |
Foot, abduction rotation bars (Dennis Browne type), attached to shoe |
62.00 |
|
L3150 |
Foot, abduction rotation bars (Denis Browne type), clamped to shoe |
62.00 |
|
L3170 |
Foot-plastic heel stabilizer |
19.00 |
|
K |
ORTHOPEDIC FOOTWEAR |
|
|
L3215 |
Orthopedic footwear, Ladies shoes, Oxford, pair |
75.99 |
|
L3216 |
Orthopedic footwear, Ladies shoes, depth inlay, pair |
140.00 |
|
L3217 |
Orthopedic footwear, Ladies shoes, hightop depth inlay, pair |
143.00 |
|
L3218 |
Orthopedic footwear, Ladies surgical boot, each |
60.00 |
|
L3219 |
Orthopedic footwear, Mens shoes, oxford, pair |
88.44 |
|
L3221 |
Orthopedic footwear, Mens shoes, depth inlay, pair |
160.00 |
|
L3222 |
Orthopedic footwear, Mens shoes, hightop, depth, inlay pair |
94.00 |
|
L3223 |
Orthopedic footwear, Mens surgical boot, each |
101.00 |
|
L3230 |
Orthopedic footwear, custom shoes, depth inlay, pair |
200.00 |
|
L3250 |
Orthopedic footwear, custom molded shoe, removable inner mold,
prosthetic shoe, each |
189.00 |
|
E3251 |
Foot, shoe molded to patient model, silicone shoe, each |
82.00 |
|
L3252 |
Foot, shoe molded to patient model - Plastazote (or similar), custom
fabricated, each |
48.00 |
|
L3253 |
Foot, molded shoe Plastozote (or similar) custom fitted each |
149.00 |
|
L3254 |
Non-standard size or width |
43.00 |
|
L3255 |
Non-standard size or length |
43.00 |
|
L3257 |
Orthopedic footwear, additional charge for split size |
96.00 |
|
L3260 |
Ambulatory surgical boot, each |
22.00 |
|
L3265 |
Plastazote sandal, each |
25.00 |
|
L |
SHOE MODIFICATIONS |
|
|
A. |
LIFTS |
|
|
L3310 |
Lift, elevation, heel and sole, neoprene
(USE LLL3311-L3316) |
|
|
L3311 |
Lift, elevation, heel and sole, neoprene, 0" to 5/8" |
39.00 |
|
L3312 |
Lift, elevation, heel and sole, neoprene, 3/4" to 1 1/2" |
61.00 |
|
L3313 |
Lift, elevation, heel and sole, neoprene, 1 5/8" to 2" |
66.00 |
|
L3314 |
Lift, elevation, heel and sole, neoprene, 2 1/8" to 2 5/8" |
76.00 |
|
L3315 |
Lift, elevation, heel and sole, neoprene, 2 3/4" to 3 1/4" |
93.00 |
|
L3316 |
Lift, elevation, heel and sole, neoprene, Over 3 1/4", add to
above |
69.00 |
|
L3320 |
Lift, elevation, heel and sole, cork, (USE L3221-L3326) |
|
|
L3321 |
Lift, elevation, heel and sole, cork, 0" to 5/8" |
114.00 |
|
L3322 |
Lift, elevation, heel and sole, cork, 3/4" to 1 1/2" |
136.00 |
|
L3323 |
Lift, elevation, heel and sole, cork, 1 5/8" to 2" |
141.00 |
|
L3324 |
Lift, elevation, heel and sole, cork 2 1/8" to 2 5/8" |
151.00 |
|
L3325 |
Lift, elevation, heel and sole, cork, 2 3/4" to 3 1/4" |
168.00 |
|
L3326 |
Over 3 1/4", add to above |
75.00 |
|
L3330 |
Lift, elevation, metal extension, "skate"
(BY REPORT PROCEDURE) |
By report |
|
B |
WEDGES |
|
|
L3340 |
Heel wedge, Sach |
37.00 |
|
L3350 |
Heel wedge |
7.00 |
|
L3360 |
Sole wedge, outside sole |
10.00 |
|
L3370 |
Sole wedge, between sole |
13.00 |
|
L3380 |
Clubfoot wedge |
13.00 |
|
L3390 |
Outflare wedge |
10.00 |
|
L3400 |
Metatarsal bar wedge, rocker |
19.00 |
|
L3410 |
Metatarsal bar wedge, between sole |
30.00 |
|
L3420 |
Full sole and heel wedge "between sole" |
23.00 |
|
C |
HEELS |
|
|
L3430 |
Heel, counter, plastic reinforced |
21.00 |
|
L3440 |
Heel, counter, leather reinforced |
21.00 |
|
L3450 |
Heel, sach cushion type |
15.00 |
|
L3455 |
Heel, new leather, standard |
6.00 |
|
L3460 |
Heel, new rubber, standard |
5.00 |
|
L3465 |
Heel, Thomas with wedge |
6.00 |
|
L3470 |
Heel, Thomas extended to ball |
15.00 |
|
L3480 |
Heel, pad and depression for spur |
11.00 |
|
L3485 |
Heel, pad, removable for spur |
11.00 |
|
D |
MISCELLANEOUS SHOE ADDITIONS |
|
|
L3500 |
Miscellaneous shoe addition, insole, leather |
9.00 |
|
L3510 |
Miscellaneous shoe addition, insole, rubber |
9.00 |
|
L3520 |
Miscellaneous shoe addition, insole, felt covered with leather |
9.00 |
|
L3530 |
Miscellaneous shoe addition, sole, half |
21.00 |
|
L3540 |
Miscellaneous shoe addition, sole, full |
16.00 |
|
L3550 |
Miscellaneous shoe addition, toe--tap, standard |
3.00 |
|
L3560 |
Miscellaneous shoe addition, toe-tap, horseshoe |
5.00 |
|
L3570 |
Miscellaneous shoe addition, special extension to instep (leather with
eyelets |
37.00 |
|
L3580 |
Miscellaneous shoe addition covert instep to Velcro closure |
24.00 |
|
L3590 |
Miscellaneous shoe addition, covert firm shoe counter to soft counter |
35.00 |
|
L3595 |
Miscellaneous shoe addition, march bar |
13.00 |
|
M |
TRANSFERS |
|
|
L3600 |
Transfers of an orthosis from one she to another, caliper plate
existing |
24.00 |
|
L3610 |
Transfers of an orthosis from one shoe to another, caliper plate new |
55.00 |
|
L3620 |
Transfer of an orthosis from one shoe to another, solid stirrup,
existing |
29.00 |
|
L3630 |
Transfer of an orthosis from one shoe to another, solid stirrup, new |
55.00 |
|
L3640 |
Transfer of an orthosis from one shoe to another, Dennis Browne splint
(Riveton), both shoes |
22.00 |
|
L3649 |
Unlisted procedures for foot orthopedic shoes, shoe modifications and
transfers
(BY REPORT PROCEDURE) |
By Report |
|
N |
UPPER LIMB: SHOULDER |
|
|
L3650 |
Shoulder Orthosis (SO), figure of "8" design abduction
restrainer |
45.16 |
|
L3660 |
Shoulder Orthosis (SO), figure of "8" design abduction
restrainer |
68.68 |
|
L3670 |
Shoulder Orthosis (SO), acromio/clavicalar (canvas and webbing type) |
72.68 |
|
O |
UPPER LIMB: ELBOW |
|
|
L3700 |
Elbow Orthosis (EO), elastic with stays |
43.87 |
|
L3710 |
Elbow Orthosis (EO), elastic with metal joints |
95.08 |
|
L3720 |
Elbow Orthosis (EO), double upright with forearm/arm cuffs, free motion |
478.74 |
|
L3730 |
Elbow Orthosis (EO), double upright with forearm/arm cuffs,
extension/flexion assistant |
580.80 |
|
L3740 |
Elbow Orthosis (EO), double upright with forearm/arm cuffs, adjustable
position lock with active control |
676.38 |
|
P |
WRIST-HAND-FINGER |
|
|
A |
WRIST-HAND-FINGER |
|
|
L3800 |
Wrist-Hand-Finger Orthosis (WHFO), short opponens, no attachments |
124.28 |
|
L3805 |
Wrist-Hand-Finger Orthosis (WHFO), short opponens, no attachments |
201.36 |
|
L3810 |
Wrist-Hand-Finger Orthosis (WHFO), addition to short and long opponens,
thumb abduction ("C") bar |
41.83 |
|
L3815 |
Wrist-Hand-Finger Orthosis (WHFO), addition to short and long opponens,
second M.P. abduction assist |
40.98 |
|
L3820 |
Wrist-Hand-Finger Orthosis (WHFO), addition to short and long opponens,
I.P. extension assist with M.O. extension stop |
73.94 |
|
L3825 |
Wrist-Hand-Finger Orthosis (WHFO), addition to short and long opponens,
M.P. extension stop |
46.72 |
|
L3830 |
Wrist-Hand-Finger Orthosis (WHFO), addition to short and long opponens,
M.P. extension assist |
55.06 |
|
L3835 |
Wrist-Hand-Finger Orthosis (WHFO), addition to short and long opponens,
M.P. spring extension assist |
58.83 |
|
L3840 |
Wrist-Hand-Finger Orthosis (WHFO), addition to short and long opponens,
spring swivel thumb |
41.65 |
|
L3845 |
Wrist-Hand-Finger Orthosis (WHFO), addition to short and long opponens,
thumb I.P. extension assist, with M.P. stop |
54.12 |
|
L3850 |
Wrist-Hand-Finger Orthosis (WHFO), addition to short and long opponens,
action wrist with dorsiflexion assist |
78.28 |
|
L3855 |
Wrist-Hand-Finger Orthosis (WHFO), addition to short and long opponens,
adjustable M.P. Flexion control |
97.60 |
|
L3860 |
Wrist-Hand-Finger Orthosis (WHFO), addition to short and long opponens,
adjustable M.P. flexion control and I.P. |
114.71 |
|
B |
FINGER FLEXION/EXTENSION |
|
|
L3900 |
Wrist-Hand-Finger Orthosis (WHFO), dynamic flexor hinge; reciprocal
wrist extension/flexion, finger flexion/extension, wrist or finer driven |
1,047.00 |
|
L3901 |
Wrist-Hand-Finger Orthosis (WHFO), dynamic flexor hinge; reciprocal
wrist extension/flexion, finger flexion/extension, cable driven external
power |
1,189.72 |
|
C |
EXTERNAL POWER |
|
|
L3902 |
Wrist-Hand-Finger Orthosis (WHFO), external powered, compressed gas |
1,765.16 |
|
L3904 |
Wrist-Hand-Finger Orthosis (WHFO), external powered, electric |
2,062.96 |
|
D |
OTHER WRIST-HAND-FINGER ORTHOSES |
|
|
L3906 |
Writs-Hand-Finger Orthosis (WHFO), molded to patient model |
253.80 |
|
L3907 |
Wrist-Hand-Finger Orthosis (WHFO), Wrist gauntlet with thumb spica,
molded to patient model |
392.35 |
|
L3908 |
Wrist-Hand-Finger Orthosis (WHFO), wrist extension control cock-up,
canvas or leather design, non-molded |
38.80 |
|
L3910 |
Wrist-Hand-Finger Orthosis (WHFO), Swanson design |
269.81 |
|
L3912 |
Wrist-Hand-Finger Orthosis (WHFO), flexion glove with elastic finger
control |
67.98 |
|
L3914 |
Wrist-Hand-Finger Orthosis (WHFO), wrist extension cock-up |
63.80 |
|
L3916 |
Wrist-Hand-Finger Orthosis (WHFO), wrist extension cock-up, with
outrigger |
89.40 |
|
L3918 |
Wrist-Hand-Finger Orthosis (WHFO), knuckle bender |
67.27 |
|
L3920 |
Wrist-Hand Finder Orthosis (WHFO), knuckle bender, with outrigger |
79.31 |
|
L3922 |
Wrist-Hand-Finger Orthosis (WHFO), knuckle bender, two segment to flex
joints |
84.72 |
|
L3924 |
Wrist-Hand-Finger Orthosis (WHFO), Oppenheimer |
92.02 |
|
L3926 |
Wrist-Hand-Finger Orthosis (WHFO), Thomas suspension |
80.12 |
|
L3928 |
Wrist-Hand-Finger Orthosis (WHFO), finger extension, with clock spring |
41.39 |
|
L3930 |
Wrist-Hand-Finger Orthosis (WHFO), finger extension, with wrist support |
53.91 |
|
L3932 |
Wrist-Hand-Finger Orthosis (WHFO), safety pin, spring wire |
38.82 |
|
L3934 |
Wrist-Hand-Finger Orthosis (WHFO), safety pin, modified |
36.53 |
|
L3936 |
Wrist-Hand-Finger Orthosis (WHFO), palmer |
76.63 |
|
L3938 |
Wrist-Hand-finger Orthosis (WHFO), dorsal wrist |
71.05 |
|
L3940 |
Wrist-Hand-Finger Orthosis (WHFO), dorsal, wrist, with outrigger
attachment |
84.26 |
|
L3942 |
Wrist Hand-Finger Orthosis (WHFO), reverse knuckle bender |
63.03 |
|
L3944 |
Wrist-Hand-Finger Orthosis (WHFO), reverse knuckle bender with
outrigger attachment |
84.69 |
|
L3946 |
Wrist-Hand-Finger Orthosis (WHFO), composite electric |
75.95 |
|
3948 |
Wrist-Hand-Finger Orthosis (WHFO), finger knuckle bender |
43.40 |
|
L3950 |
Wrist-Hand-Finger Orthosis (WHFO), combination Oppenheimer, with
knuckle bender and two attachments |
108.73 |
|
L3952 |
Wrist-Hand-Finger Orthosis (WHFO), combination Oppenheimer, with
reverse knuckle and two attachments |
116.76 |
|
L3954 |
Wrist-Hand-Finger Orthosis (WHFO), spreading hand |
67.81 |
|
Q |
UPPER LIMB: SHOULDER-ELBOW-WRIST-HAND |
|
|
A |
ABDUCTION POSITIONING-CUSTOM FITTED |
|
|
L3960 |
Shoulder-Elbow-Wrist-Hand Orthosis (SEWHO), abduction positioning,
airplane design |
468.66 |
|
L3962 |
Shoulder-Elbow-Wrist-Hand Orthosis (SEWHO), abduction positioning ,
ERBS palsey design |
495.96 |
|
L3963 |
Shoulder-Elbow-Wrist-Hand Orthosis (SEWHO), molded shoulder, arm,
forearm, and wrist, with articulating elbow joint |
1,412.83 |
|
L3964 |
Shoulder-Elbow-Wrist-Hand Orthosis (SEWHO), mobile arm support attached
to wheelchair, balanced and fitted to patient, adjustable |
612.92 |
|
L3965 |
Shoulder-Elbow-Wrist-Hand Orthosis (SEWHO), radial arm support,
attached to wheelchair balanced and fitted to patient, adjustable Rancho
type |
1,012.88 |
|
L3966 |
Shoulder-Elbow-Wrist-Hand Orthosis (SEWHO), mobile arm support attached
to wheelchair, balanced and fitted to patient, reclining |
596.37 |
|
L3968 |
Shoulder-Elbow-Wrist-Hand Orthosis (SEWHO), mobile arm support attached
to wheelchair, balanced and fitted to patient, friction arm support
(friction dampening to proximal and distal joints |
778.77 |
|
L3969 |
Shoulder-Elbow-Wrist-Hand Orthosis (SEWHO), mobile arm support,
monsuspension arm and hand support, overhead elbow forearm hand sling
support, yoke type arm suspension support |
658.22 |
|
B |
ADDITIONS TO MOBILE ARM SUPPORTS |
|
|
L3970 |
Shoulder-Elbow-Wrist-Hand Orthosis (SEWHO), addition to mobile arm
support, elevating proximal arm |
251.03 |
|
L3972 |
Shoulder-Elbow-Wrist-Hand Orthosis (SEWHO), addition to mobile arm
support, offset or lateral rocker arm with elastic balance control |
167.42 |
|
L39.74 |
Shoulder-Elbow-Wrist-Hand Orthosis (SEWHO), addition to mobile arm
support, supinator |
109.55 |
|
C |
FRACTURE ORTHOSES |
|
|
L3980 |
Upper extremity fracture orthosis, humeral |
197.36 |
|
L3982 |
Upper extremity fracture orthosis, radius/ulner |
253.26 |
|
L3984 |
Upper extremity fracture orthosis, wrist |
272.63 |
|
L3985 |
Upper extremity fracture orthosis, forearm, hand with wrist hinge |
422.40 |
|
L3986 |
Upper extremity fracture orthosis, combination of humeral,
radius/ulnar, wrists (example-colles fracture) |
398.41 |
|
L3995 |
Addition to upper extremity orthosis, sock, fracture or equal, each |
28.09 |
|
L3999 |
Unlisted procedures for upper limb orthosis
(BY REPORT PROCEDURE) |
By Report |
|
R |
SPECIFIC REPAIR |
|
|
A. |
REPLACEMENTS |
|
|
L4000 |
Replace girdle for Milwaukee orthosis |
946.51 |
|
L4010 |
Replace Trilateral socket brim |
444.59 |
|
L4020 |
Replace quadrilateral socket brim, molded to patient model |
602.78 |
|
L4030 |
Replace quadrilateral socket brim, custom fitted |
330.99 |
|
L4040 |
Replace molded thigh lacer |
271.40 |
|
L4045 |
Replace non-molded thigh lacer |
213.40 |
|
L4050 |
Replace molded calf lacer |
274.39 |
|
L4055 |
Replace non-molded calf later |
171.49 |
|
L4060 |
Replace high roll cuff |
212.40 |
|
L4070 |
Replace proximal and distal upright for KAFO |
190.70 |
|
L4080 |
Replace metal bands KAFO, proximal thigh |
89.75 |
|
L4090 |
Replace metal bands KAFO-AFO, calf or distal thigh |
78.64 |
|
L4100 |
Replace leather cuff KAFO, proximal thigh |
92.62 |
|
L4110 |
Replace leather cuff KAFO-AFO, calf or distal thigh |
74.31 |
|
L4130 |
Replace pretibial shell |
354.84 |
|
B |
ORTHOTIC REPAIRS |
|
|
L4200 |
Repair of orthotic device, hourly rate |
25.00 |
|
L4210 |
Repair of orthotic device, repair or replace minor parts |
34.00 |
|
S |
ANCILLARY ORTHOTIC SERVICES |
|
|
L4310 |
Multi-Podus or equal orthotic preparatory management system for lower
extremities |
374.61 |
|
L4320 |
Addition to AFO, multi-podus (or equal) orthotic preparatory management
system for lower extremities, flexible foot positioner with soft interface
for AFO, with velcro closure custom fitted |
116.89 |
|
L4350 |
Pneumatic ankle control splint (aircast or equal) |
69.98 |
|
L4360 |
Pneumatic walking splint (aircast or equal) |
192.89 |
|
L4370 |
Pneumatic full leg splint (aircast or equal) |
124.48 |
|
L4380 |
Pneumatic knee splint (aircast or equal) |
76.79 |
|
