016.06.04 Ark. Code R. § 065 - Prosthetics Provider Manual Update #60

State Regulations
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Section II Prosthetics

242.110 Respiratory and Diabetic Equipment All Ages

Effective for dates of service on and after October 13, 2003, when billing either electronically or on paper, procedure codes found in this section must be billed with modifier EP for recipients under 21 years of age or modifier NU for recipients age 21 and over. When a second modifier is listed, that modifier must be used in conjunction with either EP or NU.

Additionally, when billing on paper, procedure codes must be billed with a type of service (TOS) code "6" for individuals under age 21 or TOS "H" for individuals age 21 and over.

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

⁷ Procedure code became payable July 1, 2004.

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

Respiratory and Diabetic Equipment All Ages (section 242.110)

National Code	M1	M2	TOS	Description	PA	Capped Rental, Purchase or Rental Only
E0424				Stationary compressed gaseous oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing	Y4	Rental Only
E0430				Portable gaseous oxygen system, purchase, includes regulator, flowmeter, humidifier, cannula or mask, and tubing	Y*	Rental Only
E0435				Portable liquid oxygen system, purchase; includes portable container, supply reservoir, flowmeter, humidifier, contents gauge, cannula or mask, tubing and refill adapter	Y*	Rental Only
E0439				Stationary liquid oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing	Y*	Rental Only
E0441				Oxygen contents, gaseous (for use with owned gaseous stationary systems or when both a stationary and portable gaseous system are owned), one month's supply = I unit	Y	Purchase
E0442				Oxygen contents, liquid (for use with owned liquid stationary systems or when both a stationary and portable liquid system are owned), one month's supply = 1 unit	Y	Purchase

E0443				Portable oxygen contents, gaseous (for use only with portable gaseous systems when no stationary gas or liquid system is used), one month's supply=1 unit	Y*	Purchase
E0444				Portable oxygen contents, liquid (for use only with portable liquid systems when no stationary gas or liquid system is used), one month's supply=1 unit	Y*	Purchase
E0470⁷	NU EP	*01 a:* *a: a:*	H 6	Respiratory assist device, bi-level pressure capacity , w/o backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)	Y Y	Rental Only
E0471⁷	NU EP	RR RR	H 6	Respiratory assist device, bi-level press capacity, w/backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)	Y Y	Rental Only
E0472⁷	NU EP	RR RR	H 6	Respiratory assist device, bi-level pressure capacity, w/backup rate feature, used with invasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)	Y Y	Rental Only
E0560				Humidifier, durable for supplemental humidification during IPPB treatment or oxygen delivery	N	Purchase
E0561⁷	NU EP		H 6	Humidifier, non-heated, used w/positive airway pressure device	Y Y	Purchase
E0562⁷	NU EP		H 6	Humidifier, heated, used w/positive airway pressure device	Y Y	Purchase
E0570				Nebulizer, with compressor	Y*	Purchase
E0575				Nebulizer, ultrasonic, large volume	Y*	Capped Rental
E0600				Respiratory suction pump, home model, portable or stationary, electric	N	Rental Only
E1390				Oxygen concentrator, single delivery port, capable of delivering 85 % or greater oxygen concentration at the prescribed flow rate	Y*	Rental Only

E1391⁷	NU		H	02 concentrator, dual delivery port, capable of delivering 85% or [GREATER THAN] 02 concentration at the prescribed flow rate, each	Y	Purchase
E1391⁷	NU		I	02 concentrator, dual delivery port, 85% or [GREATER THAN] 02 concentration at the prescribed flow rate, each	Y	Purchase

Respiratory and Diabetic Equipment All Ages (section 242.110)

National Code	M1	M2	TOS	Local Code	Description	PA	Capped Rental, Purchase or Rental Only
E1340	NU		H	Z0425	Repair or nonroutine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes (DME Repair: Parts Only Repairs will not be approved for more than the allowed purchase price of new equipment.) (The manufacturer's invoice must be attached to the repair claim for all parts.)	N	Manually Priced
A9999⁷	NU		H	Z0428	Misc. DME supply or accessory, not otherwise specified Unlisted Durable Medical Equipment. (The manufacturer's invoice must be attached to the claim form.)	Y	Manually Priced
E0779	NU	RR		Z1569	Ambulatory infusion pump, mechanical, reusable, for infusion 8 hours or greater (payable only when services are provided to patients receiving chemotherapy, pain management or antibiotic treatment in the home).	Y*	Rental Only

A7034	NU	RR	H	Z1579	Nasal interface (mask or cannula type) used with positive airway pressure device, with or without head strap (CPAP Device Nasal Continuous Positive Airway Pressure (CPAP) Device (includes necessary accessory items) NOTE: Complete Medical data pertinent to the request must be submitted with the prior authorization request. NOTE: Bill A7034 as the Global Monthly Rental Service.	Y*	Rental Only
E0483	NU	RR	H	Z1705	High frequency chest wall oscillation air-pulse generator system, (includes hoses and vest), each (Bronchial Drainage System)	Y*	Rental Only
E0483	NU	52	H	Z1706	High frequency chest wall oscillation air-pulse generator system, (includes hoses and vest), each (Pulmonary Vest) (The manufacturer invoice must be attached to the claim form.)	Y*	Purchase
E1340	NU	U4	H	Z1719	Repair or nonroutine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes (Maintenance for Capped Rental items)	N	N/A
E1340	NU	U1	H	Z1758	Repair or nonroutine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes (Labor Only (a maximum of twenty (20) units (20 units = 5 hours of labor) per date of service is allowable.)	N	Manually Priced
E1340	EP	U1	6	Z1758	Labor Only (a maximum of twenty (20) units (20 units = 5 hours of labor) per date of service is allowable.)	N	Manually Priced

E0470	RR		H	Z1983	BIPAP Device Nasal Bilevel Positive Airway support system (includes necessary accessory items) NOTE: Complete medical data pertinent to the request must be submitted with the prior authorization request.	Y	Global Code for BIPAP
E0784	NU		H	Z2205	External ambulatory infusion pump, insulin	Y*	Purchase
A4230	NU		H	Z2208	Infusion set for external insulin pump, nonneedle cannula type (each)	Y*	Purchase
A4231	NU		H	Z2209	Infusion set for external insulin pump, needle type, (each)	Y*	Purchase
A4232	NU		H	Z2210	Syringe with needle for external insulin pump, sterile, 3cc (each)	Y*	Purchase
A4632			H	Z2211	Replacement battery for external infusion pump, any type, each	Y*	Purchase
A6021	NU		H	Z2212	Collagen dressing, pad size 16 sq. in. or less, each	Y*	Purchase
A6022	NU		H	Z2212	Collagen dressing, pad size more than 16 sq. in. but less than or equal to 48 sq. in., each	Y*	Purchase
A6023	NU		H	Z2212	Collagen dressing, pad size more than 48 sq. in., each	Y*	Purchase
A6024	NU		H	Z2212	Collagen dressing wound filler, per 6 in	Y*	Purchase
A4627	NU	52 H		Z2240	Spacer bag or reservoir without mask, for use with metered dose inhaler.	N	Purchase
A4627	NU		H	Z2241	Spacer bag or reservoir with mask, for use with metered dose inhaler.	N	Purchase

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

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

Effective for dates of service on and after October 13, 2003, when billing either electronically or on paper, procedure codes found in this section must be billed with modifier KH to indicate an initial rental of an item. Modifiers are indicated below with the heading of M1 and M2.

Additionally, when billing on paper, procedure codes must be billed with a type of service (TOS) code "I" for initial rental. Type of service is indicated by the heading of TOS.

Procedure codes shown in the list below are either covered for all ages (AA), for only individuals under age 21 (U21) or for only individuals age 21 and over (21+). A column in the list below defines the differences.

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

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

National Code	M1	M2	TOS	Description	All U21 21 +
E0166				Commode chair, mobile, with detachable arms	U21
E0181				Pressure pad, alternating with pump, heavy duty	U21
E0200				Heat lamp, without stand (table model), includes bulb, or infrared element	U21
E0205				Heat lamp, with stand includes bulb, or infrared element	U21
E0217				Water circulating heat pad with pump	U21
E0225				Hydrocollator unit, includes pad	U21
E0236				Pump for water circulating pad	U21
E0239				Hydrocollator unit, protable	U21
E0250*				Hospital bed, fixed height, with any type side rails, with mattress	U21
E0255*				Hospital bed, variable height; hi-lo, with any type side rails, with mattress	U21
E0260*			I	Hospital bed, semi-electric, (head and foot adjustment), with any type side rails with mattress	U21
E0271				Mattress, inner spring	U21
E0272				Mattress, foam rubber	U21
E0303⁷			I	Hospital bed, heavy duty, extra wide, with weight capacity [GREATER THAN] 350 but [LESS THAN] or = 600, any type side rails, w/mattress	AA
E0424				Stationary, compressed gaseous oxygen system, rental; includes container, contents, regulator flowmeter, humidifier, nebulizer cannula or mask, and tubing	AA
E0430*				Portable gaseous oxygen system, purchase, includes regulator, flowmeter, humidifier, cannula, or mask, and tubing	AA

E0435*		Portable liquid oxygen system, purchase; includes portable container, supply reservoir, flowmeter, humidifier, contents gauge, cannula or mask, tubing and refill adapter	AA
E0439		Stationary liquid oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing	AA
E0480		Percussor, electric or pneumatic, home model	U21
E0565*		Compressor, air power source for equipment which is not self-contained or cylinder driven	U21
E0575*		Nebulizer, ultrasonic, large volume	AA
E0585		Nebulizer, with compressor and heater	U21
E0600		Respiratory suction pump, home model, portable or stationary, electric	AA
E0606		Vaporizer, room type	U21
E0630*		Patient lift, hydraulic, with seat or sling	U21
E0650*		Pneumatic compressor, nonsegmental home model	U21
E0667*		Segmental pneumatic appliance for use with pneumatic compressor, full leg	U21
E0668*		Segmental pneumatic appliance for use with pneumatic compressor, full arm	U21
E0691		Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; treatment area two square feet or less	U21
E0692	I	Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; four foot panel	U21
E0693	I	Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; six foot panel	U21
E0694	I	Ultraviolet multidirectional light therapy system in six foot cabinet includes bulbs/lamps, timer and eye protection	U21
E0720*		TENS, two lead, localized stimulation	U21
E0730*		Transcutaneous electrical nerve stimulation device four or more leads, for multiple nerve stimulation	U21
E0745*	I	Neuromuscular stimulator, electronic shock unit	U21
E0747*		Osteogenesis stimulator, electrical noninvasive, other than spinal applications	U21
E0910		Trapeze bars, also known as Patient Helper, attached to bed, with grab bar	U21
E0920		Fracture frame, attached to bed, includes weights	U21

E0930	Fracture frame, freestanding, includes weights	U21
E0935*	Passive motion exercise device	U21
E0940	Trapeze bar, freestanding, complete with grab bar	U21
E0941	Gravity assisted traction device, any type	U21
E1130*	Standard wheelchair, fixed full-length arms, fixed or swing-away, detachable footrests	U21
E1224*	Wheelchair with detachable arms, elevating leg rests	U21
E1390	Oxygen concentrator, single delivery port, capable of delivering 85 % or greater oxygen concentration at the prescribed flow rate	AA

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

National Code	M1	M2	TOS	Local Code	Description	All U21 21 +
E0779			I	Z1569*	Ambulatory infusion device pump, mechanical, reusable, for infusion 8 hours or greater (payable only when services are provided to patients receiving chemotherapy, pain management or antibiotic treatment in the home)	AA
A7034			I	Z1579*	Nasal interface (mask or cannula type) used with positive airway pressure device, with or without head strap (CPAP Device Nasal Continuous Positive Airway Pressure (CPAP) Device (includes necessary accessory items) NOTE: For 21+, complete medical data pertinent to the request must be submitted with the prior authorization request.	AA
S8105				Z1588*	Oximeter for measuring blood oxygen levels noninvasively	U21
E0250			I	Z2346	Hospital bed, fixed height, with any type side rails, with mattress	21 +
E0255	KH		I	Z2347	Hospital bed, variable height; hi-lo, with any type side rails, with mattress	21 +
E0260	KH		I	Z2348*	Hospital bed, semi-electric, (head and foot adjustment), with any type side rails with mattress	21 +
E0910	KH		I	Z2353	Trapeze bars, also known as Patient Helper, attached to bed, with grab bar	21 +

E1130	KH	Z2355*	Standard wheelchair, fixed full-length arms, fixed or swing-away, detachable footrests	21 +
E1224		Z2356*	Wheelchair with detachable arms, elevating legrests	21 +
E0143		Z2359*	Walker, folding, wheeled, adjustable or fixed height	21 +
E0630	KH	Z2374	Patient lift, hydraulic, with seat or sling	21 +
E0730	KH	Z2380	Transcutaneous electrical nerve stimulation device four or more leads, for multiple nerve stimulation	21 +

NOTE: Where both a national code and a local code ("Z code") are available, the local

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

Providers will be reimbursed for a minimum of 30 days of rental when the equipment is used less than 30 days. Initial rental codes should only be billed when equipment is used less than 30 days during the first month of rental.

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

242.112 Home Blood Glucose Monitor and Supplies - Pregnant Women

Only, All Ages

Effective for dates of service on and after October 13, 2003, when billing either electronically or on paper, procedure codes found in this section must be billed with modifier NU for individuals of all ages. When a second modifier is listed, that modifier must be used in conjunction with the NU modifier.

Additionally, when billing on paper, procedure codes must be billed with a type of service (TOS) code "H" when billing for individuals of all ages. Modifiers in the section are indicated by the heading M1 and M2. Type of service is indicated by the heading TOS. Prior authorization is indicated by the heading PA.

National Code	M1	M2	TOS	Local Code	Description	PA	Capped Rental, Purchase or Rental Only
E0607	NU	U1	H	Z2272	Home Blood Glucose Monitor	N	Purchase
A4253	NU	U1	H	Z2285	Blood glucose test or reagent strips for home glucose monitor, per 50 strips	N	Purchase
A4259	NU	U2	H	Z2337	Lancets, per box of 100	N	Purchase

242.120 Medical Supplies, All Ages

Additionally, when billing on paper procedure codes must be billed with a type of service (TOS) code "H" for individuals of all ages.

Modifiers in this section are indicated by the heading M1 and M2. Type of service is indicated by the heading TOS.

¹ These supplies must be prior authorized. Form DMS-679 may be used for the request for prior authorization. View or print form DMS-679 and instructions for completion. Please note: Compression burn garments are manually priced.

⁷ Procedure code became payable July 1, 2004. Medical Supplies, All Ages (section 242.120)

National Code	M1	M2	TOS	Description
A4206	NU		H	Syringe with needle, sterile 1 cc, ea
A4216⁷	NU		H	Sterile water/saline, 10 ml
A4217⁷	NU		H	Sterile water/saline, 500 ml
A4221¹	NU			Supplies for maintenance of drug infusion catheter, per week (list drug separately)
A4222¹	NU			Supplies for external drug infusion pump, per cassette or bag (list drug separately)
A4253	NU			Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips
A4256	NU			Normal, low, and high calibrator solution/chips
A4259	NU			Lancets, per box of 100
A4265	NU			Paraffin, per pound
A4310	NU			Insertion tray without drainage bag and without catheter (accessories only)
A4311	NU			Insertion tray without drainage bag with indwelling catheter, Foley type, two-way latex with coating (Teflon, silicone, silicone elastomer or hydrophilic, etc.)

A4312	NU		Insertion tray without drainage bag with indwelling catheter, Foley type, two-way, all silicone
A4313	NU		Insertion tray without drainage bag with indwelling catheter, Foley type, three-way, for continuous irrigation
A4314	NU		Insertion tray with drainage bag with indwelling catheter, Foley type, two-way latex with coating (Teflon, silicone, silicone elastomer or hydrophilic, etc.
A4315	NU		Insertion tray with drainage bag with indwelling catheter, Foley type, two-way, all silicone
A4316	NU		Insertion tray with drainage bag with indwelling catheter, Foley type, three-way, for continuous irrigation
A4320	NU		Irrigation tray with bulb or piston syringe, any purpose
A4322	NU		Irrigation syringe, bulb or piston, each
A4326	NU		Male external catheter specialty type with intergral collection chamber, each
A4327	NU		Female external urinary collection device; metal cup, each
A4328	NU		Female external urinary collection device; pouch, each
A4330	NU		Perianal fecal collection pouch with adhesive, each
A4338	NU		Indwelling catheter, Foley type, two-way latex with coating (Teflon, silicone, silicone elastomer or hydrophilic, etc), each
A4340	NU		Indwelling catheter; specialty type, (e.g., coude, mushroom, wing, etc.), each
A4344	NU		Indwelling catheter, Foley type, two-way, all silicone, each
A4346	NU		Indwelling catheter, Foley type, three-way for continuous irrigation, each
A4347	NU		Male external catheter with or without adhesive, with or without anti-reflux device; per dozen
A4348	NU		Male external catherterwith intergral collection compartment, extended wear, each (e.g., 2 per month)
A4351	NU		Intermittent urinary catheter; straight tip, with or without coating (Teflon, silicone, silicone elastomer or hydrophilic, etc.), each
A4351	NU	U1	Intermittent urinary catheter; straight tip, with or without coating (Teflon, silicone, silicone elastomer or hydrophilic, etc.), each
A4352	NU		Intermittent urinary catheter; coude (curved) tip, with or without coating (Teflon, silicone, silicone elastomeric or hydrophilic, etc.), each

A4352	NU	U1	Intermittent urinary catheter; coude (curved) tip, with or without coating (Teflon, silicone, silicone elastomeric or hydrophilic, etc.), each
A4354	NU		Insertion tray with drainage bag but without catheter
A4355	NU		Irrigation tubing set for continuous bladder irrigation through a three-way indwelling Foley catheter, each
A4356	NU		External urethral clamp or compression device (not to be used for catheter clamp), each
A4357	NU		Bedside drainage bag, day or night, with or without anti-reflux device, with or without tube, each
A4358	NU		Urinary drainage bag, leg or abdomen, vinyl, with or without tube, with straps, each
A4359	NU		Urinary suspensory without leg bag, each
A4361	NU		Ostomy faceplate, each
A4362	NU		Skin barrier; solid, four by four or equivalent; each
A4364	NU		Adhesive, liquid, or equal, any type, per ounce
A4367	NU		Ostomy belt, each
A4369	NU		Ostomy skin barrier, liquid, (spray, brush, etc), peroz
A4371	NU		Ostomy skin barrier, power, per oz
A4397	NU		Irrigation supply; sleeve, each
A4398	NU		Ostomy irrigation supply; bag, each
A4399	NU		Ostomy irrigation supply; cone/catheter, including brush
A4400	NU		Ostomy irrigation set
A4402	NU		Lubricant, per ounce
A4404	NU		Ostomy ring, each
A4405	NU		Ostomy skin barrier, non-pectin based, paste, per ounce
A4406	NU		Ostomy skin barrier, pectin based, paste, per ounce
A4414	NU		Ostomy skin barrier, with flange (solid, flexible or accordion), without built-in convexity, 4x4 inches or smaller, each
A4450	NU	U1	Tape, non-waterproof, per 18 square inces
A4452	NU		Tape, waterproof, per 18 square inces
A4455	NU		Adhesive remover or solvent (for tape, cement or other adhesive), per ounce

A4558	NU		Conductive paste or gel
A4561	NU	U1	Pessary, rubber, any type
A4562	NU		Pessary, non rubber, any type
A4623	NU		Tracheostomy, inner cannula
A4625	NU		Tracheostomy care kit for new tracheostomy
A4626	NU		Tracheostomy cleaning brush, each
A4628	NU		Oropharyngeal suction catheter, each
A4629	NU		Tracheostomy care kit for established tracheostomy
A4772	NU		Blood glucose test strips, for dialysis, per 50
A4927	NU		Gloves, non-sterile, per 100
A5051	NU		Ostomy pouch, closed; with barrier attached (one piece), each
A5052	NU		Ostomy pouch, closed; without barrier attached (one piece), each
A5053	NU		Ostomy pouch, closed; for use on faceplate, each
A5054	NU		Ostomy pouch, closed; for use on barrier with flange (two piece), each
A5055	NU		Stoma cap
A5061	NU	U1	Ostomy pouch, drainable; with barrier attached (one piece), each
A5062	NU		Ostomy pouch, drainable; without barrier attached (one piece), each
A5063	NU		Ostomy pouch, drainable; for use on barrier with flange (two piece system), each
A5071	NU		Ostomy pouch, urinary; with barrier attached (one piece), each
A5072	NU		Ostomy pouch, urinary; without barrier attached (one piece), each
A5073	NU		Ostomy pouch, urinary; for use on barrier with flange (two piece), each
A5081	NU		Continent device; plug for continent stoma
A5082	NU		Continent device; catheter for continent stoma
A5093	NU		Ostomy accessory; convex insert
A5102	NU		Bedside drainage bottle, with or without tubing, rigid or expandable, each
A5105	NU		Urinary suspensory; with leg bag, with or without tube

A5112	NU		Urinary leg bag; latex
A5113	NU		Leg strap; latex, replacement only, per set
A5114	NU		Leg strap; foam or fabric, replacement only, per set
A5119	NU		Skin barrier; wipes, box per 50
A5121	NU		Skin barrier; solid, 6 x 6 or equivalent, each
A5122	NU		Skin barrier; solid, 8 x 8 or equivalent, each
A5126	NU		Adhesive or non-adhesive; disk or foam pad
A5131	NU		Appliance cleaner, incontinence and ostomy appliances, per 16 oz.
A6154	NU		Wound pouch, each
A6234	NU	U1	Hydrocolloid dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing
A6241	NU		Hydrocolloid dressing, wound filler, dry form, per gram
A6242	NU		Hydrocolloid dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing
A6242	NU	U1	Hydrocolloid dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing
A6248	NU		Hydrogel dressing, wound filler, gel, per fluid ounce
A6248	NU	U1	Hydrogel dressing, wound filler, gel, per fluid ounce
A6442⁷	NU		Conforming bandage, non-elastic, knitted/woven, non-sterile, width [LESS THAN] 3 in, per yd
A6445⁷	NU		Conforming bandage, non-elastic, knitted/woven sterile, width [LESS THAN]3 in, per yd
A6448⁷	NU		Light compression bandage, elastic, knitted/woven width[LESS THAN]3in, per yd
A6453⁷	NU		Self-adherent bandage, elastic, non-knitted/non-woven, width[LESS THAN]3in, per yd
A6454⁷	NU		Self-adherent bandage, elastic, non-knitted/non-woven, width [GREATER THAN] or = 3 in & [LESS THAN] 5 in, peryd
A6455⁷	NU		Self-adherent bandage, elastic, non-knitted/non-woven, width [GREATER THAN] or= 5 in, peryd
A6501¹'⁷	NU		Compression burn garment, body suit (head to foot), custom fabricated
A6502¹'⁷	NU		Compression burn garment, chin strap, custom fabricated

A6503¹'⁷	NU	Compression burn garment, facial hood, custom fabricated
A6504¹'⁷	NU	Compression burn garment, glove to wrist, custom fabricated
A6505¹'⁷	NU	Compression burn garment, glove to elbow, custom fabricated
A6506¹'⁷	NU	Compression burn garment, glove to axilla, custom fabricated
A6507¹'⁷	NU	Compression burn garment, foot to knee length, custom fabricated
A6508¹'⁷	NU	Compression burn garment, foot to thigh length, custom fabricated
A6509¹'⁷	NU	Compression burn garment, upper trunk to waist including arm openings (vest), custom fabricated
A6510¹'⁷	NU	Compression burn garment, trunk including arms down to leg openings (leotard), custom fabricated
A6511¹'⁷	NU	Compression burn garment, lower trunk including leg openings (panty), custom fabricated
A6512¹'⁷	NU	Compression burn garment, not otherwise classified
A7520⁷	NU	Trachestomy/Laryngectomy tube, non-cuffed, PVC, silicone or equal, each
A7521⁷		Trachestoomy/Laryngectomy tube, cuffed, PVC, silicone or equal, each
A7522⁷		Trachestomy/Laryngectomy tube, stainless steel or equal, (sterilizable and reusable), each
A7524⁷		PO-Tracheostoma stent/stud/button, each
A7525⁷		Tracheostomy mask, each
B4086	NU	Gastrostomy/jejunostomy tube, any material, any type, (standard or low profile), each
E0776	NU	IV pole

Medical Supplies, All Ages (section 242.120)

National Code	M1	M2	TOS	Local Code	Description
A6257	NU		H	Z1938	Transparent film, 16 sq. in. or less, each dressing
A6258	NU		H	Z1939	Transparent film, more than 16 sq. in., but less than or equal to 48 sq. in., each dressing
A6259	NU		H	Z1940	Transparent film, more than 48 sq. in., each dressing

A6216	NU	H	Z1941	Gauze, non-impregnated, non-sterile, pad size 16 sq. in. or less, without adhesive border, each dressing
A6219	NU	H	Z1941	Gauze, non-impregnated, 16 sq. in. or less with any size adhesive border, each dressing
A6228	NU	H	Z1941	Gauze, impregnated, water or normal saline, pad, size 16 sq. in. or less, without adhesive border, each dressing
A6220	NU	H	Z1942	Gauze, non-impregnated, pad more than 16 sq. in., but less than or equal to 48 sq. in., with any size adhesive border, each dressing
A6229	NU	H	Z1942	Gauze, impregnated, water or normal saline, pad size more than 16 sq. in., but less than or equal to 48 sq. in., without adhesive border, each dressing
A6403	NU	H	Z1942	Gauze, non-impregnated, sterile, pad size more than 16 sq. in. but less than 48 sq. in., without adhesive border, each dressing
A6221	NU	H	Z1943	Gauze, non-impregnated, pad size more than 48 sq. in., with any size adhesive border, each dressing
A6230	NU	H	Z1943	Gauze, impregnated, water or normal saline, pad more than 48 sq. in., without adhesive border, each dressing
A6404	NU	H	Z1943	Gauze, non-impregnated, sterile, pad size more than 48 sq. in., without adhesive border, each dressing
A4450	NU	H	Z1944	Tape, non-waterproof, per 18 square inches
A6441⁷	NU	H	Z1944	Padding bandage, non-elastic, non-woven/non-knitted, width [GREATER THAN] or = 3 inches & [LESS THAN] 5 in, per yd
A6443⁷	NU	H	Z1944	Conforming bandage, non-elastic, knitted/woven, non-sterile, width [GREATER THAN] or = 3 in & [LESS THAN] 5 in, per yd
A6444⁷	NU	H	Z1944	Conforming bandage, non-elastic, knitted/woven, non-sterile, width [GREATER THAN] or = 5 in, per yd
A6446⁷	NU	H	Z1944	Conforming bandage, non-elastic, knitted/woven, sterile, width [GREATER THAN] or = 3 in & [LESS THAN] 5 in, per yd
A6447⁷	NU	H	Z1944	Conforming bandage, non-elastic, knitted/woven, sterile, width [GREATER THAN] or= 5 in, per yd
A6245	NU	H	Z1945	Hydrogel dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive border, each dressing
A6242	NU	H	Z1945	Hydrogel dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing

A6243	NU		H	Z1946	Hydrogel dressing, wound cover, pad size more than 16 sq. in., but less than or equal to 48 sq. in., without adhesive border, each dressing
A6246	NU		H	Z1946	Hydrogel dressing, wound cover, pad size more than 16 sq. in., but less than or equal to 48 sq. in., with any size adhesive border, each dressing
A6244	NU		H	Z1947	Hydrogel dressing, wound cover, pad size more than 48 sq. in. without adhesive border, each dressing
A6247	NU		H	Z1947	Hydrogel dressing, wound cover, pad size more than 48 sq. in. with any size adhesive border, each dressing
A6248	NU		H	Z1948	Hydrogel dressing, wound filler, gel, per fluid ounce
A6234	NU		H	Z1949	Hydrocolloid dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing
A6237	NU		H	Z1949	Hydrocolloid dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive border, each dressing
A6235	NU		H	Z1950	Hydrocolloid dressing, wound cover, pad size more than 16 sq. in., but less than or equal to 48 sq. in., without adhesive border, each dressing
A6238	NU		H	Z1950	Hydrocolloid dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing
A6236	NU		H	Z1951	Hydrocolloid dressing, wound cover, pad size more than 48 sq. in., without adhesive border, each dressing
A6238	NU	U1	H	Z1951	Hydrocolloid dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing
A6239	NU		H	Z1951	Hydrocolloid dressing, wound cover, pad size more than 48 sq. in., with any size adhesive border, each dressing
A6196	NU		H	Z1952	Alginate or other fiber gelling dressing, wound cover, pad size 16 sq. in. or less, each dressing
A6197	NU	52	H	Z1953	Alginate or other fiber gelling dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in, each dressing
A6198	NU		H	Z1954	Alginate or other fiber gelling dressing, wound cover, pad size more than 48 sq. in., each dressing
A6197	NU	52	H	Z1955	Alginate or other fiber gelling dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in, each dressing (1 linear yard)

A6212	NU		H	Z1956	Foam dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive border, each dressing
A6213	NU		H	Z1957	Foam dressing, wound cover, pad size more than 16 sq. in but less than or equal to 48 sq. in., with any size adhesive border, each dressing
A6211	NU		H	Z1958	Foam dressing, wound cover, pad size more than 48 sq. in., without adhesive border, each dressing
A6203	NU		H	Z1959	Composite dressing, pad size 16 sq. in. or less, with any size adhesive border, each dressing
A6204	NU		H	Z1960	Composite dressing, pad size more than 16 sq. in. but less than 48 sq. in., with any size adhesive border, each dressing
A6205	NU		H	Z1961	Composite dressing, pad size more than 48 sq. in., with any size adhesive border, each dressing
A4253	NU	52	H	Z1963	Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips
A4353	NU	U2	H	Z1964	Intermittent urinary catheter, with insertion supplies (tray)
A4394	NU		H	Z1965	Ostomy deodorant for use in ostomy pouch, liquid, per fluid ounce
A4365	NU		H	Z1966	Adhesive remover wipes, any type, per 50
A4368	NU		H	Z1967	Ostomy filter, any type, each
A6449⁷	NU		H	Z1969	Light compression bandage, elastic, knitted/woven, width [GREATER THAN] or = 3 in & [LESS THAN] 5 in, per yd
A6450⁷	NU		H	Z1969	Light compression bandage, elastic, knitted/woven, width [GREATER THAN] or= 5 in, per yd
A6451⁷	NU		H	Z1969	Moderate compress bandage, elastic, knitted/woven load resistance of 1.25 to 1.34 foot pounds at 50% maximum stretch, width [GREATER THAN] or = 3 in & [LESS THAN] 5 in, per yd
A6452⁷	NU		H	Z1969	High compress bandage, elastic, knitted/woven, load resistance greater than or equal to 1.35 foot pounds at 50 % maximum stretch, width [GREATER THAN] or = 3 in & [LESS THAN] 5 in, per yd
A4483	NU		H	Z1993	Moisture exchanger, disposable, for use with invasive mechanical ventilation

The following items are not subject to the $250 benefit limit. Medical Supplies, All Ages (section 242.120)

National Code	M1	M2	TOS	Local Code	Description	Maximum Units
Bill on paper			H	Z2481	Thick-It per 8 oz. can 1 unit = 1 can	Maximum 4 units per date of service

L8239

Z2483*

Gradient compression stocking, NOS (Jobst) 1 unit = 1 stocking

Maximum 2 units per date of service

*NOTE: L8239 (Z2483) must be prior authorized. Form DMS-679 may be used for the

request for prior authorization. View or print form DMS-679 and instructions for completion.

242.130 Diapers and Underpads, 3 Years Old and Older -

Additionally, when billing on paper, procedure codes must be billed with a type of service (TOS) code "6" for individuals under age 21 or TOS "H" for individuals age 21 and over.

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

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

National Code	M1	M2	TOS	Local Code	Description	PA	Capped Rental, Purchase or Rental Only
A4554	NU		H	Z1721	Disposable underpads, all sizes (e.g., Chux's)	N	Purchase
A4521	NU		H	Z1722	Adult- sized incontinence product, diaper, small size, each	N	Purchase
A4522	NU		H	Z1723	Adult-sized incontinence product, diaper, medium size, each	N	Purchase
A4523	NU		H	Z1724	Adult-sized incontinence product, diaper, large size, each	N	Purchase
A4335	EP		6	Z1830	Incontinence supply; miscellaneous (Small Child Size Diaper)	N	Purchase
A4335	EP	U1	6	Z1831	Incontinence supply; miscellaneous (Medium Child Size Diaper)	N	Purchase

A4335	EP	U2	6	Z1832	Incontinence supply; miscellaneous (Large Child Size Diaper)	N	Purchase
A4533	EP		6	Z2718	Youth-sized incontinence product, diaper, each (Youth adult Diaper 45-60 lbs.)	N	Purchase
A4524	NU		H	Z2719	Adult-sized incontinence product, diaper, extra large size, each (Extra Large Adult Diaper (over 170 lbs.)	N	Purchase
A4526	NU EP		H 6	Z2720	Adult-sized incontinence product, brief, medium size, each (Over-Night Brief Medium 33-41" waist/hip, 110-170 lbs.)	N	Purchase
A4527	NU EP		H 6	Z2721	Adult-sized incontinence product, brief, large size, each (Over-Night Brief Large 42-54" waist/hip, over 170 lbs.)	N	Purchase
A4528	NU EP		H 6	Z2721	Adult-sized incontinence product, brief, extra-large size, each (Over-Night Brief Large 42-54" waist/hip, over 170 lbs.)	N	Purchase
A4535	NU EP	52	H 6	Z2722	Disposable liner/shield for incontinence, each (Panty Liners/Bladder Pads/Diaper Doublers)	N	Purchase
A4531	EP	U1	6	Z2723	Child-sized incontinence product, brief, small/medium size, each (Pull-ups Unisex up to 34 lbs.)	N	Purchase
A4531	EP		6	Z2724	Child-sized incontinence product, brief, small/medium size, each (Pull-ups Unisex over 34 lbs.)	N	Purchase
A4532	EP	U1	6	Z2725	Child-sized incontinence product, brief, large size, each (Pull-ups Unisex 45-65 lbs.)	N	Purchase
A4532	EP		6	Z2726	Child-sized incontinence product, brief, large size, each (Pull-ups Unisex 65-80 lbs.)	N	Purchase
A4335	NU EP	U1 U3	H 6	72121	Incontinence supply; miscellaneous (Under-Garment One size fits all)	N	Purchase

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

Reimbursement is based on a per unit basis with one unit equaling one item (diaper, underpad). When billing for these services that are benefit limited to a dollar amount per month, providers must bill according to the calendar month.

Providers must not span calendar months when billing for diapers and/or underpads. The date of delivery is the date of service. Providers should not bill "from" and "through" dates of service.

Refer to section 212.500 of this manual for coverage information on diapers and underpads.

242.140 Electronic Blood Pressure Monitor and Cuff, All Ages

Effective for dates of service on and after October 13, 2003, when billing either electronically or on paper, the procedure code found in this section must be billed using modifier NU for individuals of all ages.

Additionally, when billing on paper, the procedure code must be billed with a type of service (TOS) "H" for individuals of all ages.

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

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

National Code	M1	M2	TOS	Local Code	Description	PA	Capped Rental, Purchase or Rental Only
A4670	NU		H	Z1906	Automatic blood pressure monitor	Y*	Rental Only

Included with the rental of this monitor the provider will need to supply one (1) disposable blood pressure cuff each month. This item will be payable for all ages and will require prior authorization. The provider must substantiate that an accurate blood pressure reading cannot be obtained using a regular blood pressure monitor.

242.150 Nutritional Formulae, for Child Health Services (EPSDT) Recipients

Under 21 Years of Age

WIC (Women, Infants and Children Program) must be accessed first for individuals ages 0 through the fifth (5) birthday.

The prosthetics coverage listed below is payable only if the service is prescribed as a result of a Child Health Services (EPSDT) screening/referral.

Effective for dates of service on and after October 13, 2003, when billing either electronically or on paper, procedure codes found in this section must be billed with modifier EP for recipients under 21 years of age. When a second modifier is listed, that modifier must be used in conjunction with EP.

Additionally, when billing on paper, procedure codes must be billed with a type of service (TOS) code "6" for individuals under age 21.

Modifiers in this section are indicated by the headings M1 and M2. Type of service is indicated by the heading TOS.

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

National Code	M1	M2	TOS	Local Code	Description	Covered Formulae
B4150	EP		6	Z1501	Enteral formulae; category I; semi-synthetic intact protein/protein isolates, administered through an enteral feeding tube, 100 calories = 1 unit (Category I - Intact Protein/ Protein Isolates)	See list below
	Covered Formulae: Attain Attain LS Boost Boost Powder Boost w/Fiber Ceralyte Enfamil Enfamil with Iron Enfamil Next Step-Soy Enlive Ensure Ensure High Fiber Ensure HN Ensure Powder Ensure w/Fiber Entra Entrition HN Fibersource Fibersource HN Fortison
	Impact w/or without Fiber	Osmolite HN (1.0
	Intraolite	CAL)
	Isocal	PediaSure w/or
	Isomil	without Fiber
	IsoSource	Pre Attain
	IsoSource HN	Profiber
	Jevity (1.0 CAL)	Promote w/or without
	KinderCal	Fiber
	Lactofree	Prosobee
	Lonalac Powder	Protain XL
	Meritene	Renu
	Meritene	Resource Diabetic
	PowderNewtrition HN	Resource for Kids
	NuBasics	Resource Fruit
	NuBasics Juice	Beverage
	Nutrapack	Resource Liquid
	Nutrapack Isotonic	Sustagen Powder
	Nutren w/without Fiber	Travasorb
	Nutren Jr	Ultracal
	Osmolite
B4151	EP		6	Z1502	Enteral formulae; category I: natural intact protein/protein isolates, administered through an enteral feeding tube, 100 calories = 1 unit (Category IB- Blenderized Intact Protein/Protein Isolates- Naturalized)	Compleat ProBalance Vitaneed

B4152	EP		6	Z1503	Enteral formulae; category	Boost Plus
					II: Intact protein/protein	Comply
					isolates (calorically	Deliver 2
					dense), administered	Ensure Plus
					through an enteral feeding	Ensure Plus HN
					tube, 100 calories = 1 unit	Magnacal
					(Category II- Intact	NuBasics Plus
					Protein/ Protein Isolates -	Nutren 1.5
					Calorically Dense)	Nutren 2.0 Resource Plus Scandishake Two-Cal HN
B4153	EP		6	Z1504	Enteral formulae; category III: hydrolyzed protein/amino acids, administered through an enteral feeding tube, 100 calories = 1 unit (Category III- Hydrolyzed Protein/Amino Acids)	See list below
	Covered Formulae: Accupep HPF Alimentum Alitraq Criticare HN Isotein HN Neocate Neocate 1 + Neocate Jr. Nutramigen Peptamen
	Peptamen 1.5 Diet	Reabilan
	Peptamen Junior	Reabilan HN
	Peptamen VHP	SandoSource Peptide
	Peptamen with Prebio 1	Travasorb HN Powder
	Pepti	Vital HN Powder
	Precision HN Powder	Vivonex Pediatric
	Precision Isotonic Powder	Vivonex Plus
	Pregestimal	Vivonex TEN Powder


B4153	EP		6	Z1504	Enteral formulae; category III: hydrolyzed protein/amino acids, administered through an enteral feeding tube, 100 calories = 1 unit (Category III- Hydrolyzed Protein/Amino Acids)	See list below
	Covered Formulae: Accupep HPF Alimentum Alitraq Criticare HN Isotein HN Neocate Neocate 1 + Neocate Jr. Nutramigen Peptamen
	Peptamen 1.5 Diet	Reabilan
	Peptamen Junior	Reabilan HN
	Peptamen VHP	SandoSource Peptide
	Peptamen with Prebio 1	Travasorb HN Powder
	Pepti Precision HN	Vital HN Powder
	Powder	Vivonex Pediatric
	Precision Isotonic Powder	Vivonex Plus
	Pregestimal	Vivonex TEN Powder

B4154	EP		6	Z1505	Enteral formulae; category IV: defined formula for special metabolic need, administered through an enteral feeding tube, 100 calories = 1 unit (Category IV- Defined Formula for Special Metabolic Needs)	See list below
	Covered formulae: Ad vera AminAid Powder Analog MSUD Analog X Phen, Tyr Analog X Phen, Tyr, MCT Analog XP Boost Pudding Calcilo XD Choice DM Cyclinex DiabetiSource Ensure Pudding Flavinex Forta Drink Fulfill Glucerna Glytrol 1 Valex-1 1 Valex-2
	NutriHep	Low Phe/Tyr Diet
	Perative	Powder
	Periflex	Maxamaid MSUD
	Phenex I	Maxamaid XP
	Phenex II	Maxamaid XLYS-TRY
	Phenyl-Free	Maxamaid X Phen,
	PKU 1, 2 & 3	Tyr
	Portagen Powder	Maxamum MSUD
	Product 80056	MaxamumXP
	Propimax I	MSUD 1, 2 & Powder
	Propimax II	Nepro
	Pulmocare	RCF
	Hepatic Aid Powder	Respalor
	Hominex 1 & 2	Similac 60/40
	IsoSource VHN	Suplena
	Ketocal Powder	Traumacal
	Ketonex 1	TraumAid Powder
	Ketonex 2	Travasorb MCT
	Lofenalac	Powder Travasorb Renal Powder TYR 1 & 2
B4155	EP		6	Z1506	Enteral formulae; category V: modular components,	Casec Powder Fructose Powder
Bill on Paper (Indicate specific name of formula on claims.)					administered through an enteral feeding tube, 100 calories = 1 unit Category V - Modular	Gevral Protein MCT Oil MCT Powder Moducal
					Components (Protein, Carbohydrates, Fat)	Polycose Liquid Promod Provimin Sumacal
B4156	EP		6	Z1507	Enteral formulae: category VI: standardized nutrients, administered through an enteral feeding tube, 100 calories = 1 unit. (Category VI - Standard)	Precision LR Powder Enfamil Premature -24 CAL with/without IronSimalac Neosure Special Care - 20 & 24 K Calorie/ounce with Iron Tolerex Travasorb STD Powder

B4155

Z2264

Enteral formulae; category V: modular components, administered through an enteral feeding tube, 100 calories = 1 unit (Calorie Boosters)

Polycose Powder

Dextrose

Scandical

B4155

Z2273

Enteral formulae; category V: modular components, administered through an enteral feeding tube, 100 calories = 1 unit

Microlipids

B4154

Z2500

Enteral formulae; category IV: defined formula for special metabolic need, administered through an enteral feeding tube, 100 calories = 1 unit

XMTVI Maxamaid

Providers must bill the formula procedure codes with a type of service code "6." One unit of service equals 100 calories with a maximum of 30 units per day reimbursable. Supplies provided in conjunction with the nutritional formula through the prosthetics programs must be billed under the prosthetics medical supply code. These formulae are covered as nutritional supplements rather than the sole source of nutrition.

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

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

NOTE: If a specific formula is not listed, but is the same as a formula listed, it may be billed using the procedure code for the comparable formula. It is the responsibility of the provider to prove comparability when audited.

242.151 Pedia-Pop

Effective for dates of service on and after October 13, 2003, when billing either electronically or on paper, the procedure code found in this section must be billed with modifier EP. Additionally, when billing on paper, procedure code must be billed with a type of service (TOS) code "6". Reimbursement for this product is provider's cost plus ten percent. Pedia-Pop is covered for eligible Medicaid recipients of all ages. Pedia-Pop is only for oral consumption, and only in frozen form.

Modifiers in this section are indicated by the headings M1 and M2. Type of service is indicated by the heading TOS.

National Code	M1	M2	TOS	Local Code	Local Code Description	Maximum Units
Bill on paper	EP		6	Z2487	Pedia-Pop 1 unit = 1 box	2 units per date of service

242.152 Enteral Nutrition Infusion Pump and Enteral Feeding Pump Supply Kit

The procedure codes listed below will be covered on a case-by-case basis for individuals under age 21 who require supplemental feeding because of medical necessity. Sufficient medical documentation must be provided to establish that the enteral nutrition infusion pump is medically necessary (e.g., supplemental feeding must be given over an extended period of time due to reflux, cystic fibrosis, etc.). The primary care physician (PCP) or appropriate specialist must prescribe the pump, citing the medical reason that bolus feeds are inappropriate.

Effective for dates of service on and after October 13, 2003, when billing either electronically or on paper, procedure codes found in this section must be billed with modifier EP for recipients under 21 years of age. When a second modifier is listed, that modifier must be used in conjunction with EP.

Additionally, when billing on paper, procedure codes must be billed with a type of service (TOS) code "6" for individuals under age 21.

The procedure codes will require prior authorization from the Utilization Review Section of the Division of Medical Services.

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

National Code	M1	M2	TOS	Local Code	Description	Maximum Units	PA
B4035	EP		6	Z1509	Enteral feeding supply kit, pump fed, per day (1 unit = 1 day)	1 per day	Y

E1340	EP	U2	6	Z1510	Repair or nonroutine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes (Repair-Enteral Nutrition Infusion Pump)	N/A	Y
B9000	EP		6	Z1525	Enteral nutrition infusion pump - without alarm (1 day = 1 unit)	1 per day	Y

A. Enteral Nutrition Infusion Pump

Reimbursement for the enteral nutrition infusion pump is based on a rent-to-purchase methodology. Each unit reimbursed by Medicaid will apply towards the purchase price established by Medicaid. Reimbursement will only be approved for new equipment. Used equipment will not be prior authorized. Code B9000 (Z1525) Enteral Nutrition Infusion Pump, represents a new piece of equipment being reimbursed by Medicaid on the rent-to-purchase plan. Code B9000 (Z1525) is reimbursed on a per unit basis with 1 day equaling 1 unit of service per day. Medicaid will reimburse on the rent-to-purchase plan for a total of 304 units of service. After reimbursement has been made for 304 units, the equipment will become the property of the Medicaid recipient. Prior authorization is required for code B9000 (Z1525). The prior authorization request must include the serial number of the infusion pump being provided to the recipient.

B. Enteral Feeding Pump Supply Kit

Reimbursement may be made for the pump supply kit necessary for the administration of the nutrients in the recipient's place of residence, when the feeding method involves an enteral nutrition infusion pump. The pump supply kit and the infusion pump require prior authorization from the Utilization Review Section of the Division of Medical Services. The enteral feeding pump supply kit is reimbursed on a per unit basis with 1 day equaling 1 unit of service. A maximum or 1 unit per day is allowed. The pump supply kit includes the pump sets, containers and syringes necessary for administration of the nutrients.

C. All other equipment and supplies are included in the unit price of the nutrient categories and may not be billed separately.

D. Equipment Repairs

E. Reimbursement for repairs to the enteral nutrition infusion pump requires prior authorization. Repairs will be approved only on equipment purchased by Medicaid. Therefore, no repairs will be reimbursable prior to the equipment becoming the property of the Medicaid recipient.

Requests for prior authorization for enteral pump repairs must be mailed to the Utilization Review Section, Division of Medical Services as detailed in section 220.000 of this manual.

The repair invoice and the serial number of the equipment must accompany the prior authorization request form. Total repair costs to an infusion pump may not exceed $290.93. Medicaid will not reimburse for additional repairs to an infusion pump after the provider has billed repair invoices totaling $290.93. If, after billing the Medicaid maximum allowed for repairs, the equipment is still not in proper working order, the provider must supply the recipient with a new infusion pump and may bill procedure code B9000 (Z1525) after receiving prior authorization for the new piece of equipment. When billing the Medicaid Program for repairs made to the enteral infusion pump, the following procedure code must be used.

National Code	M1	M2	TOS	Local Code	Description
E1340	EP	U2	6	Z1510	Repair or nonroutine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes (Repair-Enteral Nutrition Infusion Pump)

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

Supplies

The Arkansas Medicaid Program reimburses for the MIC-KEY Skin Level Gastrostomy Tube (Mic-Key Button) and supplies for Medicaid-eligible individuals under age 21. Prior authorization (PA) from the Utilization Review Section will be required. When billing the procedure codes, providers must use type of service "6."

The procedure codes may also be authorized for Medicaid-eligible children ages 0 through 5 years who receive their sole source enteral formula through the Women, Infants and Children (WIC) Program. The Utilization Review Section must be contacted to receive the prior authorization.

To request prior authorization, complete and forward Form DMS-679, titled "Medical Equipment Request for Prior Authorization and Prescription", along with sufficient medical documentation, to the Utilization Review Section. View or print the Utilization Review Section contact information. View or print form DMS-679 and instructions for completion.

The MIC-KEY Kit will be benefit limited to 2 per state fiscal year (SFY). The accessories, extension sets and adapters will be covered under the $250 medical supply benefit limit. Benefit extensions will be considered on a case-by-case basis, if proven to be medically necessary. Prior authorization must be obtained from the Utilization Review Section for any extensions using the DMS-679.

Procedure codes listed are individually priced.

National Code	Local Code	Local Code Description
Bill on paper	Z2698	MIC-KEY Kit
Bill on paper	Z2699	SECUR-LOK Extension Set with 2 Port 'Y' and Clamp 12" Length
Bill on paper	Z2700	SECUR-LOK Extension Set with 2 Port 'Y' and Clamp 24" Length

Bill on paper	Z2702	Bolus Extension Set with Single Port Clamp 12" Length
Bill on paper	Z2703	Bolus Extension Set with Single Port Clamp 24" Length
Bill on paper	Z2704	Bolus SECUR-LOK Extension Set Single Port w/Clamp 12" Length
Bill on paper	Z2705	Bolus SECUR-LOK Extension Set Single Port w/Clamp 24" Length
Bill on paper	Z2706	Microvasive Adapter
Bill on paper	Z2714	Microvasive Decompression Tube

242.160 Durable Medical Equipment, All Ages

Additionally, when billing on paper, procedure codes must be billed with a type of service (TOS) code "6" for individuals under age 21 and TOS "H" for individuals age 21 and over. TOS "U" must be used when billing for used equipment.

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

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

*** This procedure code may not be billed for TOS "U" (used equipment).

7 Procedure code became payable July 1, 2004.

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

Durable Medical Equipment, All Ages (section 242.160)

National Code	M1	M2	TOS	PA	Description	Capped Rental, Purchase or Rental Only
A4635	NU 11		*I	N	Underarm pad, crutch, replacement, each	Purchase
A4636	NU UE		H 6 U	N	Replacement, handgrip, cane, crutch, or walker, each	Purchase
A4637	NU EP		*I	N	Replacement, tip, cane, crutch, walker, each	Purchase
E0100	NU 11		H ⁶u	N	Cane, includes canes of all materials, adjustable or fixed, with tip	Purchase
E0105	NU EP UE		H 6 U	N	Cane, quad or three-prong, includes canes of all materials, adjustable or fixed, with tips	Purchase
E0110	NU EP UE		*I	N	Crutches, forearm, includes crutches of various materials, adjustable or fixed, pair, complete with tips and handgrips	Purchase
E0111	NU EP UE	U1	H ⁶U	N	Crutch, forearm, includes crutches of various materials, adjustable or fixed, each, with tip and handgrip	Purchase
E0112	NU EP UE		u	N	Crutches, underarm, wood, adjustable or fixed, pair, with pads, tips and handgrips	Purchase
E0113	NU 11		*I	N	Crutch, underarm, wood, adjustable or fixed, each, with pad, tip and handgrip	Purchase
E0114	NU UE		H 6 U	N	Crutches, underarm, other than wood, adjustable or fixed, pair, with pads, tips and handgrips	Purchase
E0116	NU EP		*I	N	Crutch, underarm, other than wood, adjustable or fixed, each, with pad, tip and handgrip	Purchase
E0130	NU 11		H ⁶u	N	Walker, rigid (pickup), adjustable or fixed height	Purchase
E0135	NU EP UE		H 6 U	N	Walker, folding (pickup), adjustable or fixed height	Purchase
E0140⁷	NU EP		a^H	N	Walker, w/trunk support, adjustable or fixed height, any type	Purchase
E0141	3 0_ LU ZUJD		H 6 U	N	Walker, rigid, wheeled, adjustable or fixed height	Purchase

E0143	NU 11			N	Walker, folding, wheeled, adjustable or fixed height	Purchase
E0147	NU UE		H 6 U	N	Walker, heavy duty, multiple braking system, variable wheel resistance	Purchase
E0153	NU EP		:	N	Platform attachment, forearm crutch, each	Purchase
E0154	NU 11		H 5	N	Platform attachment, walker, each	Purchase
E0155	NU EP UE		H 6 U	N	Wheel attachment, rigid pick-up walker, per pair seat attachment, walker	Purchase
E0156⁷	NU EP		a^H	N	Seat attachment, walker	Purchase
E0157	3 0_ LU ZUJD		H 6 U	N	Crutch attachment, walker, each	Purchase
E0158	NU 11		*	N	Leg extensions for walker, per set of four (4)	Purchase
E0159⁷	NU EP		H 6	N	Brake attachment for wheeled walker, replacement, each	Purchase
E0160	NU		*	N	Sitztype bath or equipment, portable, used with or without commode	Purchase
E0161	NU EP UE		H 6 U	N	Sitztype bath or equipment, portable, used with or without commode, with faucet attachment(s)	Purchase
E0163	NU EP		*	N	Commode chair, stationary, with fixed arms	Purchase
E0164	NU 11		H 5	N	Commode chair, mobile, with fixed arms	Purchase
E0166	3 0_ LU ZUJD		H 6 U	N	PO-Commode chair, mobile, w/detachable arms	Capped Rental
E0166	NU EP UE	U2 U2 U2	H 6 U	N	PO-Commode chair, mobile, w/detachable arms	Purchase

E0167	NU 11		*	N	Pail or pan for use with commode chair	Purchase
E0175	NU UE		H 6 U	N	Foot rest, for use with commode chair, each	Purchase
E0178	NU EP	U4	u	N	Gel or gel-like pressure pad or cushion, nonpositioning	Purchase
E0180	NU 11		H 5	N	Pressure pad, alternating with pump	Purchase
E0181	NU EP UE		H 6 U	N	Pressure pad, alternating with pump, heavy duty	Capped Rental
E0182	NU EP UE	U1	H 6 U	N	Pump for alternating pressure pad	Purchase
E0184	NU EP UE		H ⁶U	N	Dry pressure mattress	Purchase
E0185	NU EP UE		a^H u	N	Gel or gel-like pressure pad for mattress, standard mattress length and width	Purchase
E0189	NU 11		*	N	Lambswool sheepskin pad, any size	Purchase
E0190⁷	NU UE		H 6 U	N	Positioning cushion/pillow/wedge, any shape or size	Purchase
E0191	NU EP		*	N	Heel or elbow protector, each	Purchase
E0192	NU		H 5	N	Low pressure and positioning equalization pad, for wheelchair	Purchase
E0196⁷	NU EP		H 6	N	Gel pressure mattress	Purchase
E0197	NU 11		H 5	N	Air pressure pad for mattress, standard mattress length and width	Purchase
E0200	NU EP UE		H 6 U	N	Heat lamp, without stand (table model), includes bulb, or infrared element	Capped Rental

E0202	NU 11			N	Phototherapy (bilirubin) light with photometer	Rental Only
E0205	NU UE		H 6 U	N	Heat lamp, with stand includes bulb, or infrared element	Capped Rental
E0217	NU EP		:	N	Water circulating heat pad with pump	Capped Rental
E0225	NU 11		H 5	N	Hydrocollator unit, includes pad	Capped Rental
E0235	NU EP UE		H 6 U	N	Paraffin bath unit, portable (see medical supply code A4265 for paraffin)	Purchase
E0236	NU EP UE		*	N	Pump for water circulating pad	Capped Rental
E0238	NU EP UE		H ⁶U	N	Nonelectric heat pad, moist	Purchase
E0239	NU EP UE		u	N	Hydrocollator unit, portable	Capped Rental
E0240⁷	NU 1 EP	U1 U1 U2 U2 U3 U3	H 6 H 6 H 6 H 6	N	Bath/shower chair w/wo wheels, any size	Purchase
E0247⁷	NU EP EP	U1 U1	H 6	N	Transfer bench, tub/toilet, w/wo commode opening	Purchase
E0248⁷	NU EP EP	U1 U1	a^H H 6	N	Transfer bench, heavy duty, tub/toilet w/wo commode opening	Purchase
E0249	NU EP		:	N	Pad for water circulating heat unit	Purchase
E0250	UE		U	Y4	Hospital bed, fixed height, with any type side rails, with mattress	Capped Rental

E0255	UE		u	Y*	Hospital bed, variable height; hi-lo, with any type side rails, with mattress	Capped Rental
E0260	3 0_ LU ZUJD	RR RR	H 6 U	Y*	Hospital bed, semi-electric, (head and foot adjustment), with any type side rails with mattress	Capped Rental
E0271	NU		*	N	Mattress, inner spring	Capped Rental
E0272	3 0_ LU Z LU 3		H 6 U	N	Mattress, foam rubber	Capped Rental
E0273	NU EP		*	N	Bed board	Purchase
E0275	NU 11		H 5	N	Bed pan, standard, metal or plastic	Purchase
E0276	NU EP UE		H 6 U	N	Bed pan, fracture, metal or plastic	Purchase
E0280	NU 11		*	N	Bed cradle, any type	Purchase
E0300⁷	EP EP	RR	6 6	Y Y	Pediatric crib, hospital grade, fully enclosed Pediatric crib, hospital grade, fully enclosed	Purchase Rental Only
E0303⁷	NU EP UE		u	Y Y Y	Hospital bed, heavy duty, extra wide, with weight capacity [GREATER THAN] 350 but [LESS THAN] or = 600, any type side rails, w/mattress	Rental Only (Rent to Purchase)
E0325	NU NU	U1	H H 6 u	N	Urinal; male, jug-type, any material	Purchase
E0326	NU 11		H 5	N	Urinal; female, jug-type, any material	Purchase
E0480	NU EP UE		H 6 U	N	Percussor, electric or pneumatic, home model	Capped Rental
E0565	NU EP UE		*	Y*	Compressor, air power source for equipment which is not self-contained or cylinder driven	Capped Rental

E0570	NU 11	*I	N	Nebulizer, with compressor	Purchase
E0585	NU UE	H 6 U	N	Nebulizer, with compressor and heater	Capped Rental
E0605	NU EP	*I	N	Vaporizer, room type	Purchase
E0606	NU 11	H ⁶u	N	Postural drainage board	Capped Rental
E0607***	NU EP	H 6	N	Home blood glucose monitor	Purchase
E0630	NU EP UE	*I	Y*	Patient lift, hydraulic, with seat or sling	Capped Rental
E0650	NU EP UE	H ⁶U	Y*	Pneumatic compressor, nonsegmental home model	Capped Rental
E0667	NU EP UE	u	Y*	Segmental pneumatic appliance for use with pneumatic compressor, full leg	Capped Rental
E0668	NU 11	*I	Y*	Segmental pneumatic appliance for use with pneumatic compressor, full arm	Capped Rental
E0691	NU 11	H ⁶u	N	Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; treatment area two square feet or less	Rental Only
E0692	NU EP	H 6	N	Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; four foot panel	Rental Only
E0693	NU EP	a"	N	Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; six foot panel	Rental Only
E0694	NU EP	H 6	N	Ultraviolet multidirectional light therapy system in six foot cabinet includes bulbs/lamps, timer and eye protection	Rental Only
E0720	NU EP UE	H 6 U	Y*	TENS, two lead, localized stimulation	Capped Rental

E0730	NU	*I	Y*	Transcutaneous electrical nerve stimulation device four or more leads, for multiple nerve stimulation	Capped Rental
E0740	NU UE	H 6 U	N	Incontinence treatment system, pelvic floor stimulator, monitor, sensor and/or trainer	Purchase
E0745	NU EP	*I	Y*	Neuromuscular stimulator, electronic shock unit	Capped Rental
E0747	NU	H ⁶u	Y*	Osteogenesis stimulator, electrical noninvasive, other than spinal applications	Rental Only
E0748	NU EP	H 6	N	Osteogenesis stimulator, electrical noninvasive, spinal applications	Purchase
E0749	NU EP UE	*I	Y*	Osteogenesis stimulator, electrical, surgically implanted	Purchase
E0840	NU EP UE	H ⁶U	N	Traction frame, attached to headboard, cervical traction	Purchase
E0850	NU EP UE	u	N	Traction stand, freestanding, cervical traction	Purchase
E0860	NU 11	*I	N	Traction equipment, overdoor, cervical	Purchase
E0870	NU UE	H 6 U	N	Traction frame, attached to footboard, extremity traction (e.g., Buck's)	Purchase
E0880	NU EP	*I	N	Traction stand, freestanding, extremity traction (e.g., Buck's)	Purchase
E0890	NU	H ⁶u	N	Traction frame, attached to footboard, pelvic traction	Purchase
E0900	NU EP UE	H 6 U	N	Traction stand, freestanding, pelvic traction (e.g., Buck's)	Purchase
E0910	NU EP UE	*I	N	Trapeze bars, also known as Patient Helper, attached to bed, with grab bar	Capped Rental

E0920	NU 11	*I	N	Fracture frame, attached to bed, includes weights	Capped Rental
E0930	NU UE	H 6 U	N	Fracture frame, freestanding, includes weights	Capped Rental
E0935	NU EP	*I	Y*	Passive motion exercise device	Capped Rental
E0940	NU 11	H ⁶u	N	Trapeze bar, freestanding, complete with grab bar	Capped Rental
E0941	NU EP UE	H 6 U	N	Gravity assisted traction device, any type	Capped Rental
E0942	NU EP UE	*I	N	Cervical head harness/halter	Purchase
E0944	NU EP UE	H ⁶U	N	Pelvic belt/harness/boot	Purchase
E0945	NU EP UE	u	N	Extremity belt/harness	Purchase
E0946	NU 11	*I	N	Fracture frame, dual with cross bars, attached to bed (e.g., Balken, Four Poster)	Purchase
E0947	NU UE	H 6 U	N	Fracture frame, attachments for complex pelvic traction	Purchase
E0948	NU EP	*I	N	Fracture frame, attachments for complex cervical traction	Purchase
E0950	NU 11	H ⁶u	N	Wheelchair accessory, tray, each	Purchase
E1130*	NU EP UE	H 6 U	Y*	Standard wheelchair, fixed full-length arms, fixed or swing-away, detachable footrests	Capped Rental
E1140*	NU EP UE	*I	Y*	Wheelchair, detachable arms, desk or full-length, swing-away, detachable footrests	Capped Rental

E1150*

Wheelchair; detachable arms, desk or full-length, swing-away, detachable, elevating legrests

Capped Rental

E1160*

NU UE

H 6 U

Wheelchair; fixed full-length arms, swing-away, detachable, elevating legrests

Capped Rental

E1224*

NU EP

Wheelchair with detachable arms, elevating leg rests

Capped Rental

Durable Medical Equipment, All Ages (section 242.160)

National Code	M1	M2	TOS	Local Code	Description	PA	Capped Rental, Purchase or Rental Only
E1340	NU		H	Z0425	Repair or nonroutine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes (DME Repairs/Parts Only Repairs will not be approved for more than the allowed purchase price of new equipment.) (The manufacturer's invoice must be attached to the repair claim for all parts.)	N	Manually Priced
E0779	NU		H	Z1569	Ambulatory infusion pump, mechanical, reusable, for infusion 8 hours or greater (Ambulatory infusion device payable only when services are provided to patients receiving chemotherapy, pain management or antibiotic treatment in the home.)	Y*	Rental Only
S8105	NU EP		H 6	Z1588***	Oximeter for measuring blood oxygen levels noninvasively (Pulse oximeter (including 4 disposable probes)	Y*	Rental Only

E1340	NU EP	U1 U1	H 6	Z1758***	Repair or non routine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes (Labor Only (a maximum of twenty (20) units (20 units = 5 hours of labor) per date of service is allowable.)	N	Manually Priced
E0245	NU EP	U1 U1	H 6	Z1822***	Tub stool or bench (Bath Frame Support, Large)	N	Purchase
S8096	NU EP		H 6	Z1828***	Portable peak flow meter (used by asthmatic patients)	N	Purchase
E0250	NU EP		H 6	Z1892	Hospital bed, fixed height, with any type side rails, with mattress	Y*	Purchase
E0255	NU EP	U1	H 6	Z1893	Hospital bed, variable height; hi-lo, with any type side rails, with mattress	Y*	Purchase
E0260	NU EP		H 6	Z1894	Hospital bed, semi-electric, (head and foot adjustment), with any type side rails with mattress	Y*	Purchase

Procedure codes E0250* (Z1892*), E0255 (Z1893*) and E0260 (Z1894*) must be billed when hospital beds are purchased for eligible Medicaid recipients of all ages.

The hospital beds must be new, not used. When billing electronically, the above procedure codes must be billed with a modifier of NU for individuals age 21 and over, or modifier EP when billing for individuals under the age of 21. A type of service code "6" must be used for billing paper claims for recipients under age 21 and type of service code "H" for recipients age 21 and over. The codes all require prior authorization. Providers must only provide these purchase-only services to recipients who are expected to require the bed for a long period of time. Each procedure code for hospital beds listed above may only be billed once every 10 years.

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

242.161 Used Durable Medical Equipment, Age 21 and Over

Effective for dates of service on and after October 13, 2003, when billing either electronically or on paper, procedure codes found in this section must be billed with modifier UE for used equipment.

Additionally, when billing on paper, bill for recipients age 21 and over using these procedure codes with a type of service code "U," for used equipment.

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

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

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

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

National Code	M1	M2	TOS	Local Code	Description	PA	Capped Rental, Purchase or Rental Only
E0163	UE		U	Z2344	Commode chair, stationary with fixed arms	N	Purchase
E0255	UE		u	Z2347	Hospital bed, variable height; hi-lo, with any type side rails, with mattress	Y	Capped Rental
E0260	UE		u	Z2348	Hospital bed, semi-electric, (head and foot adjustment), with any type side rails with mattress	Y*	Capped Rental
E0910	UE		u	Z2353	Trapeze bars, also known as Patient Helper, attached to bed, with grab bar	N	Capped Rental
E1130	UE		u	Z2355*	Standard wheelchair; fixed full-length arms, fixed or swing-away, detachable footrests	Y*	Capped Rental
E1224	UE		u	Z2356*	Wheelchair with detachable arms, elevating legrests	Y*	Capped Rental
E0143	UE		u	Z2359	Walker, folding, wheeled, adjustable or fixed height	N	Capped Rental
E0630	UE		u	Z2374	Patient lift, hydraulic, with seat or sling	Y*	Capped Rental
E0730	UE		u	Z2380	Transcutaneous electrical nerve stimulation device four or more leads, for multiple nerve stimulation	Y*	Capped Rental
E0105	UE		u	Z2387	Cane, quad or three-prong, includes canes of all materials, adjustable or fixed, with tips	N	Purchase

E0143	UE	U	Z2395	Walker, folding, wheeled, adjustable or fixed height	N	Purchase
E0180	UE	U	Z2410	Pressure pad, alternating with pump	N	Purchase
E0191	UE	U	Z2416	Heel or elbow protector, each	N	Purchase
E0192	UE	U	Z2417	Low pressure and positioning equalization pad for wheelchair	N	Purchase
E0202	UE	U	Z2419	Phototherapy (bilirubin) light with photometer	N	Rental Only

242.170 Apnea Monitors for Individuals Under 1 Year of Age

Additionally, when billing on paper, procedure codes must be billed with a type of service (TOS) code "6" for individuals under 21 years of age or type of service "U", for used equipment.

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

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

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

National Code

TOS

Local Code

Description

Capped Rental, Purchase or Rental Only

E0618

EP EP

Apnea monitor, without recording feature

Y(on

31st day)*

Rental Only (Daily Rental)

E0619

E0608

Apnea monitor, with recording feature

Y(on

31st day)*

Rental Only (Daily Rental)

Bill on paper	6	Z1684	Technical and lab services for setting up pneumogram or event recording (not including professional services)	N	Purchase
E0618	!	Z1685	Apnea monitor, without recording feature (Initial set up of apnea monitor includes 30 days rental)	N	First Month's Rental
E0619		Z1685	Apnea monitor, with recording feature (Initial set up of apnea monitor includes 30 days rental)	N	First Month's Rental

242.180 Orthotic Appliances, All Ages

Additionally, when billing on paper, procedure codes must be billed with a type of service (TOS) code "6" for individuals under age 21 or TOS code "H" for individuals age 21 and over.

Modifiers in this section are indicated by the headings M1 and M2. Type of service is indicated by the heading TOS.

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

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

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

Orthotic Appliances, All Ages (section 242.180)

National Code	M1	M2	TOS	Description	All U21 21 +	PA 21 +	Capped Rental, Purchase or Rental Only
A5500	NU		H	For diabetics only, fitting (including follow-up) custom preparation and supply of off-the-sheld depth-inlay shoe manufactured to accommodate multi-density insert(s), per shoe	21 +	Y	Purchase
A5501	NU		H	For diabetics only, fitting (including follow-up) custom preparation and supply of molded from cast(s) of patient's foot (custom molded shoe), per shoe	21 +	Y	Purchase
A5503	NU		H	For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with roller or rigid rocker bottom, per shoe	21 +	Y	Purchase
A5504	NU		H	For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with wedge(s), per shoe	21 +	Y	Purchase
A5505	NU		H	For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with metatarsal bar, per shoe	21 +	Y	Purchase
A5506	NU		H	For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with off-set heel(s), per shoe	21 +	Y	Purchase
A5507	NU		H	For diabetics only, not otherwise specified modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe, per shoe	21 +	Y	Purchase
A5509	NU		H	For diabetics only, direct formed, molded to foot with external heat source (i.e., heat gun) multiple density inserts(s), prefabricated, per shoe	21 +	Y	Purchase
A5510	NU		H	For diabetics only, direct formed, compression molded to patient's foot without external heat source, multiple-density insert(s) prefabricated, per shoe	21 +	Y	Purchase

A5511	NU	H	For diabetics only, custom-molded from model of patient's foot multiple-density insert(s) custom-fabricated, per shoe	21 +	Y	Purchase
L0100	NU EP	H 6	Cranial orthosis (helmet), with or without soft interface, molded to patient model	All	N	Purchase
L0110	NU EP	H 6	Cranial orthosis (helmet), with or without soft interface, non-molded	All	N	Purchase
L0120	NU EP	H 6	Cervical, flexible, nonadjustable (foam collar)	All	N	Purchase
L0130	NU EP	H 6	Cervical, flexible, thermoplastic collar, molded to patient	All	N	Purchase
L0140	NU EP	H 6	Cervical, semi-rigid, adjustable (plastic collar)	All	N	Purchase
L0150	NU EP	H 6	Cervical, semi-rigid, adjustable molded chin cup (plastic collar with mandibular/occipital piece)	All	N	Purchase
L0160	NU EP	H 6	Cervical, semi-rigid wire frame occipital/mandibular support	All	N	Purchase
L0170	NU EP	H 6	Cervical, collar, molded to patient model	All	N	Purchase
L0172	NU EP	H 6	Cervical, collar, semi-rigid thermoplastic foam, two piece	All	N	Purchase
L0174	NU EP	H 6	Cervical, collar, semi-rigid thermoplastic foam, two piece with thoracic extension	All	N	Purchase
L0180	NU EP	H 6	Cervical, multiple post collar, occipital/mandibular supports, adjustable	All	N	Purchase
L0190	NU EP	H 6	Cervical, multiple post collar, occipital/mandibular supports, adjustable cervical bars (Somi, Guilford, Taylor types)	All	N	Purchase
L0200	NU EP	H 6	Cervical, multiple post collar, occipital/mandibular supports, adjustable cervical bars, and thoracic extension	All	N	Purchase
L0210	NU EP	H 6	Thoracic, rib belt	All	N	Purchase
L0220	NU EP	H 6	Thoracic, rib belt, custom fabricated	All	N	Purchase

L0450	NU EP	H 6	TLSO, flexible, provides trunk support, upper thoracic region, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, prefabricated, includes fitting and adjustment	All	N	Purchase
L0452	NU EP	H 6	TLSO, flexible, provides trunk support, upper thoracic region, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, custom fabricated	All	N	Purchase
L0454	NU EP	H 6	TLSO, flexible, provides trunk support, extends from sacrococcygeal junction to above T-9 vertebra, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, prefabricated, includes fitting and adjustment	All	N	Purchase
L0456	NU EP	H 6	TLSO, flexible, provides trunk support, thoracic region, rigid posterior panel and soft anterior apron, extends from sacrococcygeal junction and terminates just inferior to the scapular spine, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks, includes straps and closures, prefabricated, includes fitting and adjustment	All	N	Purchase

L0458	NU EP	H 6	TLSO, triplanar control, modular segmented spinal system, two rigid plastic shells, posterior extends from sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal, coronal and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment	All	N	Purchase
L0460	NU EP	H 6	TLSO, triplanar control modular segmented spinal system, two rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, including straps and closures, prefabricated, includes fitting and adjustment	All	N	Purchase
L0462	NU EP	H 6	TLSO, triplanar control modular segmented spinal system, three rigid plastic shells, posterior extends from sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, including straps and closures, prefabricated, includes fitting and adjustment	All	N	Purchase

L0464	NU EP	H 6	TLSO, triplanar control modular segmented spinal system, four rigid plastic shells, posterior extends from sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in sagittal, coronal and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, including straps and closures, prefabricated, includes fitting and adjustment	All	N	Purchase
L0466	NU EP	H 6	TLSO, sagittal control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, restricts gross trunk motion in sagittal plane, produces intracavitary pressure to reduce load on intervertebral disks, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment	All	N	Purchase
L0468	NU EP	H 6	TLSO, sagittal-coronal control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, extends from sacrococcygeal junction over scapulae, lateral strength provided by pelvic, thoracic, and lateral frame pieces, restricts gross trunk motion in sagittal and coronal planes, produces intracavitary pressure to reduce load on intervertebral disks, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment	All	N	Purchase

L0470	NU EP	H 6	TLSO, triplanar control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, extends from sacrococcygeal junction to scapula, lateral strength provided by pelvic, thoracic, and lateral frame pieces, rotational strength provided by subclavicular extensions, restricts gross trunk motion in sagittal, coronal and transverse planes, produces intracavitary pressure to reduce load on intervertebral disks, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment	All	N	Purchase
L0472	NU EP	H 6	TLSO, triplanar control, hyperextension, rigid anterior and lateral frame extends from symphysis pubis to sternal notch with two anterior components (one pubic and one sternal) posterior and lateral pads with straps and closures, limits spinal flexion, restricts gross trunk motion in sagittal, coronal and transverse planes, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment	All	N	Purchase
L0474	NU EP	H 6	TLSO, triplanar control, rigid posterior frame with multiple straps, closures and padding, extends from sacrococcygeal junction to scapula, lateral strength provided by pelvic, thoracic, and lateral frame pieces, rotational strength provided by subclavicular extensions, restricts gross trunk motion in sagittal, coronal and transverse planes, produces intracavitary pressure to reduce load on the intervertebral disks, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment	All	N	Purchase

L0476	NU EP	H 6	TLSO, sagittal-coronal control, flexion compression jacket, two rigid plastic shells with soft liner, posterior extends from sacrococcygeal junction and terminates at or before the T9 vertebra, anterior extends from symphysis pubis to xiphoid, usually laced together on one side, restricts gross trunk motion in sagittal and coronal planes, allows free flexion and compression of the LS region, includes straps and closures, prefabricated, includes fitting and adjustment	All	N	Purchase
L0478	NU EP	H 6	TLSO, sagittal-coronal control, flexion compression jacket, two rigid plastic shells with soft liner, posterior extends from sacrococcygeal junction and terminates at or before the T9 vertebra, anterior extends from symphysis pubis to xiphoid, usually laced together on one side, restricts gross trunk motion in sagittal and coronal planes, allows free flexion and compression of the LS region, includes straps and closures, custom fabricated	All	N	Purchase
L0480	NU EP	H 6	TLSO, triplanar control, one piece rigid plastic shell without interface liner, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated	All	N	Purchase

L0482	NU EP	H 6	TLSO, triplanar control, one piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated	All	N	Purchase
L0484	NU EP	H 6	TLSO, triplanar control, two piece rigid plastic shell without interface liner, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, lateral strength is enhanced by overlapping plastic, restricts gross trunk motion in the sagittal, coronal and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated	All	N	Purchase
L0486	NU EP	H 6	TLSO, triplanar control, two piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, lateral strength is enhanced by overlapping plastic, restricts gross trunk motion in the sagittal, coronal and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated	All	N	Purchase

L0488	NU EP	H 6	TLSO, triplanar control, one piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal and transverse planes, prefabricated, includes fitting and adjustment	All	N	Purchase
L0490	NU EP	H 6	TLSO, sagittal-coronal control, one piece rigid plastic shell with overlapping reinforced anterior, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates at or before the T9 vertebra, anterior extends from symphysis pubis to xiphoid, anterior opening, restricts gross trunk motion in sagittal and coronal planes, prefabricated, includes fitting and adjustment	All	N	Purchase
L0500	NU	H	Lumbar-sacral-orthosis (LSO), flexible, (lumbo-sacral support)	21 +	N	Purchase
L0510	NU	H	LSO, flexible, (lumbo-sacral support), custom fabricated	21 +	N	Purchase
L0515	NU	H	LSO, anterior-posterior control, with rigid or semi-rigid posterior panel, prefabricated	21 +	N	Purchase
L0520	NU EP	H 6	LSO, anterior-posterior-lateral control, (Knight, Wilcox types), with apron front	All	N	Purchase
L0530	NU EP	H 6	LSO, anterior-posterior control (Macausland type), with apron front	All	N	Manually Priced
L0540	NU EP	H 6	LSO, lumbar flexion (Williams flexion type)	All	N	Purchase
L0550	NU EP	H 6	LSO, anterior-posterior-lateral control, molded to patient model	All	Y	Purchase
L0560	NU EP	H 6	LSO, anterior-posterior-lateral control, molded to patient model, with interface material	All	Y	Purchase

L0565	NU EP	H 6	LSO, anterior-posterior-lateral control, custom fitted	All	Y	Purchase
L0600	NU EP	H 6	Sacroiliac, flexible (sacroiliac surgical support)	All	N	Purchase
L0610	NU EP	H 6	Sacroiliac, flexible (sacroiliac surgical support, custom fabricated	All	N	Purchase
L0620	NU EP	H 6	Sacroiliac, semi-rigid (Goldthwaite, Osgood types), with apron front	All	N	Purchase
L0700	NU EP	H 6	Cervical-thoracic-lumbar-sacral-orthoses (CTLSO), anterior-posterior- lateral control, molded to patient model, (Minerva type)	All	Y	Purchase
L0710	NU EP	H 6	CTLSO, anterior-posterior-lateral-control, molded to patient model, with interface material, (Minerva type)	All	Y	Purchase
L0810	NU EP	H 6	Halo procedure, cervical halo incorporated into jacket vest	All	Y	Purchase
L0820	NU EP	H 6	Halo procedure, cervical halo incorporated into plaster body jacket	All	Y	Purchase
L0830	NU EP	H 6	Halo procedure, cervical halo incorporated into Milwaukee type orthosis	All	Y	Purchase
L0860	NU EP	H 6	Addition to halo procedure, magnetic reasonance image compatible system	All	Y	Purchase
L0960	NU EP	H 6	Torso support, post surgical support, pads for post surgical support	All	N	Purchase
L0970	NU EP	H 6	TLSO, corset front	All	N	Purchase
L0972	NU EP	H 6	LSO, corset front	All	N	Purchase
L0974	NU EP	H 6	TLSO, full corset	All	N	Purchase
L0976	NU EP	H 6	LSO, full corset	All	N	Purchase
L0978	NU EP	H 6	Axillary crutch extension	All	N	Purchase
L0980	NU EP	H 6	Peroneal straps, pair	All	N	Purchase

L0982	NU EP	H 6	Stocking supporter grips, set of four (4)	All	N	Purchase
L0984	NU	H	Protective body sock, each	21 +	N	Purchase
L1000	NU EP	H 6	CTLSO (Milwaukee), inclusive of furnishing initial orthosis, including model	All	Y	Purchase
L1010	NU EP	H 6	TLSO or scoliosis orthosis, axilla sling	All	N	Purchase
L1020	NU EP	H 6	Addition to CTLSO or scoliosis orthosis, kyphosis pad	All	N	Purchase
L1025	NU EP	H 6	Addition to CTLSO or scoliosis orthosis, kyphosis pad, floating	All	N	Purchase
L1030	NU EP	H 6	Addition to CTLSO or scoliosis orthosis, lumbar bolster pad	All	N	Purchase
L1040	NU EP	H 6	Addition to CTLSO or scoliosis orthosis, lumbar or lumbar rib pad	All	N	Purchase
L1050	NU EP	H 6	Addition to CTLSO or scoliosis orthosis, sternal pad	All	N	Purchase
L1060	NU EP	H 6	Addition to CTLSO or scoliosis orthosis, thoracic pad	All	N	Purchase
L1070	NU EP	H 6	Addition to CTLSO or scoliosis orthosis, trapezius sling	All	N	Purchase
L1080	NU EP	H 6	Addition to CTLSO or scoliosis orthosis, outrigger	All	N	Purchase
L1085	NU EP	H 6	Addition to CTLSO or scoliosis orthosis, outrigger, bilateral with vertical extensions	All	N	Purchase
L1090	NU EP	H 6	Addition to CTLSO or scoliosis orthosis, lumbar sling	All	N	Purchase
L1100	NU EP	H 6	Addition to CTLSO or scoliosis orthosis, ring flange, plastic or leather	All	N	Purchase
L1110	NU EP	H 6	Addition to CTLSO or scoliosis orthosis, ring flange, plastic or leather, molded to patient model	All	N	Purchase
L1120	NU EP	H 6	Addition to CTLSO, scoliosis orthosis, cover for upright, each	All	N	Purchase
L1200	NU EP	H 6	Thoracic-lumbar-sacral-orthosis (TLSO), inclusive of furnishing initial orthosis only	All	Y	Purchase

L1210	NU EP	H 6	Addition to TLSO, (low profile), lateral thoracic extension	All	N	Purchase
L1220	NU EP	H 6	Addition to TLSO, (low profile), anterior thoracic extension	All	N	Purchase
L1230	NU EP	H 6	Addition to TLSO, (low profile), Milwaukee type superstructure	All	N	Purchase
L1240	NU EP	H 6	Addition to TLSO, (low profile), lumbar derotation pad	All	N	Purchase
L1250	NU EP	H 6	Addition to TLSO, (low profile), anterior ASIS pad	All	N	Purchase
L1260	NU EP	H 6	Addition to TLSO, (low profile), anterior thoracic derotation pad	All	N	Purchase
L1270	NU EP	H 6	Addition to TLSO, (low profile), abdominal pad	All	N	Purchase
L1280	NU EP	H 6	Addition to TLSO, (low profile), rib gusset (elastic), each	All	N	Purchase
L1290	NU EP	H 6	Addition to TLSO, (low profile), lateral trochanteric pad	All	N	Purchase
L1300	NU EP	H 6	Other scoliosis procedure, body jacket molded to patient model	All	Y	Purchase
L1310	NU EP	H 6	Other scoliosis procedure, postoperative body jacket	All	Y	Purchase
L1499	NU EP	H 6	Spinal orthosis, not otherwise specified	All	Y	Manually Priced
L1500	NU EP	H 6	THKAO, mobility frame (Newington, Parapodium types)	All	Y	Purchase
L1510	NU EP	H 6	THKAO, standing frame, with or without tray and accessories	All	Y	Purchase
L1520	NU EP	H 6	THKAO, swivel walker	All	Y	Purchase
L1600	NU EP	H 6	HO, abduction control of hip joints, flexible, Frejka type with cover, prefabricated, includes fitting and adjustment	All	N	Purchase
L1610	NU EP	H 6	HO, abduction control of hip joints, flexible, (Frejka cover only) prefabricated, includes fitting and adjustment	All	N	Purchase

L1620	NU EP	H 6	HO, abduction control of hip joints, flexible, (Pavlik harness), prefabricated, includes fitting and adjustment	All	N	Purchase
L1630	NU EP	H 6	HO, abduction control of hip joints, semi-flexible (Von Rosen type), custom fabricated	All	N	Purchase
L1640	NU EP	H 6	HO, abduction control of hip joints, static, pelvic band or spreader bar, thigh cuffs, custom fabricated	All	N	Purchase
L1650	NU EP	H 6	HO, abduction control of hip joints, static, adjustable, custom fitted (llfled type), prefabricated, includes fitting and adjustment	All	N	Purchase
L1660	NU EP	H 6	HO, abduction control of hip joints, static, plastic, prefabricated, includes fitting and adjustment	All	N	Purchase
L1680	NU EP	H 6	HO; abduction control of hip joints, dynamic, pelvic control, adjustable hip motion control, thigh cuffs (Rancho hip action type), custom fabricated	All	Y	Purchase
L1685	NU EP	H 6	HO, abduction control of hip joint, post operative hip abduction type, custom fabricated	All	Y	Purchase
L1686	NU EP	H 6	HO, abduction control of hip joint, post operative hip abduction type, prefabricated, includes fitting and adjustments	All	Y	Purchase
L1690	NU	H	Combination, bilateral, lumbosacral, hip, femur orthosis providing adduction and internal rotation control, prefabricated, includes fitting and adjustment	21 +	Y	Purchase
L1700	NU EP	H 6	Legg Perthes orthosis, (Toronto type), custom fabricated	All	Y	Purchase
L1710	NU EP	H 6	Legg Perthes orthosis, (Newington type), custom fabricated	All	Y	Purchase
L1720	NU EP	H 6	Legg Perthes orthosis, trilateral, (Tachdijan type), custom fabricated	All	Y	Purchase
L1730	NU EP	H 6	Legg Perthes orthosis, (Scottish Rite type) custom fabricated	All	Y	Purchase

L1750	NU EP	H 6	Legg Perthes orthosis, Legg Perthes sling (Sam Brown type), prefabricated, includes fitting and adjustment	All	N	Purchase
L1755	NU EP	H 6	Legg Perthes orthosis, (Patten bottom type), custom fabricated	All	Y	Purchase
L1800	NU EP	H 6	KO, elastic with stays, prefabricated, includes fitting and adjustment	All	N	Purchase
L1810	NU EP	H 6	KO, elastic with joints, prefabricated, includes fitting and adjustment	All	N	Purchase
L1815	NU EP	H 6	KO, elastic or other elsastic type material with condylar pad(s), prefabricated, includes fitting and adjustment	All	N	Purchase
L1820	NU EP	H 6	KO, elastic with condyle pads and joints, prefabricated, includes fitting and adjustment	All	N	Purchase
L1825	NU EP	H 6	KO, elastic knee cap. prefabricated, includes fitting and adjustment	All	N	Purchase
L1830	NU EP	H 6	KO, immobilizer, canvas longitudinal, prefabricated, includes fitting and adjustment	All	N	Purchase
L1832	NU EP	H 6	KO, adjustable knee joints, positional orthosis, rigid support, prefabricated, includes fitting and adjustment rigid support	All	N	Purchase
L1834	NU EP	H 6	KO, without knee joint, rigid, custom fabricated	All	N	Purchase
L1840	NU EP	H 6	KO, derotation, medial-lateral, anterior cruciate ligament, custom fabricated	All	Y	Purchase
L1843	NU	H	Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint, medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, includes fitting and adjustment	21 +	Y	Purchase

L1844	NU	H	KO, single upright, thigh and calf, with adjustable flexion and extension joint, medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated	21 +	Y	Purchase
L1845	NU EP	H 6	KO, double upright, thigh and calf, with adjustable flexion and extension joint, medial-lateral and rotation control, prefabricated, includes fitting and adjustment	All	Y	Purchase
L1846	NU EP	H 6	KO, double upright, thigh and calf, with adjustable flexion and extension joint, medial-lateral and rotation control, custom fabricated	All	Y	Purchase
L1847	NU	H	Knee orthosis, double upright with adjustable joint, with inflatable air support chamber(s) prefabricated, includes fitting and adjustment	21 +	N	Purchase
L1850	NU EP	H 6	KO, Swedish type, prefabricated, includes fitting and adjustment	All	N	Purchase
L1855	NU EP	H 6	KO, molded plastic, thigh and calf sections, with double upright knee joints, custom fabricated	All	Y	Purchase
L1858	NU EP	H 6	KO, molded plastic, polycentric knee joints, pneumatic knee pads (CTI), custom fabricated	All	Y	Purchase
L1860	NU EP	H 6	KO, modification of supracondylar prosthetic socket, custom fabricated (SK)	All	Y	Purchase
L1870	NU EP	H 6	KO, double upright, thigh and calf lacers, with knee joints, custom fabricated	All	Y	Purchase
L1880	NU EP	H 6	KO, double upright, nonmolded thigh and calf cuff/lacers with knee joints, custom fabricated	All	N	Purchase
L1900	NU EP	H 6	AFO, spring wire, dorsiflexion assist calf band, custom fabricated	All	N	Purchase
L1902	NU EP	H 6	AFO, ankle gauntlet, prefabricated, includes fitting and adjustment	All	N	Purchase
L1904	NU EP	H 6	AFO, molded ankle gauntlet, custom fabricated	All	N	Purchase

L1906	NU EP	H 6	AFO, multigamentus ankle support, prefabricated, includes fitting and adjustment	All	N	Purchase
L1910	NU EP	H 6	AFO, posterior, single bar, clasp attachment to shoe counter prefabricated, includes fitting and adjustment,	All	N	Purchase
L1920	NU EP	H 6	AFO, single upright with static or adjustable stop (Phelps or Perlstein type, custom fabricated	All	N	Purchase
L1930	NU EP	H 6	AFO, plastic or other material, prefabricated, includes fitting and adjustment	All	N	Purchase
L1940	NU EP	H 6	AFO, plastic or other material, custom-fabricated	All	N	Purchase
L1945	NU EP	H 6	AFO, molded to patient model, plastic, rigid anterior tibial section (floor reaction), custom fabricated	All	Y	Purchase
L1950	NU EP	H 6	AFO, spiral, (Institute of Rehabilitative Medicine type), plastic, custom fabricated	All	N	Purchase
L1960	NU EP	H 6	AFO, posterior solid ankle, plastic, custom fabricated	All	N	Purchase
L1970	NU EP	H 6	AFO, plastic, with ankle joint, custom fabricated	All	N	Purchase
L1980	NU EP	H 6	AFO, single upright free plantar dorsiflexion, solid stirrup, calf band/cuff (single bar "BK" orthosis), custom fabricated	All	N	Purchase
L1990	NU EP	H 6	AFO, double upright free plantar dorsiflexion, solid stirrup, calf band/cuff (double bar "BK" orthosis), custom fabricated	All	N	Purchase
L2000	NU EP	H 6	KAFO, single upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar "AK" orthosis), custom fabricated	All	Y	Purchase
L2010	NU EP	H 6	KAFO, single upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar "AK" orthosis), without knee joint, custom fabricated	All	Y	Purchase

L2020	NU EP	H 6	KAFO, double upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (double bar "AK" orthosis), custom fabricated	All	Y	Purchase
L2030	NU EP	H 6	KAFO, double upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs, (double bar "AK" orthosis), without knee joint, custom fabricated	All	Y	Purchase
L2035	NU	H	KAFO, full plastic, static prefabricated (pediatric size) prefabricated, includes fitting and adjustment	21 +	N	Purchase
L2036	NU EP	H 6	KAFO, full plastic, double upright, free knee, custom fabricated	All	Y	Purchase
L2037	NU EP	H 6	KAFO, full plastic, single upright, free knee, custom fabricated	All	Y	Purchase
L2038	NU EP	H 6	KAFO, full plastic, without knee joint, multi-axis ankle, (Lively orthosis or equal), custom fabricated	All	Y	Purchase
L2039	NU	H	KAFO, full plastic, single upright, poly-axial hinge, medial lateral rotation control, custom fabricated	21 +	Y	Purchase
L2040	NU EP	H 6	HKAFO, torsion control, bilateral rotation straps, pelvic band/belt, custom fabricated	All	N	Purchase
L2050	NU EP	H 6	HKAFO, torsion control, bilateral torsion cables, hip joint, pelvic band/belt, custom fabricated	All	N	Purchase
L2060	NU EP	H 6	HKAFO, torsion control, bilateral torsion cables, ball bearing hip joint, pelvic band/belt, custom fabricated	All	N	Purchase
L2070	NU EP	H 6	HKAFO, torsion control, unilateral rotation straps, pelvic band/belt, custom fabricated	All	N	Purchase
L2080	NU EP	H 6	HKAFO, torsion control, unilateral torsion cable, hip joint, pelvic band/belt, custom fabricated	All	N	Purchase
L2090	NU EP	H 6	HKAFO, torsion control, unilateral torsion cable, ball bearing hip joint, pelvic band/belt, custom fabricated	All	N	Purchase

L2106	NU EP	H 6	AFO, fracture orthosis, tibial fracture cast orthosis, thermoplastic type casting material, custom fabricated	All	N	Purchase
L2108	NU EP	H 6	AFO, fracture orthosis, tibial fracture cast orthosis, custom fabricated	All	Y	Purchase
L2112	NU EP	H 6	AFO, fracture orthosis, tibial fracture orthosis, soft, prefabricated, includes fitting and adjustment	All	N	Purchase
L2114	NU EP	H 6	AFO, fracture orthosis, tibial fracture orthosis, semi-rigid, prefabricated, includes fitting and adjustment	All	N	Purchase
L2116	NU EP	H 6	AFO, fracture orthosis, tibial fracture orthosis, rigid, prefabricated, includes fitting and adjustment	All	N	Purchase
L2126	NU EP	H 6	KAFO, fracture orthosis, femoral fracture cast orthosis, thermoplastic type casting material, molded to patient	All	Y	Purchase
L2128	NU EP	H 6	KAFO, fracture orthosis, femoral fracture cast orthosis, thermoplastic type casting material, custom fabricated	All	Y	Purchase
L2132	NU EP	H 6	KAFO, fracture orthosis, femoral fracture cast orthosis, soft, prefabricated, includes fitting and adjustment	All	Y	Purchase
L2134	NU EP	H 6	KAFO, fracture orthosis, femoral fracture cast orthosis, semi-rigid custom fitted	All	Y	Purchase
L2136	NU EP	H 6	KAFO, fracture orthosis, femoral fracture cast orthosis, rigid, prefabricated, includes fitting and adjustment	All	Y	Purchase
L2180	NU EP	H 6	Addition to lower extremity fracture orthosis, plastic shoe insert with ankle joints	All	N	Purchase
L2182	NU EP	H 6	Addition to lower extremity fracture orthosis, drop lock knee joint	All	N	Purchase
L2184	NU EP	H 6	Addition to lower extremity fracture orthosis, limited motion knee joint	All	N	Purchase
L2186	NU EP	H 6	Addition to lower extremity fracture orthosis, adjustable motion knee joint (Lerman type)	All	N	Purchase

L2188	NU EP	H 6	Addition to lower extremity fracture orthosis, quadrilateral brim	All	N	Purchase
L2190	NU EP	H 6	Addition to lower extremity fracture orthosis, waist belt	All	N	Purchase
L2192	NU EP	H 6	Addition to lower extremity fracture orthosis, hip joint, pelvic band, thigh flange, and pelvic belt	All	N	Purchase
L2200	NU EP	H 6	Additions to lower extremity, dorsiflexion and plantar flexion	All	N	Purchase
L2210	NU EP	H 6	Addition to lower extremity, dorsiflexion assist (plantar flexion resist), each joint	All	N	Purchase
L2220	NU EP	H 6	Addition to lower extremity, dorsiflexion and plantar flexion assist/resist, each joint	All	N	Purchase
L2230	NU EP	H 6	Addition to lower extremity, split flat caliper stirrups and plate attachment	All	N	Purchase
L2240	NU EP	H 6	Addition to lower extremity, round caliper and plate attachment	All	N	Purchase
L2250	NU EP	H 6	Addition to lower extremity, foot plate, molded to patient model, stirrup attachment	All	N	Purchase
L2260	NU EP	H 6	Addition to lower extremity, reinforced solid stirrup (Scott-Craig type)	All	N	Purchase
L2265	NU EP	H 6	Addition to lower extremity, long tongue stirrup	All	N	Purchase
L2270	NU EP	H 6	Addition to lower extremity, varus/valgus correction ("T") strap, padded/lined or malleolus pad	All	N	Purchase
L2275	NU	H	Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined	21 +	N	Purchase
L2280	NU EP	H 6	Addition to lower extremity, molded inner boot	All	N	Purchase
L2300	NU EP	H 6	Addition to lower extremity, abduction bar (bilateral hip involvement), jointed, adjustable	All	N	Purchase
L2310	NU EP	H 6	Addition to lower extremity, abduction bar straight	All	N	Purchase

L2320	NU EP	H 6	Addition to lower extremity, nonmolded lacer	All	N	Purchase
L2330	NU EP	H 6	Addition to lower extremity, lacer molded to patient model	All	N	Purchase
L2335	NU EP	H 6	Addition to lower extremity, anterior swing band	All	N	Purchase
L2340	NU EP	H 6	Addition to lower extremity, pretidial shell, molded to patient model	All	N	Purchase
L2350	NU EP	H 6	Addition to lower extremity, prosthetic type, (BK) socket, molded to patient model, (used for "PTB" "AFO" orthoses)	All	Y	Purchase
L2360	NU EP	H 6	Addition to lower extremity, extended steel shank	All	N	Purchase
L2370	NU EP	H 6	Addition to lower extremity, Patten bottom	All	N	Purchase
L2375	NU EP	H 6	Addition to lower extremity, torsion control, ankle joint and half solid stirrup	All	N	Purchase
L2380	NU EP	H 6	Addition to lower extremity, torsion control, straight knee joint, each joint	All	N	Purchase
L2385	NU EP	H 6	Addition to lower extremity, straight knee joint, heavy duty, each joint	All	N	Purchase
L2390	NU EP	H 6	Addition to lower extremity, offset knee joint, each joint	All	N	Purchase
L2395	NU EP	H 6	Addition to lower extremity, offset knee joint, heavy duty, each joint	All	N	Purchase
L2397	NU	H	Addition to lower extremity orthosis, suspension sleeve	21 +	N	Purchase
L2405	NU EP	H 6	Addition to knee joint, lock; drop, stance or swing phase, each joint	All	N	Purchase
L2415	NU EP	H 6	Addition to knee lock with integrated release mechanism , (bail, cable or equal, any material, each joint	All	N	Purchase
L2425	NU EP	H 6	Addition to knee joint, disc or dial lock for adjustable knee flexion, each joint	All	N	Purchase
L2430	NU	H	Addition to knee joint, ratchet lock for active and progressive knee extension, each joint	21 +	N	Purchase

L2435	NU EP	H 6	Addition to knee joint, polycentric joint, each joint	All	N	Purchase
L2492	NU EP	H 6	Addition to knee joint, lift loop for drop lock ring	All	N	Purchase
L2500	NU EP	H 6	Addition to lower extremity, thigh/weight bearing, gulteal/ischial weight bearing, ring	All	N	Purchase
L2510	NU EP	H 6	Addition to lower extremity, thigh/weight bearing, quadrilateral brim, molded to patient model	All	N	Purchase
L2520	NU EP	H 6	Addition to lower extremity, thigh/weight bearing, quadrilateral brim, custom fitted	All	N	Purchase
L2525	NU EP	H 6	Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim molded to patient model	All	N	Purchase
L2526	NU EP	H 6	Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim, custom fitted	All	N	Purchase
L2530	NU EP	H 6	Addition to lower extremity, thigh/weight bearing, lacer, non-molded	All	N	Purchase
L2540	NU EP	H 6	Addition to lower extremity, thigh/weight bearing, lacer, molded to patient model	All	N	Purchase
L2550	NU EP	H 6	Addition to lower extremity, thigh/weight bearing, high roll cuff	All	N	Purchase
L2570	NU EP	H 6	Addition to lower extremity, pelvic control, hip joint, clevis type two position joint, each	All	N	Purchase
L2580	NU EP	H 6	Addition to lower extremity, pelvic control, pelvic sling	All	N	Purchase
L2600	NU EP	H 6	Addition to lower extremity, pelvic control, hip joint, Clevis type, or thrust bearing free, each	All	N	Purchase
L2610	NU EP	H 6	Addition to lower extremity, pelvic control, hip joint, Clevis or thrust bearing, lock, each	All	N	Purchase
L2620	NU EP	H 6	Addition to lower extremity, pelvic control, hip joint, heavy duty, each	All	N	Purchase

L2622	NU EP	H 6	Addition to lower extremity, pelvic control, hip joint, adjustable flexion, each	All	N	Purchase
L2624	NU EP	H 6	Addition to lower extremity, pelvic control, hip joint, adjustable flexion, extension, abduction control, each	All	N	Purchase
L2627	NU EP	H 6	Addition to lower extremity, pelvic control, plastic, molded to patient model, reciprocating hip joint and cables	All	N	Purchase
L2628	NU EP	H 6	Addition to lower extremity, pelvic control, metal frame, reciprocating hip joint and cables	All	N	Purchase
L2630	NU EP	H 6	Addition to lower extremity, pelvic control, band and belt unilateral	All	N	Purchase
L2640	NU EP	H 6	Addition to lower extremity, pelvic control, band and belt bilateral	All	N	Purchase
L2650	NU EP	H 6	Addition to lower extremity, pelvic and thoracic control, gluteal pad, each	All	N	Purchase
L2660	NU EP	H 6	Addition to lower extremity, thoracic control, thoracic band	All	N	Purchase
L2670	NU EP	H 6	Addition to lower extremity, thoracic control, paraspinal uprights	All	N	Purchase
L2680	NU EP	H 6	Addition to lower extremity, thoracic control, lateral support uprights	All	N	Purchase
L2750	NU EP	H 6	Addition to lower extremity orthosis, plating chrome or nickel, per bar	All	N	Purchase
L2755	NU	H	Addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepreg composite, per segment	21 +	N	Purchase
L2760	NU EP	H 6	Addition to lower extremity orthosis, extension, per extension, per bar (for linear adjustment for growth)	All	N	Purchase
L2770	NU EP	H 6	Addition to lower extremity orthosis, any material, per bar or joint	All	N	Purchase
L2780	NU EP	H 6	Addition to lower extremity orthosis, non-corrosive finish, per bar	All	N	Purchase
L2785	NU EP	H 6	Addition to lower extremity orthosis, drop lock retainer, each	All	N	Purchase

L2795	NU EP	H 6	Addition to lower extremity orthosis, knee control, full kneecap	All	N	Purchase
L2800	NU EP	H 6	Addition to lower extremity orthosis, knee control, kneecap, medial or lateral pull	All	N	Purchase
L2810	NU EP	H 6	Addition to lower extremity orthosis, knee control, condylar pad	All	N	Purchase
L2820	NU EP	H 6	Addition to lower extremity orthosis, soft interface for molded plastic, below knee section	All	N	Purchase
L2830	NU EP	H 6	Addition to lower extremity orthosis, soft interface for molded plastic, above knee section	All	N	Purchase
L2840	NU EP	H 6	Addition to lower extremity orthosis, tibial length sock, fracture or equal, each	All	N	Purchase
L2850	NU EP	H 6	Addition to lower extremity orthosis, femoral length sock, fracture or equal, each	All	N	Purchase
L2999	NU EP	H 6	Lower extremity orthoses, NOS	All	N	Manually Priced
L3000	NU EP	H 6	Foot insert, removable, molded to patient model, "UCB" type, Berkeley shell, each	All	N	Purchase
L3002	NU EP	H 6	Foot insert, removable, molded to patient model, Plastazote or equal, each	All	N	Manually Priced
L3010	NU EP	H 6	Foot insert, removable, molded to patient model, longitudinal arch support, each	All	N	Purchase
L3020	NU EP	H 6	Foot insert, removable, molded to patient model, longitudinal/metatarsal support, each	All	N	Purchase
L3030	NU EP	H 6	Foot insert, removable, formed to patient foot, each	All	N	Purchase
L3040	NU EP	H 6	Foot, arch support, removable, premolded, longitudinal, each	All	N	Purchase
L3050	NU EP	H 6	Foot, arch support, removable, premolded, metatarsal, each	All	N	Purchase

L3060	NU EP	H 6	Foot, arch support, removable, premolded, longitudinal/metatarsal, each	All	N	Purchase
L3070	NU EP	H 6	Foot, arch support, non removable attached to shoe, longitudinal, each	All	N	Purchase
L3080	NU EP	H 6	Foot, arch support, non removable attached to shoe, metatarsal, each	All	N	Purchase
L3090	NU EP	H 6	Foot, arch support, non removable attached to shoe, longitudinal/metatarsal, each	All	N	Purchase
L3100	NU EP	H 6	Hallus - valgus night dynamic splint	All	N	Purchase
L3150	NU EP	H 6	Foot, abduction rotation bar, without shoes	All	N	Purchase
L3170	NU EP	H 6	Foot, plastic heel stabilizer	All	N	Purchase
L3202	EP	6	Orthopedic shoe, oxford with supinator or pronator, child	U21	N/A	Purchase
L3204	EP	6	Orthopedic shoe, hightop with supinator or pronator, infant	U21	N/A	Purchase
L3208	EP	6	Surgical boot, each, infant	U21	N/A	Purchase
L3209	EP	6	Surgical boot, each, child	U21	N/A	Purchase
L3215	NU EP	H 6	Orthopedic footwear, woman's shoes, oxford	All	Y	Manually Priced
L3216	NU EP	H 6	Orthopedic footwear, woman's shoes, depth inlay	All	Y	Purchase
L3219	NU EP	H 6	Orthopedic footwear, man's shoes, oxford	All	Y	Manually Priced
L3221	NU EP	H 6	Orthopedic footwear, man's shoes, depth inlay	All	Y	Purchase
L3224	NU	H	Orthopedic footwear, woman's shoe, Oxford, used as an integral part of a brace (orthosis)	+21	N	Purchase
L3225	NU	H	Orthopedic footwear, man's shoe, oxford, used as an integral part of a brace (orthosis)	+21	N	Purchase
L3230	NU EP	H 6	Orthopedic footwear, custom shoes, depth inlay	All	Y	Purchase
L3250	NU EP	H 6	Orthopedic footwear, custom molded shoe, removable inner molded, prosthetic shoe, each	All	Y	Manually Priced

L3253	NU EP	H 6	Foot, molded shoe Plastazate (or similar), custom fitted, each	All	Y	Purchase
L3257	NU EP	H 6	Orthopedic footwear, additional charge for split size	All	Y	Purchase
L3260	NU EP	H 6	Surgical boot/shoe, each	All	N	Purchase
L3265	NU EP	H 6	Plastazote sandal, each	All	N	Purchase
L3310	NU EP	H 6	Lift, elevation, heel and sole, neoprene, per inch	All	N	Purchase
L3332	NU EP	H 6	Lift, elevation, inside shoe, tapered, up to one-half inch	All	N	Purchase
L3334	NU EP	H 6	Lift, elevation, heel, per inch	All	N	Purchase
L3350	NU EP	H 6	Heel wedge	All	N	Purchase
L3360	NU EP	H 6	Sole wedge, outside sole	All	N	Purchase
L3370	NU EP	H 6	Sole wedge, between sole	All	N	Purchase
L3400	NU EP	H 6	Metatarsal bar wedge, rocker	All	N	Purchase
L3420	NU EP	H 6	Full sole and heel wedge, between sole	All	N	Purchase
L3450	NU EP	H 6	Heel, SACH cushion type	All	N	Purchase
L3455	NU EP	H 6	Heel, new leather, standard	All	N	Purchase
L3465	NU EP	H 6	Heel, Thomas with wedge	All	N	Purchase
L3540	NU EP	H 6	Orthopedic shoe addition, sole full	All	N	Purchase
L3580	NU EP	H 6	Orthopedic shoe addition, convert instep to velcro closure	All	N	Purchase
L3590	NU EP	H 6	Orthopedic shoe addition, convert firm shoe counter to soft counter	All	N	Purchase
L3600	NU EP	H 6	Transfer for an orthosis from one shoe to another, caliper plate, existing	All	N	Purchase

L3620	NU EP	H 6	Transfer of an orthosis from one shoe to another, solid stirrup, existing	All	N	Purchase
L3630	NU EP	H 6	Transfer of an orthosis from one shoe to another, solid stirrup, new	All	N	Purchase
L3649	EP	6	Orthopedic shoe, modification, addition or transfer, NOS	U21	N/A	Manually Priced
L3650	NU EP	H 6	SO, figure of eight design abduction re-strainer prefabricated, includes fitting and adjustment	All	N	Purchase
L3660	NU EP	H 6	SO, figure of eight design, abduction restrainer, canvas and webbing, prefabricated, includes fitting and adjustment	All	N	Purchase
L3670	NU EP	H 6	SO, acromio/clavicular (canvas and webbing type) prefabricated, includes fitting and adjustment	All	N	Purchase
L3675	NU	H	SO, vest type abduction restrainer, canvas webbing type, or equal, prefabricated, includes fitting and adjustment	21 +	N	Purchase
L3700	NU EP	H 6	Elbow orthoses (EO), elastic with stays, prefabricated, includes fitting and adjustment	All	N	Purchase
L3710	NU EP	H 6	EO, elastic with metal joints, prefabricated, includes fitting and adjustment	All	N	Purchase
L3720	NU EP	H 6	EO, double upright with forearm/arm cuffs, free motion, custom fabricated	All	N	Purchase
L3730	NU EP	H 6	EO, double upright with forearm/arm cuffs, extension/flexion assist, custom fabricated	All	Y	Purchase
L3740	NU EP	H 6	EO, double upright with forearm/arm cuffs, adjustable position lock with active control, custom fabricated	All	Y	Purchase
L3800	NU EP	H 6	WHFO, short opponens, no attachments, custom fabricated	All	N	Purchase
L3805	NU EP	H 6	WHFO, long opponens, no attachment, custom fabricated	All	N	Purchase

L3810	NU EP	H 6	WHFO, addition to short and long opponens, thumb abduction ("C") bar	All	N	Purchase
L3815	NU EP	H 6	WHFO, addition to short and long opponens, second M.P. abduction assist	All	N	Purchase
L3820	NU EP	H 6	WHFO, addition to short and long opponens, LP. extension assist, with M.P. extension stop	All	N	Purchase
L3825	NU EP	H 6	WHFO, addition to short and long opponens, M.P. extension stop	All	N	Purchase
L3830	NU EP	H 6	WHFO, addition to short and long opponens, M.P. extension assist	All	N	Purchase
L3835	NU EP	H 6	WHFO, addition to short and long opponens, M.P. spring extension assist	All	N	Purchase
L3840	NU EP	H 6	WHFO, addition to short and long opponens, spring swivel thumb	All	N	Purchase
L3845	NU EP	H 6	WHFO, addition to short and long opponens, thumb I.P. extension assist, with M.P. stop	All	N	Purchase
L3850	NU EP	H 6	WHO, addition to short and long opponens, action wrist with dorsiflexion assist	All	N	Purchase
L3855	NU EP	H 6	WHFO, addition to short and long opponens, adjustable M.P. flexion control	All	N	Purchase
L3860	NU EP	H 6	WHFO, addition to short and long opponens, adjustable M.P. flexion control and LP.	All	N	Purchase
L3900	NU EP	H 6	WHFO, dynamic flexor hinge, reciprocal wrist extension/flexion, finger flexion/extension, wrist or finger driven, custom fabricated	All	Y	Purchase
L3901	NU EP	H 6	WHFO, dynamic flexor hinge, reciprocal wrist extension/flexion, finger flexion/extension, cable driven, custom fabricated	All	Y	Purchase
L3902	NU EP	H 6	WHFO, external powered, compressed gas, custom fabricated	All	Y	Purchase
L3904	NU EP	H 6	WHFO, external powered, electric, custom fabricated	All	Y	Purchase

L3906**	NU EP	H 6	WHFO, wrist guantlet, molded to patient model, custom fabricated	All	N	Purchase
L3907**	NU EP	H 6	WHFO, wrist guantlet with thumb spica, molded to patient model, custom fabricated	All	N	Purchase
L3908	NU EP	H 6	WHFO, wrist extension control cock-up, nonmolded, prefabricated, includes fitting and adjustment	All	N	Purchase
L3910	NU EP	H 6	WHFO, Swanson design, prefabricated, includes fitting and adjustment	All	N	Purchase
L3912	NU EP	H 6	HFO, flexion glove with elastic finger control, prefabricated, includes fitting and adjustment	All	N	Purchase
L3914	NU EP	H 6	WHO, wrist extension (cock-up) prefabricated, includes fitting and adjustment	All	N	Purchase
L3916	NU EP	H 6	WHFO, wrist extension (cock-up), with outrigger, prefabricated, includes fitting and adjustment	All	N	Purchase
L3918	NU EP	H 6	HFO, knuckle bender prefabricated, includes fitting and adjustment	All	N	Purchase
L3920	NU EP	H 6	HFO, knuckle bender, with outrigger prefabricated, includes fitting and adjustment	All	N	Purchase
L3922	NU EP	H 6	HFO, knuckle bender, two segment to flex joints prefabricated, includes fitting and adjustment	All	N	Purchase
L3924	NU EP	H 6	WHFO, Oppenheimer, prefabricated, includes fitting and adjustment	All	N	Purchase
L3926	NU EP	H 6	WHFO, Thomas suspension, prefabricated, includes fitting and adjustment	All	N	Purchase
L3928	NU EP	H 6	HFO, finger extension, with lock spring, prefabricated, includes fitting and adjustment	All	N	Purchase
L3930	NU EP	H 6	WHFO, finger extension, with wrist support, prefabricated, includes fitting and adjustment	All	N	Purchase
L3932	NU EP	H 6	FO, safety pin, spring wire, prefabricated, includes fitting and adjustment	All	N	Purchase

L3934	NU EP	H 6	FO, safety pin, modified, prefabricated, includes fitting and adjustment	All	N	Purchase
L3936	NU EP	H 6	WHFO, Palmer prefabricated, includes fitting and adjustment	All	N	Purchase
L3938	NU EP	H 6	WHFO, Dorsal wrist, prefabricated, includes fitting and adjustment	All	N	Purchase
L3940	NU EP	H 6	WHFO, Dorsal wrist, with outrigger attachment, prefabricated, includes fitting and adjustment	All	N	Purchase
L3942	NU EP	H 6	HFO, reverse knuckle bender, prefabricated, includes fitting and adjustment	All	N	Purchase
L3944	NU EP	H 6	HFO, reverse knuckle bender, with outrigger, prefabricated, includes fitting and adjustment	All	N	Purchase
L3946	NU EP	H 6	HFO, composite elastic, prefabricated, includes fitting and adjustment	All	N	Purchase
L3948	NU EP	H 6	FO, finger knuckle bender, prefabricated, includes fitting and adjustment	All	N	Purchase
L3950	NU EP	H 6	WHFO, combination Oppenheimer, with knuckle bender and two attachments, prefabricated, includes fitting and adjustment	All	N	Purchase
L3952	NU EP	H 6	WHFO, combination Oppenheimer, with reverse knuckle and two attachments, prefabricated, includes fitting and adjustment	All	N	Purchase
L3954	NU EP	H 6	HFO, spreading hand, prefabricated, includes fitting and adjustment	All	N	Purchase
L3956	NU	H	Addition of joint to upper extremity orthosis, any material; per joint	21 +	N	Purchase
L3960	NU EP	H 6	SEWHO, abduction, positioning, airplane design, prefabricated, includes fitting and adjustment	All	Y	Purchase
L3962	NU EP	H 6	SEWHO, abduction positioning, Erb's palsy design, prefabricated, includes fitting and adjustment	All	N	Purchase

L3963	NU EP	H 6	SEWHO, molded shoulder, arm, forearm, and wrist, with articulating elbow joint, custom fabricated	All	Y	Purchase
L3964	NU EP	H 6	SEO, mobile arm supports attached to wheelchair, balanced, adjustable, prefabricated, includes fitting and adjustment	All	N	Purchase
L3965	NU EP	H 6	SEO mobile arm support attached to wheelchair, balanced, adjustable Rancho type, prefabricated, includes fitting and adjustment	All	Y	Purchase
L3966	NU EP	H 6	SEO, mobile arm support attached to wheelchair, balanced, reclining, prefabricated, includes fitting and adjustment	All	Y	Purchase
L3968	NU EP	H 6	SEO, mobile arm support attached to wheelchair, balanced, friction arm support, (friction dampening to proximal and distal joints), prefabricated, includes fitting and adjustment	All	Y	Purchase
L3969	NU EP	H 6	SEO, mobile arm support, monosuspension arm and hand support, overhead elbow forearm hand sling support, yoke type arm suspension support, prefabricated, includes fitting and adjustment	All	N	Purchase
L3970	NU EP	H 6	SEO, addition to mobile arm support elevating proximal arm	All	N	Purchase
L3972	NU EP	H 6	SEO , addition to mobile arm support, offset or lateral rocker arm with elastic balance control	All	N	Purchase
L3974	NU EP	H 6	SEO, addition to mobile arm support, supinator	All	N	Purchase
L3980	NU EP	H 6	Upper extremity fracture orthosis, humeral, prefabricated, includes fitting and adjustment	All	N	Purchase
L3982	NU EP	H 6	Upper extremity fracture orthosis, radius/ulnar prefabricated, includes fitting and adjustment	All	N	Purchase
L3984	NU EP	H 6	Upper extremity fracture orthosis, wrist, prefabricated, includes fitting and adjustment	All	N	Purchase

L3985	NU EP	H 6	Upper extremity fracture orthosis, forearm, hand with wrist hinge, custom fabricated	All	N	Purchase
L3986	NU EP	H 6	Upper extremity fracture orthosis, combination of humeral, radius/ulnar, wrist, (example -Colles' fracture), custom fabricated	All	N	Purchase
L3995	NU EP	H 6	Addition to upper extremity orthosis sock, fracture or equal, each	All	N	Purchase
L3999	EP	6	Upper limb othosis, NOS	U21	N/A	Manually Priced
L4000	NU EP	H 6	Replace girdle for spinal orthosis (CTLSO or SO)	All	Y	Purchase
L4010	NU EP	H 6	Replace trilateral socket brim	All	N	Purchase
L4020	NU EP	H 6	Replace quadrilateral socket brim, molded to patient model	All	N	Purchase
L4030	NU EP	H 6	Replace quadrilateral socket brim, custom fitted	All	N	Purchase
L4040	NU EP	H 6	Replace molded thigh lacer	All	N	Purchase
L4045	NU EP	H 6	Replace nonmolded thigh lacer	All	N	Purchase
L4050	NU EP	H 6	Replace molded calf lacer	All	N	Purchase
L4055	NU EP	H 6	Replace nonmolded calf lacer	All	N	Purchase
L4060	NU EP	H 6	Replace high roll cuff	All	N	Purchase
L4070	NU EP	H 6	Replace proximal and distal upright for KAFO	All	N	Purchase
L4080	NU EP	H 6	Replace metal bands KAFO, proximal thigh	All	N	Purchase
L4090	NU EP	H 6	Replace metal bands KAFO-AFO, calf or distal thigh	All	N	Purchase
L4100	NU EP	H 6	Replace leather cuff KAFO, proximal thigh	All	N	Purchase
L4110	NU EP	H 6	Replace leather cuff KAFO-AFO, calf or distal thigh	All	N	Purchase

L4130	NU EP	H 6	Replace pretibial shell	All	N	Purchase
L4350	NU EP	H 6	Ankle control orthosis, stirrup style, rigid, includes any type interface (e.g., pneumatic, gel), prefabricated, includes fitting and adjustment	All	N	Purchase
L4360	NU EP	H 6	Walking boot, pneumatic with or without joints, with or without interface material, prefabricated, includes fitting and adjustment	All	N	Purchase
L4370	NU EP	H 6	Pneumatic full leg splint, prefabricated, includes fitting and adjustment	All	N	Purchase
L4380	NU EP	H 6	Pneumatic knee splint, prefabricated, includes fitting and adjustment	All	N	Purchase
L4392	NU EP	H 6	Replacement soft interface material, static AFO	All	N	Purchase
L4394	NU	H	Replace soft interface material, foot drop splint	21 +	N	Purchase
L4396	NU	H	Static AFO, including soft interface material, adjustable for fit, for positioning, pressure reduction, may be used for minimal ambulation, prefabricated, includes fitting and adjustment	21 +	N	Purchase
L4398	NU	H	Foot drop splint, recumbent positioning device, prefabricated, includes fitting and adjustment	21 +	N	Purchase

Orthotic Appliances, All Ages (section 242.180)

National Code	M1	M2	TOS	Local Code	Description	PA 21 +	Capped Rental, Purchase or Rental Only
L1499	NU EP		H 6	Z1645	Spinal orthosis, not otherwise specified (Unlisted Prosthetic Devices or Orthotic Appliances (The Manufacturer's invoice must be attached to all claims.)	Y N/A	Manually Priced

L2999	NU EP		H 6	Z1645	Lower extremity orthoses, NOS (Unlisted Prosthetic Devices or Orthotic Appliances (The Manufacturer's invoice must be attached to all claims.)	Y N/A	Manually Priced
L3649	NU EP	U1	H 6	Z1645	Orthopedic shoe, modification, addition or transfer, NOS (Unlisted Prosthetic Devices or Orthotic Appliances) (The Manufacturer's invoice must be attached to all claims.)	Y N/A	Manually Priced
L3999	NU EP		H 6	Z1645	Upper limb orthosis, NOS (Unlisted Prosthetic Devices or Orthotic Appliances) (The Manufacturer's invoice must be attached to all claims.)	Y N/A	Manually Priced
L5999	NU EP		H 6	Z1645	Lower extremity prothesis, not otherwise specified (Unlisted Prosthetic Devices or Orthotic Appliances (The Manufacturer's invoice must be attached to all claims.)	Y N/A	Manually Priced
L7499	NU EP		H 6	Z1645	Upper extremity porsthesis, NOS (Unlisted Prosthetic Devices or Orthotic Appliances) (The Manufacturer's invoice must be attached to all claims.)	Y N/A	Manually Priced
L8499	NU EP		H 6	Z1645	Unlisted procedure for miscellaneous prosthetic services (Unlisted Prosthetic Devices or Orthotic Appliances) (The Manufacturer's invoice must be attached to all claims.)	Y N/A	Manually Priced Purchase
L4205	NU EP		H 6	Z1683	Repair of orthotic device, labor component, per 15 minutes	Y N/A	Manually Priced Purchase
L4210	NU EP		H 6	Z1683	Repair of orthotic device, repair or replace minor parts	Y N/A	Manually Priced Purchase
L7510	NU EP	52	H 6	Z1683	Repair of prosthetic device, hourly rate	Y N/A	Manually Priced Purchase
L7520	NU EP		H 6	Z1683	Repair prosthetic device, labor component, per 15 minutes	Y N/A	Manually Priced Purchase

L2040	NU	U1	H	Z1732	HKAFO, torsion control, bilateral rotation straps, pelvic band/belt,	N	Manually Priced
	EP	U1	6		custom fabricated (Night "A" frame-KAFO, torsion control, bilateral night "A" frame)	N/A	Purchase
L1920	EP		6	Z1733	AFO, single upright with static or adjustable stop (Phelps or Peristein type), custom fabricated (Custom night "A" frame-KAFO, torsion control, bilateral night "A" frame)	N/A	Purchase
L2810	EP		6	Z1733	Addition to lower extremity orthosis, knee control, condylar pad (Custom night "A" frame-KAFO, torsion control, bilateral night "A" frame)	N/A	Purchase
L3150	EP		6	Z1733	Foot, abduction rotation bar, without shoes (Custom night "A" frame-KAFO, torsion control, bilateral night "A" frame)	N/A	Purchase
L4090	EP		6	Z1733	Replace metal bands KAFO-AFO, calf or distal thigh (Custom night "A" frame-KAFO, torsion control, bilateral night "A" frame)	N/A	Purchase
L3140	NU EP	52	H 6	Z1735	Foot, abduction rotation bar, including shoes (Bebox foot orthosis clubfoot abduction orthosis)	N N/A	Manually Priced Purchase
L3140	NU		H	Z1736	Foot, abduction rotation bar, including shoes (Don Joy Knee orthosis)	Y	Manually Priced
L3649	NU EP		H 6	Z1738	Orthopedic shoe, modification, addition or transfer, NOS (Orthopedic footwear, wooden sole shoe, each)	N N/A	Manually Priced Purchase
L3204	NU EP		H 6	Z1739	Orthopedic shoe, hightop with supinator or pronator, infant (Straight last high top shoe, each, size 2-8)	N N/A	Manually Priced Purchase
L3206	NU EP		H 6	Z1739	Orthopedic shoe, hightop with supinator or pronator, child (Straight last high top shoe, each, size 2-8)	N N/A	Manually Priced Purchase
L3207	NU EP		H 6	Z1739	Orthopedic shoe, hightop with supinator or pronator junior (Straight last high top shoe, each, size 2-8)	N N/A	Manually Priced Purchase
L3217	NU EP		H 6	Z1739	Orthopedic footwear, woman's shoes, hightop, depth inlay (Straight last high top shoe, each, size 2-8)	N N/A	Manually Priced Purchase

L3222	NU EP		H 6	Z1739	Orthopedic footwear, man's shoes, hightop, depth inlay (Straight last high top shoe, each, size 2-8)	N N/A	Manually Priced Purchase
L3204	NU EP	U1	H 6	Z1740	Orthopedic shoe, hightop with supinator or pronator, infant (Straight last high top shoe, each, size 8 1/2-12)	N N/A	Manually Priced Purchase
L3206	NU EP	U1	H 6	Z1740	Orthopedic shoe, hightop with supinator or pronator, child (Straight last high top shoe, each, size 8 1/2-12)	N N/A	Manually Priced Purchase
L3207	NU EP	U1	H 6	Z1740	Orthopedic shoe, hightop with supinator or pronator, junior (Straight last high top shoe, each, size 8 1/2-12)	N N/A	Manually Priced Purchase
L3217	NU EP	U1 U1	H 6	Z1740	Orthopedic footwear, woman's shoes, hightop, depth inlay (Straight last high top shoe, each, size 8 1/2-12)	N N/A	Manually Priced Purchase
L3222	NU EP	U1	H 6	Z1740	Orthopedic footwear, man's shoes, hightop, depth inlay (Straight last high top shoe, each, size 8 1/2-12)	N N/A	Manually Priced Purchase
L3204	NU EP	U1	H 6	Z1741	Orthopedic shoe, hightop with supinator or pronator, infant (Regular last high top shoe, each, size 3-6)	N N/A	Manually Priced Purchase
L3206	NU EP	U1	H 6	Z1741	Orthopedic shoe, hightop with supinator or pronator, child (Regular last high top shoe, each, size 3-6)	N N/A	Manually Priced Purchase
L3207	NU EP	U1	H 6	Z1741	Orthopedic shoe, hightop with supinator or pronator, junior (Regular last high top shoe, each, size 3-6)	N N/A	Manually Priced Purchase
L3217	NU EP	U1	H 6	Z1741	Orthopedic footwear, woman's shoes, hightop, depth inlay (Regular last high top shoe, each, size 3-6)	N N/A	Manually Priced Purchase
L3222	NU EP	U1	H 6	Z1741	Orthopedic footwear, man's shoes, hightop, depth inlay (Regular last high top shoe, each, size 3-6)	N N/A	Manually Priced Purchase
L3204	NU EP	U1	H 6	Z1743	Orthopedic shoe, hightop with supinator or pronator, infant (Regular last high top shoe, each, 8 Vi -12)	N N/A	Purchase
L3206	NU EP	U1	H 6	Z1743	Orthopedic shoe, hightop with supinator or pronator, child (Regular last high top shoe, each, 8 Vi -12)	N N/A	Purchase

L3207	NU EP	U1	H 6	Z1743	Orthopedic shoe, hightop with supinator or pronator, junior (Regular last high top shoe, each, 8 Vi -12)	N N/A	Purchase
L3217	NU EP	U1	H 6	Z1743	Orthopedic footwear, woman's shoes, hightop, depth inlay (Regular last high top shoe, each, 8 %-12)	N N/A	Purchase
L3222	NU EP	U1	H 6	Z1743	Orthopedic footwear, man's shoes, hightop, depth inlay (Regular last high top shoe, each, 8 %-12)	N N/A	Purchase
L3204	NU EP	U1	H 6	Z1744	Orthopedic shoe, hightop with supinator or pronator, infant (Reverse last closed toe	N N/A	Manually Priced Purchase
L3206	NU EP	U1	H 6	Z1744	Orthopedic shoe, hightop with supinator or pronator, child (Reverse last closed toe)	N N/A	Manually Priced Purchase
L3207	NU EP	U1	H 6	Z1744	Orthopedic shoe, hightop with supinator or pronator, junior (Reverse last closed toe)	N N/A	Manually Priced Purchase
L3217	NU EP	U1	H 6	Z1744	Orthopedic footwear, woman's shoes, hightop, depth inlay (Reverse last closed toe)	N N/A	Manually Priced Purchase
L3222	NU EP	U1	H 6	Z1744	Orthopedic footwear, man's shoes, hightop, depth inlay (Reverse last closed toe)	N N/A	Manually Priced Purchase
L3204	NU		H	Z1745	Orthopedic shoe, hightop with supinator or pronator, infant (Orthopedic shoe, high top, normal last, each, size 3-8)	N	Manually Priced
L3206	NU		H	Z1745	Orthopedic shoe, hightop with supinator or pronator, child (Orthopedic shoe, high top, normal last, each, size 3-8)	N	Manually Priced
L3207	NU		H	Z1745	Orthopedic shoe, hightop with supinator or pronator, junior (Orthopedic shoe, high top, normal last, each, size 3-8)	N	Manually Priced
L3204	NU EP	U1	H 6	Z1746	Orthopedic shoe, hightop with supinator or pronator, infant (Orthopedic shoe, high top, normal last, each 8 ¹/₂-12)	N N/A	Manually Priced Purchase
L3206	NU EP	U1	H 6	Z1746	Orthopedic shoe, hightop with supinator or pronator, child (Orthopedic shoe, high top, normal last, each 8 ¹/₂-12)	N N/A	Manually Priced Purchase

L3207	NU	H	Z1746 i	Orthopedic shoe, hightop with supinator or pronator, junior	N	Manually Priced
	EP	6	i I	(Orthopedic shoe, high top, normal last, each 8 ¹/₂-12)	N/A	Purchase
L2755	NU	H	Z1747 I I	Addition to lower extremity orthosis, high strength, lightweight material, all	N	Manually Priced
	EP	6	I I	hybrid lamination/prepreg composite, per segment (Carbon composite ankles (addition to AFO)	N/A	Purchase

242.190 Prosthetic Devices, All Ages

Effective for dates of service on and after October 13, 2003, when billing either electronically or on paper, procedure codes found in this section must be billed with modifier EP for recipients under 21 years of age or modifier NU for individual age 21 and over. When a second modifier is listed, that modifier must be used in conjunction with either EP or NU.

Additionally, when billing on paper, procedure codes must be billed with type of service (TOS) code "6" for individuals under age 21 or TOS code "H" for recipients age 21 and over.

Modifiers in this section are indicated by the headings M1 and M2. Type of service is indicated by the heading TOS.

Prior authorization requirements are shown under the heading PA. If prior authorization is needed for individuals age 21 and over, that information is indicated with a "Y" in the column, if not, an "N" is shownWhen codes are payable for all ages, "AN" is indicated in the column, "U21" is shown when the code is payable only for individuals under age 21 and "21+" is shown when the code is payable only for those individuals age 21 and over.

Prosthetic Devices, All Ages (section 242.190)

National Code	M1	M2	TOS	Description	All U21 21 +	PA 21 +	Capped Rental, Purchase or Rental Only
L5000	NU EP		H 6	Partial foot, shoe insert with longitudinal arch, toe filler	All	N	Purchase
L5010	NU EP		H 6	Partial foot, molded socket, ankle height, with toe filler	All	Y	Purchase

L5020	NU EP	H 6	Partial foot, molded socket, tibial tubercle height, with toe filler	All	Y	Purchase
L5050	NU EP	H 6	Ankle, Symes, molded socket, SACH foot	All	Y	Purchase
L5060	NU EP	H 6	Ankle, Symes, metal frame, molded leather socket, articulated ankle/foot	All	Y	Purchase
L5100	NU EP	H 6	Below knee, molded socket, shin, SACH foot	All	Y	Purchase
L5105	NU EP	H 6	Below knee, plastic socket, joints and thigh lacer, SACH foot	All	Y	Purchase
L5150	NU EP	H 6	Knee disarticulation (or through knee), molded socket, external knee joints, shin, SACH foot	All	Y	Purchase
L5160	NU EP	H 6	Knee disarticulation (or through knee), molded socket, bent knee configuration, external knee joints, shin, SACH foot	All	Y	Purchase
L5200	NU EP	H 6	Above knee, molded socket, single axis constant friction knee, shin, SACH foot	All	Y	Purchase
L5210	NU EP	H 6	Above knee, short prosthesis, no knee joint ("stubbies"), with foot blocks, no ankle joints, each	All	Y	Purchase
L5220	NU EP	H 6	Above knee, short prosthesis, no knee joint (stubbies), with articulated ankle/foot, dynamically aligned, each	All	Y	Purchase
L5230	NU EP	H 6	Above knee, for proximal femoral focal deficiency, constant friction knee, shin, SACH foot	All	Y	Purchase
L5250	NU EP	H 6	Hip disarticulation, Canadian type, molded socket, hip joint, single axis constant friction knee, shin, SACH foot	All	Y	Purchase
L5270	NU EP	H 6	Hip disarticulation, tilt table type, molded socket, locking hip joint, single axis constant friction knee, shin, SACH foot	All	Y	Purchase
L5280	NU EP	H 6	Hemipelvectomy, Canadian type, molded socket, hip joint, single axis constant friction knee, shin, SACH foot	All	Y	Purchase

L5301	NU EP	H 6	Below knee, molded socket, shin, SACH foot, endoskeletal system	All	Y	Purchase
L5311	NU EP	H 6	Knee disarticulation (or through knee), molded socket, external knee joints, shin, SACH foot, endoskeletal system	All	Y	Purchase
L5321	NU EP	H 6	Above knee, molded socket, open end, SACH foot, endoskeletal system, single axis knee	All	Y	Purchase
L5331	NU EP	H 6	Hip disarticulation, Canadian type, molded socket, endoskeletal system, hip joint, single axis knee, SACH foot	All	Y	Purchase
L5341	NU EP	H 6	Hemipelvectomy, Canadian type, molded socket, endoskeletal system, hip joint, single axis knee, SACH foot	All	Y	Purchase
L5400	NU EP	H 6	Immediate post surgical or early fitting, application of initial rigid dressing, including fitting, alignment, suspension, and one cast change, below knee	All	N	Purchase
L5410	NU EP	H 6	Immediate post surgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension, below knee, each additional cast change and realignment	All	N	Purchase
L5420	NU EP	H 6	Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension, and one cast change "AK" or knee disarticulation	All	Y	Purchase
L5430	NU EP	H 6	Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension , "AK" or knee disarticulation, each additional cast change and realignment	All	N	Purchase
L5450	NU EP	H 6	Immediate postsurgical or early fitting, application of nonweight bearing rigid dressing, below knee	All	N	Purchase
L5460	NU EP	H 6	Immediate post surgical or early fitting, application of nonweight bearing rigid dressing, above knee	All	N	Purchase

L5500	NU EP	H 6	Initial, below knee ("PTB" type socket, non-alignable system, pylon, no cover, SACH foot, plaster socket, direct formed	All	N	Purchase
L5505	NU EP	H 6	Initial, above knee-knee disarticulation (ischial level socket, non-alignable system, pylon, no cover, SACH foot plaster socket, direct formed	All	Y	Purchase
L5510	NU EP	H 6	Preparatory, below knee "PTB" type socket, non-alignable system, pylon, no cover, SACH foot, plaster socket, molded to model	All	Y	Purchase
L5520	NU EP	H 6	Preparatory, below knee "PTB" type socket, non-alignable pylon, no cover, SACH foot, thermoplastic or equal, direct formed	All	Y	Purchase
L5530	NU EP	H 6	Preparatory, below knee "PTB" type socket, non-alignable system, pylon, no cover, SACH foot, thermoplastic or equal, molded to model	All	Y	Purchase
L5535	NU EP	H 6	Preparatory, below knee "PTB" type socket, non-alignable system, pylon, no cover, SACH foot, prefabricated, adjustable open end socket	All	Y	Purchase
L5540	NU EP	H 6	Preparatory, below knee "PTB" type socket, non alignable, pylon, no cover, SACH foot, laminated socket, molded to model	All	Y	Purchase
L5560	NU EP	H 6	Preparatory, above knee-knee disarticulation ischial level socket, non-alignable system, pylon, no cover, SACH foot, plaster socket, molded to model	All	Y	Purchase
L5570	NU EP	H 6	Preparatory, above knee-knee disarticulation ischial level socket, non-alignable system, pylon, no cover, SACH foot thermoplastic or equal, direct formed	All	Y	Purchase

L5580	NU EP	H 6	Preparatory, above knee-knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, SACH foot, thermoplastic or equal, molded to model	All	Y	Purchase
L5585	NU EP	H 6	Preparatory, above knee-knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, SACH foot, prefabricated adjustable open end socket	All	Y	Purchase
L5590	NU EP	H 6	Preparatory, above knee-knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, SACH foot, laminated socket, molded to model	All	Y	Purchase
L5595	NU EP	H 6	Preparatory, hip disarticulation-hemipelvectomy, pylon, no cover, SACH foot, thermoplastic or equal, molded to patient model	All	Y	Purchase
L5600	NU EP	H 6	Preparatory, hip disarticulation-hemipelvectomy, pylon, no cover, SACH foot, laminated socket, molded to patient model	All	Y	Purchase
L5610	NU EP	H 6	Addition to lower extremity, endoskeletal system, above knee, hydracadence system	All	Y	Purchase
L5611	NU EP	H 6	Addition to lower extremity, endoskeletal system, above knee-knee disarticulation, 4-bar linkage, with friction swing phase control	All	N	Purchase
L5613	NU EP	H 6	Addition to lower extremity, endoskeletal system, above knee-knee disarticulation, 4-bar linkage, with hydraulic swing phase control	All	Y	Purchase
L5614	NU	H	Addition to lower extremity, endoskeletal system, above knee -knee disarticulation, 4-bar linkage, with pneumatic swing phase control	21 +	Y	Purchase
L5616	NU EP	H 6	Addition to lower extremity, endoskeletal system above knee, universal multiplex system, friction swing phase control	All	Y	Purchase
L5617	NU	H	Addition to lower extremity, quick change self-aligning unit, above or below knee, each	21 +	Y	Purchase

L5618	NU EP	H 6	Addition to lower extremity, test socket, Symes	All	N	Purchase
L5620	NU EP	H 6	Addition to lower extremity, test socket, below knee	All	N	Purchase
L5622	NU EP	H 6	Addition to lower extremity, test socket, knee disarticulation	All	N	Purchase
L5624	NU EP	H 6	Addition to lower extremity, test socket, above knee	All	N	Purchase
L5626	NU EP	H 6	Addition to lower extremity, test socket, hip disarticulation	All	N	Purchase
L5628	NU EP	H 6	Addition to lower extremity, test socket, hemipelvectomy	All	N	Purchase
L5629	NU EP	H 6	Addition to lower extremity, below knee, acrylic socket	All	N	Purchase
L5630	NU EP	H 6	Addition to lower extremity, Symes type, expandable wall socket	All	N	Purchase
L5631	NU EP	H 6	Addition to lower extremity, above knee or knee disarticulation, acrylic socket	All	N	Purchase
L5632	NU EP	H 6	Addition to lower extremity, Symes type, "PTB" brim design socket	All	N	Purchase
L5634	NU EP	H 6	Addition to lower extremity, Symes type posterior opening (Canadian) socket	All	N	Purchase
L5636	NU EP	H 6	Additions to lower extremity, Symes type, medial opening socket	All	N	Purchase
L5637	NU EP	H 6	Addition to lower extremity, below knee, total contact	All	N	Purchase
L5638	NU EP	H 6	Addition to lower extremity, below knee, leather socket	All	N	Purchase
L5639	NU EP	H 6	Addition to lower extremity, below knee, wood socket	All	N	Purchase
L5640	NU EP	H 6	Addition to lower extremity, knee disarticulation, leather socket	All	N	Purchase
L5642	NU EP	H 6	Addition to lower extremity, above knee, leather socket	All	N	Purchase
L5643	NU EP	H 6	Addition to lower extremity, hip disarticulation, flexible inner socket, external frame	All	Y	Purchase
L5644	NU EP	H 6	Addition to lower extremity, above knee, wood socket	All	N	Purchase

L5645	NU EP	H 6	Addition to lower extremity, below knee, flexible inner socket, external frame	All	N	Purchase
L5646	NU EP	H 6	Addition to lower extremity, below knee, air, fluid, gel or equal, cushion socket	All	N	Purchase
L5647	NU EP	H 6	Addition to lower extremity, below knee suction socket	All	N	Purchase
L5648	NU EP	H 6	Addition to lower extremity, above knee, air, fluid, gel or equal, cushion socket	All	N	Purchase
L5649	NU EP	H 6	Addition to lower extremity, ischial containment/narrow M-L socket	All	Y	Purchase
L5650	NU EP	H 6	Addition to lower extremity, total contact, above knee or knee disarticulation socket	All	N	Purchase
L5651	NU EP	H 6	Addition to lower extremity, above knee, flexible inner socket, external frame	All	N	Purchase
L5652	NU EP	H 6	Addition to lower extremity, suction suspension, above knee or knee disarticulation, socket	All	N	Purchase
L5653	NU EP	H 6	Addition to lower extremity, knee disarticulation, expandable wall socket	All	N	Purchase
L5654	NU EP	H 6	Addition to lower extremity, socket insert, Symes, (Kemblo, Pelite, Aliplast, Plastazote or equal)	All	N	Purchase
L5655	NU EP	H 6	Addition to lower extremity, socket insert, below knee (Kemblo, Pelite, Aliplast, Plastazote or equal)	All	N	Purchase
L5656	NU EP	H 6	Addition to lower extremity, socket insert, knee disarticulation (Kemblo, Pelite, Aliplast, Plastazote or equal)	All	N	Purchase
L5658	NU EP	H 6	Addition to lower extremity, socket insert, above knee (Kemblo, Pelite, Aliplast, Plastazote or equal)	All	N	Purchase
L5661	NU EP	H 6	Addition to lower extremity, socket insert, multi durometer Symes	All	N	Purchase
L5665	EP	6	Addition to lower extremity, socket insert, multo-durometer, below knee	U21	N/A	Purchase

L5666	NU EP	H 6	Additions to lower extremity, below knee, cuff suspension	All	N	Purchase
L5668	NU EP	H 6	Addition to lower extremity, below knee, molded distal cushion	All	N	Purchase
L5670	NU EP	H 6	Addition to lower extremity, below knee, molded supracondyular suspension ("PTS" or similar)	All	N	Purchase
L5672	NU EP	H 6	Addition to lower extremity, below knee, removable medial brim suspension	All	N	Purchase
L5674	NU EP	H 6	Addition to lower extremity, below knee, suspension sleeve, any material, each	All	N	Purchase
L5675	NU EP	H 6	Addition to lower extremity, below knee, suspension sleeve, heavy duty, any material, each	All	N	Purchase
L5676	NU EP	H 6	Addition to lower extremity, below knee, knee joints, single axis, pair	All	N	Purchase
L5677	NU EP	H 6	Addition to lower extremity, below knee, knee joints, polycentric, pair	All	N	Purchase
L5678	NU EP	H 6	Addition to lower extremity, below knee, joint covers, pair	All	N	Purchase
L5680	NU EP	H 6	Addition to lower extremity, below knee, thigh lacer, nonmolded	All	N	Purchase
L5682	NU EP	H 6	Addition to lower extremity, below knee, thigh lacer, gluteal/ischial, molded	All	N	Purchase
L5684	NU EP	H 6	Addition to lower extremity, below knee, fork strap	All	N	Purchase
L5686	NU EP	H 6	Addition to lower extremity, below knee, back check (extension control)	All	N	Purchase
L5688	NU EP	H 6	Addition to lower extremity, below knee, waist belt, webbing	All	N	Purchase
L5690	NU EP	H 6	Addition to lower extremity, below knee, waist belt, padded and lined	All	N	Purchase
L5692	NU EP	H 6	Addition to lower extremity, above knee, pelvic control belt, light	All	N	Purchase
L5694	NU EP	H 6	Addition to lower extremity, above knee, pelvic control belt, padded and lined	All	N	Purchase

L5695	NU EP	H 6	Addition to lower extremity, above knee, pelvic control, sleeve suspension, neoprene or equal, each	All	N	Purchase
L5696	NU EP	H 6	Addition to lower extremity, above knee or knee disarticulation, pelvic joint	All	N	Purchase
L5697	NU EP	H 6	Addition to lower extremity, above knee or knee disarticulation, pelvic band	All	N	Purchase
L5698	NU EP	H 6	Addition to lower extremity, above knee or knee disarticulation, silesian bandage	All	N	Purchase
L5699	NU EP	H 6	All lower extremity prosthesis, shoulder harness	All	N	Purchase
L5700	NU	H	Replacement, socket, below knee, molded to patient model	21 +	Y	Purchase
L5701	NU	H	Replacement, socket, above knee/knee disarticulation, including attachment plate, molded to patient model	21 +	Y	Purchase
L5702	NU	H	Replacement, socket, hip disarticulation, including hip joint, molded to patient model	21 +	Y	Purchase
L5704	NU	H	Custom shaped protective cover, below knee	21 +	N	Purchase
L5705	NU	H	Custom shaped protective cover, above knee	21 +	N	Purchase
L5706	NU	H	Custom shaped protective cover, knee disarticulation	21 +	N	Purchase
L5707	NU	H	Custom shaped protective cover, hip disarticulation	21 +	N	Purchase
L5710	NU EP	H 6	Addition, exoskeletal knee-shin system, single axis, manual lock	All	N	Purchase
L5711	NU EP	H 6	Addition exoskeletal knee-shin system, single axis, manual lock, ultra-light material	All	N	Purchase
L5712	NU EP	H 6	Addition exoskeletal knee-shin system, single axis, friction swing and stance phase control (safety knee)	All	N	Purchase

L5714	NU EP	H 6	Addition, exoskeletal knee-shin system, single axis, variable friction swing phase control	All	N	Purchase
L5716	NU EP	H 6	Addition, exoskeletal knee-shin system, polycentric, mechanical stance phase lock	All	N	Purchase
L5718	NU EP	H 6	Addition, exoskeletal knee-shin system, polycentric, friction swing and stance phase control	All	N	Purchase
L5722	NU EP	H 6	Addition, exoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase control	All	N	Purchase
L5724	NU EP	H 6	Addition, exoskeletal knee-shin system, single axis, fluid swing phase control	All	Y	Purchase
L5726	NU EP	H 6	Addition, exoskeletal knee-shin system, single axis, external joints, fluid swing phase control	All	Y	Purchase
L5728	NU EP	H 6	Addition, exoskeletal knee-shin system, single axis, fluid swing and stance phase control	All	Y	Purchase
L5780	NU EP	H 6	Addition, exoskeletal knee-shin system, single axis, pneumatic/hydra pneumatic swing phase control	All	N	Purchase
L5785	NU EP	H 6	Addition, exoskeletal system, below knee, ultra-light material (titanium, carbon fiber or equal)	All	N	Purchase
L5790	NU EP	H 6	Addition, exoskeletal system, above knee, ultra-light material (titanium, carbon fiber or equal)	All	N	Purchase
L5795	NU EP	H 6	Addition, exoskeletal system, hip disarticulation, ultra-light material (titanium, carbon fiber or equal)	All	N	Purchase
L5810	NU EP	H 6	Addition, endoskeletal knee-shin system, single axis, manual lock	All	N	Purchase
L5811	NU EP	H 6	Addition, endoskeletal knee-shin system, single axis, manual lock, ultra-light material	All	N	Purchase
L5812	NU EP	H 6	Addition, endoskeletal knee-shin system, single axis, friction swing and stance phase control (safety knee)	All	N	Purchase

L5816	NU EP	H 6	Addition, endoskeletal knee-shin system, polycentric, mechanical stance phase lock	All	N	Purchase
L5818 L5822	NU EP NU EP	H 6 H 6	Addition, endoskeletal knee-shin system, polycentric, friction swing, and stance phase control Addition, endoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase control	All All	N Y	Purchase Purchase
L5824	NU EP	H 6	Addition, endoskeletal knee-shin system, single axis, fluid swing phase control	All	Y	Purchase
L5826	NU	H	Addition, endoskeletal knee-shin system, single axis, hydraulic swing phase control with miniature high activity frame	21 +	Y	Purchase
L5828	NU EP	H 6	Addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control	All	Y	Purchase
L5830	NU EP	H 6	Addition, endoskeletal knee-shin system, single axis, pneumatic/swing phase control	All	Y	Purchase
L5840	NU	H	Addition, endoskeletal knee-shin system, 4-bar linkage or multiaxial, pneumatic swing phase control	21 +	N	Purchase
L5845	NU	H	Addition, endoskeletal knee-shin system, stance flexion feature, adjustable	21 +	Y	Purchase
L5846	NU	H	Addition, endoskeletal knee-shin system, microprocessor control feature, swing phase only	21 +	Y	Purchase
L5850	NU EP	H 6	Addition, endoskeletal system, above knee or hip disarticulation, knee extension assist	All	N	Purchase
L5855	NU EP	H 6	Addition, endoskeletal system, hip disarticulation, mechanical hip extension assist	All	N	Purchase
L5910	NU EP	H 6	Addition, endoskeletal system, below knee, alignable system	All	N	Purchase
L5920	NU EP	H 6	Addition, endoskeletal system, above knee or hip disarticulation, alignable system	All	N	Purchase

L5925	NU	H	Addition, endoskeletal system, above knee, knee disarticulation, manual lock	21 +	N	Purchase
L5930	NU	H	Addition, endoskeletal system, high activity knee control frame	21 +	Y	Purchase
L5940	NU EP	H 6	Addition, endoskeletal system, below knee, ultra-light material (titanium, carbon fiber or equal)	All	N	Purchase
L5950	NU EP	H 6	Addition, endoskeletal system, above knee, ultra-light material (titanium, carbon fiber or equal)	All	N	Purchase
L5960	NU EP	H 6	Addition, endoskeletal system, hip disarticulation, ultra-light material (titanium, carbon fiber or equal)	All	N	Purchase
L5962	NU	H	Addition, endoskeletal system, below knee, flexible protective outer surface covering system	21 +	N	Purchase
L5964	NU	H	Addition, endoskeletal system, above knee, flexible protective outer surface covering system	21 +	N	Purchase
L5966	NU	H	Addition, endoskeletal system, hip disarticulation, flexible protective outer surface covering system	21 +	N	Purchase
L5968	NU	H	Addition to lower limb prostheses, multiaxial ankle with swing phase active dorsiflexion feature	21 +	Y	Purchase
L5970	NU EP	H 6	All lower extremity prostheses, foot, external keel, SACH foot	All	N	Purchase
L5972	NU EP	H 6	All lower extremity prostheses, flexible keel foot (Safe, Sten, Bock Dynamic or equal)	All	N	Purchase
L5974	NU EP	H 6	All lower extremity prostheses, foot, single axis ankle/foot	All	N	Purchase
L5975	NU	H	All lower extremity prosthesis, combination single axis ankle and flexible keel foot	21 +	N	Purchase
L5976	NU EP	H 6	All lower extremity prostheses, energy storing foot (Seattle Carbon Copy II or equal)	All	N	Purchase
L5978	NU EP	H 6	All lower extremity prostheses, foot, multiaxial ankle/foot	All	N	Purchase

L5979	NU	H	All lower extremity prostheses, multi-axial ankle, dynamic response foot, one piece system	21 +	Y	Purchase
L5980	NU EP	H 6	All lower extremity prostheses, flex-foot system	All	Y	Purchase
L5981	NU	H	All lower extremity prostheses, flex -walk system or equal	21 +	Y	Purchase
L5982	NU EP	H 6	All exoskeletal lower extremity prostheses, axial rotation unit	All	N	Purchase
L5984	NU EP	H 6	All endoskeletal lower extremity prosthesis, axial rotation unit, with or without adjustability	All	N	Purchase
L5985	NU	H	All endoskeletal lower extremity prostheses, dynamic prosthetic pylon	21 +	N	Purchase
L5986	NU EP	H 6	All lower extremity prostheses, multi-axial rotation unit ("MCP" or equal)	All	N	Purchase
L5987	NU	H	All lower extremity prostheses, shank foot system with vertical loading pylon	21 +	Y	Purchase
L5988	NU	H	Addition to lower limb prosthesis, vertical shock reducing pylon feature	21 +	Y	Purchase
L6000	NU EP	H 6	Partial hand, Robin-Aids, thumb remaining (or equal)	All	N	Purchase
L6010	NU EP	H 6	Partial hand, Robin-Aids, little and/or ring finger remaining (or equal)	All	N	Purchase
L6020	NU EP	H 6	Partial hand, Robin-Aids, no finger remaining (or equal)	All	N	Purchase
L6050	NU EP	H 6	Wrist disarticulation, molded socket, flexible elbow hinges, triceps pad	All	Y	Purchase
L6055	NU EP	H 6	Wrist disarticulation, molded socket with expandable interface, flexible elbow hinges, triceps pad	All	Y	Purchase
L6100	NU EP	H 6	Below elbow, molded socket, flexible elbow hinge, triceps pad	All	Y	Purchase
L6110	NU EP	H 6	Below elbow, molded socket (Muenster or Northwestern suspension types)	All	Y	Purchase

L6120	NU EP	H 6	Below elbow, molded double wall split socket, step-up hinges, half cuff	All	Y	Purchase
L6130	NU EP	H 6	Below elbow, molded double wall split socket, stump activated locking hinge, half cuff	All	Y	Purchase
L6200	NU EP	H 6	Elbow disarticulation, molded socket, outside locking hinge, forearm	All	Y	Purchase
L6205	NU EP	H 6	Elbow disarticulation, molded socket with expandable interface, outside locking hinges, forearm	All	Y	Purchase
L6250	NU EP	H 6	Above elbow, molded double wall socket, internal locking elbow, forearm	All	Y	Purchase
L6300	NU EP	H 6	Shoulder disarticulation, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearm	All	Y	Purchase
L6310	NU EP	H 6	Shoulder disarticulation, passive restoration (complete prosthesis)	All	Y	Purchase
L6320	NU EP	H 6	Shoulder disarticulation, passive restoration (shoulder cap only)	All	Y	Purchase
L6350	NU	H	Interscapular thoracic, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearm	21 +	Y	Purchase
L6360	NU EP	H 6	Interscapular thoracic, passive restoration (complete prosthesis)	All	Y	Purchase
L6370	NU EP	H 6	Interscapular thoracic, passive restoration (shoulder cap only)	All	Y	Purchase
L6380	NU EP	H 6	Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting alignment and suspension of components, and one cast change, wrist disarticulation or below elbow	All	N	Purchase
L6382	NU EP	H 6	Immediate postsurgical or early fitting, application of initial rigid dressing including fitting alignment and suspension of components, and one cast change, elbow disarticulation or above elbow	All	N	Purchase

L6384	NU EP	H 6	Immediate postsurgical or early fitting, application of initial rigid dressing including fitting alignment and suspension of components, and one cast change, shoulder disarticulation or interscapular thoracic	All	Y	Purchase
L6386	NU EP	H 6	Immediate postsurgical or early fitting, each additional cast change and realignment	All	N	Purchase
L6388	NU EP	H 6	Immediate postsurgical or early fitting, application of rigid dressing only	All	N	Purchase
L6400	NU EP	H 6	Below elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping	All	Y	Purchase
L6450	NU EP	H 6	Elbow disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue shaping	All	Y	Purchase
L6500	NU EP	H 6	Above elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping	All	Y	Purchase
L6550	NU EP	H 6	Shoulder disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue shaping	All	Y	Purchase
L6570	NU EP	H 6	Interscapular thoracic, molded socket, endoskeletal system including soft prosthetic tissue shaping	All	Y	Purchase
L6580	NU EP	H 6	Preparatory, wrist disarticulation or below elbow, single wall plastic socket, friction wrist, flexible elbow hinges, figure of eight harness, humeral cuff, Bowden cable control, "USMC" or equal pylon, no cover, molded to patient model	All	Y	Purchase
L6582	NU EP	H 6	Preparatory, wrist disarticulation or below elbow, single wall socket, friction wrist, flexible elbow hinges, figure of eight harness, humeral cuff, Bowden cable control, "USMC" or equal pylon, no cover, direct formed	All	N	Purchase

L6584	NU EP	H 6	Preparatory, elbow disarticulation or above elbow, single wall plastic socket, friction wrist, locking elbow, figure of eight harness, fair lead cable control, "USMC" or equal pylon, no cover, molded to patient model	All	Y	Purchase
L6586	NU EP	H 6	Preparatory, elbow disarticulation or above elbow, single wall socket, friction wrist, locking elbow, figure of eight harness, fair lead cable control, "USMC" or equal pylon, no cover, direct formed	All	Y	Purchase
L6588	NU EP	H 6	Preparatory, shoulder disarticulation or interscapular thoracic, single wall plastic socket, shoulder joint, locking elbow, friction wrist, chest strap, fair lead cable control, "USMC" or equal pylon, no cover, molded to patient model	All	Y	Purchase
L6590	NU EP	H 6	Preparatory, shoulder disarticulation or interscapular thoracic, single wall socket, shoulder joint, locking elbow, friction wrist, chest strap, fair lead cable control, "USMC" or equal pylon, no cover, direct formed	All	Y	Purchase
L6600	NU EP	H 6	Upper extremity additions, polycentric hinge, pair	All	N	Purchase
L6605	NU EP	H 6	Upper extremity additions, single pivot hinge, pair	All	N	Purchase
L6610	NU EP	H 6	Upper extremity additions, flexible metal hinge, pair	All	N	Purchase
L6615	NU EP	H 6	Upper extremity addition, disconnect locking wrist unit	All	N	Purchase
L6616	NU EP	H 6	Upper extremity addition, additional disconnect insert for locking wrist unit, each	All	N	Purchase
L6620	NU EP	H 6	Upper extremity addition, flexion/extension wrist unit, with or without friction	All	N	Purchase
L6623	NU EP	H 6	Upper extremity addition, spring assisted rotational wrist unit with latch release	All	N	Purchase

L6625	NU EP	H 6	Upper extremity addition, rotation wrist unit with cable lock	All	N	Purchase
L6628	NU EP	H 6	Upper extremity addition, quick disconnect hook adapter, Otto Bock or equal	All	N	Purchase
L6629	NU EP	H 6	Upper extremity addition, quick disconnect lamination collar with coupling piece, Otto Bock or equal	All	N	Purchase
L6630	NU EP	H 6	Upper extremity addition, stainless steel, any wrist	All	N	Purchase
L6632	NU EP	H 6	Upper extremity addition, latex suspension sleeve, each	All	N	Purchase
L6635	NU EP	H 6	Upper extremity additions, lift assist for elbow	All	N	Purchase
L6637	NU EP	H 6	Upper extremity addition, nudge control elbow lock	All	N	Purchase
L6640	NU EP	H 6	Upper extremity additions, shoulder abduction joint, pair	All	N	Purchase
L6641	NU EP	H 6	Upper extremity addition, excursion amplifier, pulley type	All	N	Purchase
L6642	NU EP	H 6	Upper extremity addition, excursion amplifier, lever type	All	N	Purchase
L6645	NU EP	H 6	Upper extremity addition, shoulder flexion-abduction joint, each	All	N	Purchase
L6650	NU EP	H 6	Upper extremity addition, shoulder universal joint, each	All	N	Purchase
L6655	NU EP	H 6	Upper extremity addition, standard control cable, extra	All	N	Purchase
L6660	NU EP	H 6	Upper extremity addition, heavy duty control cable	All	N	Purchase
L6665	NU EP	H 6	Upper extremity addition, teflon, or equal, cable lining	All	N	Purchase
L6670	NU EP	H 6	Upper extremity addition, hook to hand cable adapter	All	N	Purchase
L6672	NU EP	H 6	Upper extremity addition, harness, chest or shoulder, saddle type	All	N	Purchase
L6675	NU EP	H 6	Upper extremity addition, harness, (e.g., figure of eight type), single cable design	All	N	Purchase

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

L6725	NU EP	H 6	Terminal device, hook, Dorrance or equal, model # 7	All	N	Purchase
L6730	NU EP	H 6	Terminal device, hook, Dorrance or equal, model # 7LO	All	N	Purchase
L6735	NU EP	H 6	Terminal device, hook, Dorrance or equal, model # 8	All	N	Purchase
L6740	NU EP	H 6	Terminal device, hook, Dorrance or equal, model # 8x	All	N	Purchase
L6745	NU EP	H 6	Terminal device, hook, Dorrance or equal, model # 88x	All	N	Purchase
L6750	NU EP	H 6	Terminal device, hook, Dorrance or equal, model # 10P	All	N	Purchase
L6755	NU EP	H 6	Terminal device, hook, Dorrance or equal, model # 10x	All	N	Purchase
L6765	NU EP	H 6	Terminal device, hook, Dorrance or equal, model # 12P	All	N	Purchase
L6770	NU EP	H 6	Terminal device, hook, Dorrance or equal, model # 99x	All	N	Purchase
L6775	NU EP	H 6	Terminal device, hook, Dorrance or equal, model # 555	All	N	Purchase
L6780	NU EP	H 6	Terminal device, hook, Dorrance or equal, model # SS555	All	N	Purchase
L6790	NU EP	H 6	Terminal device, hook-Accu hook or equal	All	N	Purchase
L6795	NU EP	H 6	Terminal device, hook 2 load or equal	All	N	Purchase
L6800	NU EP	H 6	Terminal device, hook-APRL VC or equal	All	N	Purchase
L6805	NU EP	H 6	Terminal device, modifier wrist flexion unit	All	N	Purchase
L6806	NU EP	H 6	Terminal device, hook, TRS grip, Grip III, VC, or equal	All	Y	Purchase
L6807	NU EP	H 6	Terminal device, hook, Grip I, Grip II, VC, or equal	All	N	Purchase
L6808	NU EP	H 6	Terminal device, hook, TRS Adept, infant or child, VC, or equal	All	N	Purchase
L6809	NU EP	H 6	Terminal device, hook, TRS Super Sport, passive	All	N	Purchase
L6810	NU EP	H 6	Terminal device, pinchertool, Otto Bock or equal	All	N	Purchase

L6825	NU EP	H 6	Terminal device, hand, Dorrance, VO	All	N	Purchase
L6830	NU EP	H 6	Terminal device, hand, APRL, VC	All	N	Purchase
L6835	NU EP	H 6	Terminal device, hand, Sierra, VO	All	N	Purchase
L6840	NU EP	H 6	Terminal device, hand, Becker Imperial	All	N	Purchase
L6845	NU EP	H 6	Terminal device, hand, Becker Lock Grip	All	N	Purchase
L6850	NU EP	H 6	Terminal device, hand, Becker Plylite	All	N	Purchase
L6855	NU EP	H 6	Terminal device, hand, Robin-Aids, VO	All	N	Purchase
L6860	NU EP	H 6	Terminal device, hand, Robin-Aids, VO soft	All	N	Purchase
L6865	NU EP	H 6	Terminal device, hand, passive hand	All	N	Purchase
L6867	NU EP	H 6	Terminal device, hand, Detroit Infant Hand (mechanical)	All	N	Purchase
L6868	NU EP	H 6	Terminal device, hand, passive infant hand, Steeper, Hosmeror equal	All	N	Purchase
L6870	NU EP	H 6	Terminal device, hand, child mitt	All	N	Purchase
L6872	NU EP	H 6	Terminal device, hand, NYU child hand	All	N	Purchase
L6873	NU EP	H 6	Terminal device, hand, mechanical infant hand, Steeper or equal	All	N	Purchase
L6875	NU EP	H 6	Terminal device, hand, Bock, VC	All	N	Purchase
L6880	NU EP	H 6	Terminal device, hand, Bock, VO	All	N	Purchase
L6890	NU EP	H 6	Terminal device, gloves for above hands, production glove	All	N	Purchase
L6895	NU EP	H 6	Terminal device, glove for above hands, custom glove	All	N	Purchase
L6900	NU EP	H 6	Hand restoration (casts, shading and measurements included), partial hand, with glove, thumb or one finger remaining	All	N	Purchase

L6905	NU EP	H 6	Hand restoration (casts, shading and measurements included), partial hand, with glove, multiple fingers remaining	All	N	Purchase
L6910	NU EP	H 6	Hand restoration (casts, shading and measurements included), partial hand, with glove, no fingers remaining	All	N	Purchase
L6915	NU EP	H 6	Hand restoration (shading and measurements included), replacement glove for above	All	N	Purchase
L6920*	NU EP	H 6	Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal, switch, cables, two batteries and one charger, switch control of terminal device	All	Y	Purchase
L6925*	NU EP	H 6	Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device	All	Y	Purchase
L6930*	NU EP	H 6	Below elbow, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal switch, cables, two batteries and one charger, switch control of terminal device	All	Y	Purchase
L6935*	NU EP	H 6	Below elbow, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device	All	Y	Purchase
L6940*	NU EP	H 6	Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, Otto Bock or equal switch, cables, two batteries and one charger, switch control of terminal device	All	Y	Purchase

L6945*	NU EP	H 6	Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device	All	Y	Purchase
L6950*	NU EP	H 6	Above elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, Otto Bock or equal switch, cables, two batteries and one charger, switch control of terminal device	All	Y	Purchase
L6955*	NU EP	H 6	Above elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device	All	Y	Purchase
L6960*	NU EP	H 6	Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal switch, cables, two batteries and one charger, switch control of terminal device	All	Y	Purchase
L6965*	NU EP	H 6	Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device	All	Y	Purchase
L6970*	NU EP	H 6	Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal switch, cables, two batteries and one charger, switch control of terminal device	All	Y	Purchase

L6975*	NU EP	H 6	Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device	All	Y	Purchase
L7010*	NU EP	H 6	Electronic hand, Otto Bock, Steeper or equal, switch controlled	All	Y	Purchase
L7015*	NU EP	H 6	Electronic hand, System Teknik, Variety Village or equal, switch controlled	All	Y	Purchase
L7020*	NU EP	H 6	Electronic greifer, Otto Bock or equal, switch controlled	All	Y	Purchase
L7025*	NU EP	H 6	Electronic hand, Otto Bock or equal, myoelectronically controlled	All	Y	Purchase
L7030*	NU EP	H 6	Electronic hand, System Teknik, Variety Village or equal, myoelectronically controlled	All	Y	Purchase
L7035*	NU EP	H 6	Electronic greifer, Otto Bock or equal, myoelectronically controlled	All	Y	Purchase
L7040*	NU EP	H 6	Prehensile actuator, Hosmer or equal, switch controlled	All	Y	Purchase
L7045*	NU EP	H 6	Electronic hook, child, Michigan or equal, switch controlled	All	Y	Purchase
L7170*	NU EP	H 6	Electronic elbow, Hosmer or equal, switch controlled	All	Y	Purchase
L7180*	NU EP	H 6	Electronic elbow, Utah or equal, myoelectronically controlled	All	Y	Purchase
L7185	EP	6	Electronic elbow, adolescent, Variety Village or equal, switch controlled	U21	N/A	Purchase
L7186	EP	6	Electronic elbow, child, Variety Village or equal, switch controlled	U21	N/A	Purchase
L7190	EP	6	Electronic elbow, adolescent, Variety Village or equal, myoelectronically controlled	U21	N/A	Purchase
L7191	EP	6	Electronic elbow, child, Variety Village or equal, myoelectronically controlled	U21	N/A	Purchase

L7260*	NU EP	H 6	Electronic wrist rotator, Otto Bock or equal	All	Y	Purchase
L7261*	NU EP	H 6	Electronic wrist rotator, for Utah arm	All	Y	Purchase
L7266*	NU EP	H 6	Servo control, Steeper or equal	All	N	Purchase
L7272*	NU EP	H 6	Analogue control, UNB or equal	All	Y	Purchase
L7274*	NU EP	H 6	Proportional control, 6-12 volt, Liberty, Utah or equal	All	Y	Purchase
L7360*	NU EP	H 6	Six volt battery, Otto Bock or equal, each	All	N	Purchase
L7362*	NU EP	H 6	Battery charger, six volt, Otto Bock or equal	All	N	Purchase
L7364*	NU EP	H 6	Twelve volt battery, Utah or equal, each	All	N	Purchase
L7366*	NU EP	H 6	Battery charger, twelve volt, Utah or equal	All	N	Purchase
L8000	NU EP	H 6	Breast prosthesis, mastectomy bra	All	N	Purchase
L8010	NU EP	H 6	Breast prosthesis, mastectomy sleeve	All	N	Purchase
L8015	NU	H	External breast prosthesis garment, with mastectomy form, post-mastectomy	21 +	N	Purchase
L8020	NU EP	H 6	Breast prosthesis, mastectomy form	All	N	Purchase
L8030	NU EP	H 6	Breast prosthesis, silicone or equal	All	N	Purchase
L8100	NU EP	H 6	Gradient support compression stocking, below knee, 18-30 mmhg, each	All	N	Purchase
L8300	NU EP	H 6	Truss, single with standard pad	All	N	Purchase
L8310	NU EP	H 6	Truss, double with standard pads	All	N	Purchase
L8320	NU EP	H 6	Truss, addition to standard pad, water pad	All	N	Purchase
L8330	NU EP	H 6	Truss, addition to standard pad, scrotal pad	All	N	Purchase

L8400	NU EP	H 6	Prosthetic sheath, below knee, each	All	N	Purchase
L8410	NU EP	H 6	Prosthetic sheath, above knee, each	All	N	Purchase
L8415	NU EP	H 6	Prosthetic sheath, upper limb, each	All	N	Purchase
L8417	NU	H	Prosthetic sheath/sock, including a gel cushion layer, below knee or above knee, each	21 +	N	Purchase
L8420	NU EP	H 6	Prosthetic sock, multiple ply, below knee,each	All	N	Purchase
L8430	NU EP	H 6	Prosthetic sock, multiple ply, above knee,each	All	N	Purchase
L8435	NU EP	H 6	Prosthetic sock, multiple ply upper limb, each	All	N	Purchase
L8440	NU EP	H 6	Prosthetic shrinker, below knee, each	All	N	Purchase
L8460	NU EP	H 6	Prosthetic shrinker, above knee, each	All	N	Purchase
L8465	NU EP	H 6	Prosthetic shrinker, upper limb, each	All	N	Purchase
L8470	NU EP	H 6	Prosthetic sock, single ply, fitting below knee, each	All	N	Purchase
L8480	NU EP	H 6	Prosthetic sock, single ply fitting, above knee, each	All	N	Purchase
L8485	NU	H	Prosthetic sock, single ply, fitting, upper limb, each	21 +	N	Purchase
L8490	NU	H	Addition to prosthetic sheath/sock, air seal suction retention system	21 +	N	Purchase
L8500	NU EP	H 6	Artificial larynx, any type	All	N	Purchase
L8501	NU EP	H 6	Tracheostomy speaking valve	All	N	Purchase
L8600	NU EP	H 6	Implantable breast prosthesis, silicone or equal	All	N	Manually Priced

*Replacement only

L1499	NU		H	Z1645	Spinal orthosis, not otherwise specified (Unlisted Prosthetic	Y	Manually Priced
	EP		6		Devices or Orthotic Appliances (The manufacturer's invoice must be attached to all claims.)	N/A	Manually Priced
L2999	NU EP		H 6	Z1645	Lower extremity orthoses, NOS (Unlisted Prosthetic Devices or Orthotic Appliances (The manufacturer's invoice must be attached to all claims.)	Y N/A	Manually Priced Manually Priced
L3649	NU EP	U1	H 6	Z1645	Orthopedic shoe, modification, adition or transfer, NOS (Unlisted Prosthetic Devices or Orthotic Appliances (The manufacturer's invoice must be attached to all claims.)	Y N/A	Manually Priced Manually Priced
L3999	NU EP		H 6	Z1645	Upper limb orthosis, NOS (Unlisted Prosthetic Devices or Orthotic Appliances (The manufacturer's invoice must be attached to all claims.)	Y N/A	Manually Priced Manually Priced
L5999	NU EP		H 6	Z1645	Lower extremity prosthesis, not otherwise specified (Unlisted Prosthetic Devices or Orthotic Appliances (The manufacturer's invoice must be attached to all claims.)	Y N/A	Manually Priced Manually Priced
L7499	NU EP		H 6	Z1645	Upper extremity prothesis, NOS (Unlisted Prosthetic Devices or Orthotic Appliances (The manufacturer's invoice must be attached to all claims.)	Y N/A	Manually Priced Manually Priced

L8499	NU EP		H 6	Z1645	Unlisted procedure for miscellaneous prosthetic services (Unlisted Prosthetic Devices or Orthotic Appliances (The manufacturer's invoice must be attached to all claims.)	Y N/A	Manually Priced Manually Priced
L4205	NU EP		H 6	Z1683	Repair of orthotic device, labor component, per 15 minutes (Orthotics and Prosthetics Repairs)	Y N/A	Manually Priced Purchase
L4210	NU EP		H 6	Z1683	Repair of orthotic device, repair or replace minor parts (Orthotics and Prosthetics Repairs)	Y N/A	Manually Priced Purchase
L7510	NU EP	52	H 6	Z1683	Repair of prosthetic device, repair or replace minor parts (Orthotics and Prosthetics Repairs)	Y N/A	Manually Priced Purchase
L7520	NU EP		H 6	Z1683	Repair prosthetic device, labor component, per 15 minutes (Orthotics and Prosthetics Repairs)	Y N/A	Manually Priced Purchase
L7510	NU EP		H 6	Z1748	Repair of prosthetic device, repair or replace minor parts (Twister cables -repair/replace)	N N/A	Manually Priced Purchase

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

Additionally, when billing on paper, procedure codes found in this section must be billed with a type of service (TOS) code "6" for individuals under age 21 or TOS code "H" for individuals age 21 and over.

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

Other coding information found in the chart:

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

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

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

** Bill only for TOS code "6".

* This procedure code is payable for individuals ages 2 through 20, using TOS code "6". Prior authorization is required through Utilization Review.

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

⁷ This procedure code became covered July 1, 2004.

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

Note: W/C or w/c indicates wheelchair

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

National Code	M1	M2	TOS	PA	Description	Capped Rental, Purchase or Rental Only
E0950⁷	NU EP	U7 U7	H 6	N	Wheelchair accessory, tray, each	Purchase
E0951	NU EP		H 6	K 1****	Heel loop/holder, with or without ankle strap, each	Purchase
E0952	NU EP		H 6	K 1****	Toe loop/holder, each	Purchase
E0954	NU EP		H 6	K 1****	Semi-pneumatic caster, each	Purchase
E0955⁷	NU EP		H 6	N	W/C accessory, headrest, cushioned, prefabricated, w/fixed mounting hardware, each	Purchase
E0957⁷	NU EP		H 6	N	W/C accessory, medial thigh support, prefabricated, w/fixed mounting hardware, each	Purchase
E0958	NU EP		H 6	K 1****	Manual W/C accessory, one-arm drive attachment, each	Purchase
E0959⁷	NU EP	U1 U1	H 6	N	Manual W/C accessory, adapter for amputee, each	Purchase

E0960⁷	NU EP		H 6	N	W/C accessory, shoulder harness/straps or chest strap including any type mounting hardware	Purchase
E0961	NU EP		H 6	K 1****	Manual W/C accessory, wheel lock brake extension (handle), each	Purchase
E0967⁷	NU EP		H 6	N	Manual W/C accessory, hand rim w/projections, each	Purchase
E0967⁷	NU EP	U1 U1	H 6	N	Manual W/C accessory, hand rim w/projections, each	Purchase
E0967⁷	NU EP	U2 U2	H 6	N	Manual W/C accessory, hand rim w/projections, each	Purchase
E0967⁷	NU EP	U3 U3	H 6	N	Manual W/C accessory, hand rim w/projections, each	Purchase
E0967⁷	NU EP	U4 U4	H 6	N	Manual W/C accessory, hand rim w/projections, each	Purchase
E0970	NU EP		H 6	K 1****	No. 2. footplates, except for elevating legrest	Purchase
E0971	NU EP		H 6	K 1****	Anti-tipping device W/C	Purchase
E0974	NU EP		H 6	K 1****	Manual W/C accessory, anti-rollback device, each	Purchase
E0978⁷	NU EP	U2	H 6	K 1****	W/C accessory, safety belt/pelvic strap, each	Purchase
E0981⁷	NU EP		H 6	N	W/C accessory, seat upholstery, replacement only, each	Purchase
E0992	NU EP		H 6	K 1****	Manual w/c accessory, solid seat insert	Purchase
E0994	NU EP		H 6	K 1****	Armrest, each	Purchase
E1002⁷	NU EP		H 6	Y	W/C accessory, power seating system, tilt only	Purchase
E1004⁷	NU EP		H 6	Y	W/C accessory, power seat system, recline only, w/mechanical shear reduction	Purchase
E1006⁷	NU EP		H 6	Y	W/C accessory, power seating system, combination tilt and recline, w/o shear reduction	Purchase
E1010⁷	NU EP		H 6	Y	W/C accessory, addition to power seating system, power leg elevation system, including leg rest, each	Purchase

E1019⁷	NU EP	H 6	Y	W/C accessory, power seating, heavy duty feature, patient weight capacity greater than 250 lbs, and less than or equal to 400 lbs	Purchase
E1030⁷	NU EP	H 6	Y	Wheelchair accessory, ventilator tray, gimbaled	Purchase
E1065*	NU EP	H 6	Y*	Power attachment (to convert any W/C to motorized W/C, e.g., Solo)	Purchase
E1084*	NU EP	H 6	K 1****	Hemi-W/C; detachable arms, desk or full-length, swing-away, detachable, elevating legrests	Purchase
E1086*	NU EP	H 6	K 1****	Hemi W/C; detachable arms, desk or full-length, swing-away, detachable footrests	Purchase
E1088*	NU EP	H 6	Y*	High strength lightweight W/C; detachable arms, desk or full-length, swing-away, detachable, elevating legrests	Purchase
E1090	NU EP	H 6	K 1****	High-strength lightweight W/C; detachable arms, desk or full-length, swing-away, detachable footrests	Purchase
E1092*	NU EP	H 6	Y*	Wde, heavy-duty W/C; detachable arms, desk or full-length, swing-away, detachable, elevating legrests	Purchase
E1093*	NU EP	H 6	Y*	Wde, heavy-duty W/C; detachable arms, desk or full-length arms, swing-away, detachable footrests	Purchase
E1110*	NU EP	H 6	Y*	Semi-reclining W/C; detachable arms, desk or full-length, elevating legrest	Purchase
E1170*	NU EP	H 6	K 1****	Amputee W/C; fixed full-length arms, swing-away, detachable, elevating legrests	Purchase
E1172*	NU EP	H 6	Y*	Amputee W/C; detachable arms, desk or full-length, without footrests or legrests	Purchase
E1180*	NU EP	H 6	Y*	Amputee W/C; detachable arms, desk or full-length, swing-away, detachable footrests	Purchase
E1200*	NU EP	H 6	K 1**** *	Amputee W/C; fixed full-length arms, swing-away, detachable footrests	Purchase
E1211*	NU EP	H 6	Y*	Motorized W/C; detachable arms, desk or full-length, swing-away, detachable, elevating legrests	Purchase

E1213*	NU EP		H 6	Y*	Motorized W/C; detachable arms, desk or full-length, swing-away, detachable footrests	Purchase
E1220*	NU EP		H 6	Y	W/C, specially sized or constructed (indicate brand name, model number, if any, and justification)	Manually Priced
E1230*	NU EP		H 6	Y*	Power operated vehicle (three- or four-wheel nonhighway), specify brand name and model number	Purchase
E1240*	NU EP		H 6	Y*	Lightweight W/C; detachable arms, desk or full-length, swing-away, detachable, elevating legrest	Purchase
E1260*	NU EP		H 6	K 1****	Lightweight W/C; detachable arms, desk or full-length, swing-away, detachable footrests	Purchase
E1280*	NU EP		H 6	Y*	Heavy-duty W/C; detachable arms, desk or full-length, elevating legrests	Purchase
E1290*	NU EP		H 6	Y*	Heavy-duty W/C; detachable arms, swing-away, detachable footrests	Purchase
E2203⁷	NU EP	U4 U4	H 6	N	Manual w/c accessory, nonstandard seat frame depth, 20 to less than 22 inches	Manually Priced Purchase
E2310⁷	NU EP		H 6	Y	Power w/c accessory, electronic connection between wheelchair controller and one power seating system motor, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware	Purchase
E2311⁷	NU EP		H 6	Y	Power w/c accessory, electronic connection between wheelchair controller and two or more power seating system motors, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware	Purchase
E2320⁷	NU EP		H 6	Y	Power w/c accessory, hand or chin control interface, remote joystick or touchpad, proportional, including all related electronics and fixed mounting hardware	Purchase

E2322⁷	NU EP		H 6	Y	Power w/c accessory, hand control interface, multiple mechanical switches, nonproportional, including all related electronics, mechanical stop switch, and fixed mounting hardware	Purchase
E2323⁷	NU EP		H 6	N	Power w/c accessory, specialty joystick handle for hand control interface, prefabricated	Purchase
E2324⁷	NU EP		H 6	N	Power w/c accessory, chin cup for chin control interface	Purchase
E2325⁷	NU EP		H 6	Y	Power w/c accessory, sip & puff interface nonproportional, including all related electronics, mechanical stop switch, and manual swingaway mounting hardware	Purchase
E2326⁷	NU EP		H 6	Y	Power w/c accessory, breath tube kit for sip & puff interface	Purchase
E2327⁷	NU EP		H 6	Y	Power w/c accessory, head control interface, mechanical, proportional, including all related electronics, mechanical direction change switch, and fixed mounting hardware	Purchase
E2363⁷	NU EP		H 6	N	Power w/c accessory, group 24 sealed lead acid battery, each	Purchase
E2363⁷	NU EP	U1 U1	H 6	N	Power w/c accessory, group 24 sealed lead acid battery, each (e.g., gel cell, absorbed glassmat)	Purchase
E2365⁷	NU EP		H 6	N	Power w/c accessory, U-1 sealed lead acid battery, each, gel cell	Purchase
E2365⁷	NU EP	U1 U1	H 6	N	Power w/c accessory, U-1 sealed lead acid battery, each, gel cell	Purchase

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

National Code	M1	M2	TOS	Local Code	Description	PA	Capped Rental, Purchase or Rental Only
E1050	NU EP		H 6	Z1590*	Full reclining W/C, fixed full-length arms, swing-away, detachable elevating legrests	K I****	Purchase

E1060	NU EP		H 6	Z1592*	Full reclining W/C, detachable arms, desk or full-length, swing-away detachable, elevating legrests	Y*	Purchase
E1260	NU EP	U1	H 6	Z1597*	Lightweight W/C, detachable arms, desk or full-length, swing-away, detachable footrests	K 1****	Purchase
E1086	NU EP	U1 U1	H 6	Z1599*	Hemi- W/C, detachable arms, desk or full-length, swing-away detachable footrests	Y*	Purchase
E0973⁷	NU EP		H 6	Z1605	W/C accessory, adjustable height, detachable armrest, complete assembly, each	K 1****	Purchase
K0023	NU EP		H 6	Z1606	Solid back insert, planar back, single density foam, attached with straps	K 1****	Purchase
K0116	NU EP	U2	H 6	Z1608	Seating system, combined back and seat module, custom fabricated for attachment to W/C base	K 1****	Manually Priced
K0038	NU EP		H 6	Z1609	Leg strap, each	K 1****	Purchase
K0039	NU EP		H 6	Z1610	Leg strap, H style, each	K 1****	Purchase
K0040	NU EP		H 6	Z1611	Adjustable angle footplate, each	K 1****	Purchase
K0047	NU EP		H 6	Z1614	Elevating legrest, upper hanger bracket, each	K 1****	Purchase
K0059	NU EP		H 6	Z1615	Plastic coated handrim, each	K 1****	Purchase
K0108	NU EP		H 6	Z1616	Other accessories (Applicable pages from the manufacturer's catalog must be attached to the claim form.)	K 1****	Manually Priced

E1340	NU EP	U3 U3	H 6	Z1619	Repair or nonroutine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes (Unlisted Repairs/Parts Only Wheelchairs) (Applicable pages from the manufacturer's catalog must be attached to the claim form.)	K 1****	Manually Priced
K0071	NU EP	U1 U1	H 6	Z1625	Front caster assembly, complete, with pneumatic tire, each 22", rear wheels	K 1****	Purchase
K0064	NU EP		H 6	Z1628	Zero pressure tube (flat free insert), any size, each	K 1****	Purchase
K0065	NU EP		H 6	Z1629	Spoke protectors, each	K 1****	Purchase
K0074	NU EP		H 6	Z1630	Pneumatic caster tire, any size each (8 x 1 1/4") front casters)	K 1****	Purchase
K0074	NU EP		H 6	Z1631	Pneumatic caster tire, any size each (Pneumatic casters 8 x 1 3/4" (each), front casters)	K 1****	Purchase
K0071	NU EP		H 6	Z1632	Front caster assembly, complete, with pneumatic tire, each (Polyurethane caster 5")	K 1****	Purchase
K0072	NU EP		H 6	Z1632	Front caster assembly, complete, with semipneumatic tire, each (Polyurethane caster 5")	K 1****	Purchase
K0073	NU EP		H 6	Z1633	Caster pin lock, each	K 1****	Purchase
K0102	NU EP		H 6	Z1653	Crutch and cane holder, each	K 1****	Purchase
E0972	NU EP	U1 U1	H 6	Z1654	W/C accessory, transfer board or device, each (Wood transfer board)	N	Purchase
E0972	NU EP		H 6	Z1655	W/C accessory, transfer board or device, each (Plastic transfer board)	N	Purchase
K0104	NU EP		H 6	Z1656	Cylinder tank carrier, each	N	Purchase

E2360⁷	NU EP		H 6	Z1658	Power w/c accessory, 22 NF non-sealed lead acid battery, each	N	Purchase
E2362	NU EP		H 6	Z1659	Power wheelchair accessory, group 24 non-sealed lead acid battery, each	N	Purchase
E2364	NU EP		H 6	Z1660	Power wheelchair accessory, U-1 non-sealed lead acid battery, each	N	Purchase
E2365	NU EP		H 6	Z1661	Power wheelchair accessory, U-1 sealed lead acid battery, each, (e.g., gel cell, absorbed glassmat)	N	Purchase
E2361⁷	NU EP		H 6	Z1662	Power w/c accessory, 22 NF sealed lead acid battery, each, (e.g., gel cell, absorbed glassmat)	N	Purchase
E1091	EP	52	6	Z1667**	Youth stroller	K 1****	Purchase
E0700	NU EP	U2 U2	H 6	Z1669	Safety equipment (e.g., belt, harness or vest) Travel restraint auto safe harness (E-Z on vest)	K 1****	Purchase
E0962	NU EP		H 6	Z1672	One-inch cushion, for W/C	K 1****	Manually Priced
E0963	NU EP		H 6	Z1672	Two-inch cushion, for W/C	K 1****	Manually Priced
E0964	NU EP		H 6	Z1672	Three-inch cushion, for W/C	K 1****	Manually Priced
E0965	NU EP		H 6	Z1672	Four-inch cushion, for W/C	K 1****	Manually Priced
E0956⁷	NU EP		H 6	Z1677	W/C accessory, lateral trunk or hip support, prefabricated w/fixed mounting hardware, each(Trunk supports for any W/C (other than travel) with hardware)	K 1****	Purchase
E2201⁷	NU EP	U3 U3	H 6	Z1678	Manual w/c accessory, nonstandard seat frame width [GREATER THAN] than or equal to 20 inches and [LESS THAN]24 inches	K 1****	Manually Priced

K0056	NU EP		H 6	Z1678	Seat height less than 17 inches or equal to or greater than 21 inches for a high strength, lightweight, orultralightweight W/C	K 1****	Manually Priced
E1232	EP		6	Z1679*	W/C, pediatric size, tilt-in-space, folding, adjustable, with seating system	Y*	Purchase
E1233	EP		6	Z1679*	W/C, pediatric size, tilt-in-space, rigid, adjustable, without seating system	Y*	Purchase
E1234	EP		6	Z1679*	W/C, pediatric size, tilt-in-space, folding, adjustable, without seating system	Y*	Purchase
E1235	NU EP		H 6	Z1679*	W/C, pediatric size, rigid, adjustable, with seating system	Y*	Purchase
E1237	NU EP		H 6	Z1679*	W/C, pediatric size, rigid, adjustable, without seating system	Y*	Purchase
E1238	NU EP		H 6	Z1679*	W/C, pediatric size, folding, adjustable, without seating system	Y*	Purchase
K0005	NU EP		H 6	Z1680*	Ultralightweight W/C High performance manual W/C-adult	Y*	Purchase
K0005	NU EP	U1 U1	H 6	Z1681*	Ultralightweight W/C (High performance manual W/C with growth adjustability-child)	Y*	Purchase
K0116	NU EP	U2	H 6	Z1682	Seating system, combined back and seat module, custom fabricated for attachment to W/C base	K 1****	Manually Priced
E1340	NU EP	U1 U1	H 6	Z1758	Repair or nonroutine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes (Labor Only (a maximum of twenty [20] units [20 units = 5 hours of labor] per date of service is allowable.)	N	Manually Priced

K0116	NU EP	U1 U1	H 6	Z1765	Seating system, combined back and seat module, custom fabricated for attachment to W/C base (Foam-ln-Place Back Pindot, Contour U System, Quick Foam)	K 1****	Purchase
K0116	NU EP	U3 U3	H 6	Z1766	Seating system, combined back and seat module, custom fabricated for attachment to W/C base (Foam-ln-Place Seat (Pindot Quick Foam Contour System)	K 1****	Purchase
E0992	NU EP	U3 U3	H 6	Z1768	Manual w/c access, solid seat insert (Foam & Plywood Seat, MPI Like)	K 1****	Purchase
E0992	NU EP	U2 U2	H 6	Z1769	Manual w/c access, solid seat insert (Foam and Plywood Flat Side)	K 1****	Purchase
K0023	NU EP	U1 U1	H 6	Z1771	Solid back insert, planar back, single density foam, attached with straps (Foam & Plywood Back, MPI Like)	K 1****	Purchase
K0023	NU EP	U1 U1	H 6	Z1772	Solid back insert, planar back, single density foam, attached with straps (Foam & Plywood Flat Back)	K 1****	Purchase
E0966⁷	NU EP		H 6	Z1783	Manual W/C accessory, headrest extension, each (Headrest/Fixture, O.B. (46-LG 45-SM)	K 1****	Purchase
K0038	NU EP	U2 U2	H 6	Z1790	Leg strap, each (Foot Straps (Pair)	K 1****	Purchase
E0980	NU EP		H 6	Z1797	Safety vest, W/C (Chest panel 21-SM22-LG)	K 1****	Purchase
E0978	NU EP	U1	H 6	Z1799	W/C accessory, safety belt/ pelvic strap, each (Belt, safety or chest, w/pad)	K 1**** N	Purchase
K0038	EP	U1	6	Z1802**	Leg strap, each (Knee strap)	N	Purchase
E0980	NU EP	U1 U1	H 6	Z1803	Safety vest, W/C (Shoulder retractors)	K 1****	Purchase
E0950	NU EP	U2 U2	H 6	Z1804	W/C accessory, tray, each (ABS tray (4-SM 5-LG)	K 1****	Purchase

E0950	NU EP	U5 U5	H 6	Z1805	W/C accessory, tray, each (Clear upper Ex support system)	K 1****	Purchase
E0950	NU EP	U4 U4	H 6	Z1807	W/C accessory, tray, each (Tray, customized)	N	Purchase
E0950	NU EP		H 6	Z1810	W/C accessory, tray, each	N	Purchase
K0019	NU EP		H 6	Z1813	Arm pad, each	N	Purchase
K0066	NU EP		H 6	Z1992	Solid tire, any size, each (20-26" Tires for manual W/C (ea.) (Replacement)	N	Purchase
K0012	NU EP		H 6	Z2108	Lightweight portable motorized/power W/C (Motorized folding frame, DA, swing away foot rests)	Y*	Purchase
K0012	NU EP	U1 U1	H 6	Z2109	Lightweight portable motorized/power W/C (Motorized folding frame, DA, swing away ELR)	Y*	Purchase
K0010	NU EP		H 6	Z2110	Standard weight frame motorized/power W/C (Motorized, standard frame, DA, swing away foot rests)	Y*	Purchase
K0010	NU EP	U1 U1	H 6	Z2111	Standard weight frame motorized/power W/C (Motorized, standard frame, DA, swing away ELR)	Y*	Purchase
K0011	NU EP		H 6	Z2112	Standard-weight frame motorized/power, W/C with programmable control parameters for speed adjustment, tremor dampening, acceleration control and braking	Y*	Purchase
K0011	NU EP	U1 U1	H 6	Z2113	Standard-weight frame motorized/power, W/C with programmable control parameters for speed adjustment, tremor dampening, acceleration control and braking	Y*	Purchase
E1004	NU EP		H 6	Z2114	W/C accessory, power seating system, recline only, with mechanical shear reduction	Y*	Purchase

E1002	NU EP		H 6	Z2115	W/C accessory power seating system, tilt only	Y*	Purchase
E1006	NU EP	U1 U1	H 6	Z2116	W/C accessory, power seating system, combination tilt and recline, without mechanical shear reduction (Power tilt and recline system with zero sheer)	Y*	Purchase
K0017	NU EP	U1 U1	H 6	Z2117	Detachable, adjustable height armrest, base, each (Dual post and adjustable height DA)	K 1****	Purchase
E0950	NU EP UE	U7 U7	H 6 U	Z2119	W/C accessory, tray, each (Removable Hinged Overlay for Tray)	K 1****	Purchase
E0982⁷	NU EP	U1 U1	H 6	Z2120	W/C accessory, back upholstery, replacement only, each (Standard back upholstery replacement)	K 1****	Purchase
K0024	NU EP		H 6	Z2121	Solid back insert, planar back, single density foam, with adjustable hook on hardware	K 1****	Manually Priced
K0045	NU EP		H 6	Z2122	Footrest, complete assembly (padded custom foot box)	K 1****	Purchase
E0967⁷	NU EP		H 6	Z2123	Manual W/C accessory, hand rim w/projections, each (Vertical/oblique projection hand rims 8-10-12 )	K 1****	Purchase
E0959	NU EP		H 6	Z2124	Manual W/C accessory, adapter for amputee, each	K 1****	Purchase
E0959	NU EP		H 6	Z2125	Manual W/C accessory, adapter for amputee, each (Amputee axle plate for high performance manual W/C (ea)	K 1****	Purchase
K0070	NU EP		H 6	Z2126	Rear wheel assembly, complete with pneumatic tire, spokes or molded, each (207227247267ea. replacement)	K 1****	Purchase
K0097	NU EP		H 6	Z2127	Wheel, zero pressure tire tube (flat free insert) for power base, any size, each	K 1****	Purchase
K0093	NU EP		H 6	Z2128	Rear wheel zero pressure tire tube (flat free insert) for power W/C any size, each	K 1****	Purchase

K0074	NU EP	U2 U2	H 6	Z2129	Pneumatic caster tire, any size each (9x2 3/4" for power base W/C)	K 1****	Purchase
K0099	NU EP		H 6	Z2130	Front caster for power W/C (9 x 2 3/4" foam filled)	K 1****	Purchase
K0064	NU EP	U1 U1	H 6	Z2131	Zero pressure tube (flat free insert), any size, each (12" or 14")	K 1****	Purchase
E2367⁷	NU EP		H 6	Z2132	Power w/c accessory, battery charger, dual mode, sealed or non-sealed, each (24-Volt Battery Charger- Dual Mode (Replacement)	N	Purchase
E2366⁷	NU EP		H 6	Z2133	Power w/c accessory, battery charger, single mode, for use with only one battery type, sealed or non-sealed, each (24-Volt Battery Charger - Standard (Replacement)	N	Purchase
E1091	NU EP		H 6	Z2134	Youth positioning stroller	N	Purchase
E0956⁷	NU EP	U1 U1	H 6	Z2136	W/C accessory, lateral trunk or hip support, prefabricated w/fixed mounting hardware, each (Lateral trunk supports (swing away) (ea)	K 1****	Purchase
E1161	NU EP		H 6	Z2146	Manual adult size W/C, includes tilt in space	Y*	Purchase
E0178	NU EP		H 6	Z2147	Gel or gel-like pressure pad or cushion, nonpositioning (Sm., 10"-14"Gel)	N	Purchase
E0178	NU EP	U1 U1	H 6	Z2148	Gel or gel-like pressure pad or cushion, nonpositioning (Med., 14"-18" Gel, low pressure)	N	Purchase
E0178	NU EP	U2 U2	H 6	Z2149	Gel or gel-like pressure pad or cushion, nonpositioning (Lg., over 18" Gel, width or depth)	N	Purchase
E0176	NU EP		H 6	Z2150	Air pressure pad or cushion, nonpositioning (ll-LW-no maintenance, low pressure and positioning cushion)	N	Purchase

E0178	NU EP	U3 U3	H 6	Z2151	Gel or gel-like pressure pad or cushion, nonpositioning (Gel Growth - Adj., low pressure and positioning cushion)	N	Purchase
K0114	NU EP		H 6	Z2152	Back support system for use with a W/C, with inner frame, prefabricated (Positioning back standard height)	K 1****	Purchase
E1228	NU EP	U2 U2	H 6	Z2153	Special back height for W/C (Positioning tall back)	K 1****	Purchase
E0992	NU EP	U4 U4	H 6	Z2155	Manual w/c accessory, solid seat insert (Adjustable solid standard seat w/hardware)	K 1****	Purchase
E0992	NU EP	U1 U1	H 6	Z2156	Manual w/c accessory, solid seat insert (Large adjustable solid seat w/hardware)	K 1****	Purchase
E0192	NU EP	U1 U1	H 6	Z2160	Low pressure and positioning equalization pad, for W/C (air flotation cushion w/cover)	N	Purchase
E0192	NU EP	U2	H 6	Z2161	Low pressure and positioning equalization pad, for W/C (Low pressure & positioning air and foam flotation cushion w/cover)	N	Purchase
K0068	NU EP		H 6	Z2162	Pneumatic tire tube, each (20-26" for manual W/C (ea) Replacement)	N	Purchase
K0074	NU EP	U1 U1	H 6	Z2163	Pneumatic caster tire, any size, each (6"-8" for manual W/C (ea) Replacement)	N	Purchase
K0078	NU EP		H 6	Z2164	Pneumatic caster tire tube, each (6"-8" for manual W/C (ea) (Replacement)	N	Purchase
E0953	NU EP		H 6	Z2165	Pneumatic tire, each (8" x 2" for manual W/C (ea) Replacement)	N	Purchase
K0078	NU EP	U1 U1	H 6	Z2166	Pneumatic caster tire tube, each (8" x 2" tubes for manual W/C (ea) (Replacement)	N	Purchase
K0094	NU EP		H 6	Z2167	Wheel tire for power base, any size, each (20" x 2 1/8" Replacement)	N	Purchase

K0091	NU EP	U1 U1	H 6	Z2168	Rear wheel tire tube other than zero pressure for power W/C, any size, each (20" x 2 1/8" tubes for power W/C (ea) (Replacement)	N	Purchase
K0076	NU EP	U1 U1	H 6	Z2169	Solid caster tire, any size, each 10" x 3" Rear Wheel for Power W/C (ea) Replacement	N	Purchase
K0091	NU EP		H 6	Z2170	Rear wheel tire tube other than zero pressure for power W/C, any size, each (10" x 3" Rear Wheel Caster Tube for Power W/C (ea) Replacement)	N	Purchase
K0076	NU EP		H 6	Z2171	Solid caster tire, any size, each (9" x 3" Caster Tire for Power W/C (ea) (Replacement)	N	Purchase
K0078	NU EP	U2 U2	H 6	Z2172	Pneumatic caster tire tube, each (9" x 3" for Power W/C (ea) (Replacement)	N	Purchase
K0452	NU EP	U1 U1	H 6	Z2173	W/C bearings, any type (Rear Wheel Stem (Replacement)	N	Purchase
K0452	NU EP		H 6	Z2174	W/C bearings, any type (Caster Bearing (Replacement)	N	Purchase
K0452	NU EP	U2 U2	H 6	Z2176	W/C bearings, any type (Power Base Wheel Bearing (Replacement)	K 1****	Purchase
K0044	NU EP		H 6	Z2177	Footrest, upper hanger bracket, each (SWFR Hanger bracket, replacement)	K 1****	Purchase
K0081	NU EP		H 6	Z2179	Wheel lock assembly, complete, each (High push or pull wheel lock (replacement)	K 1****	Purchase
K0043	NU EP		H 6	Z2182	Footrest, lower extension tube, each (SWFR, replacement)	N	Purchase
K0076	NU EP	U2 U2	H 6	Z2193	Solid caster tire, any size, each (Polyurethane 5" (Replacement)	K 1****	Purchase
E0973⁷	NU EP	U1 U1	H 6	Z2194	W/C accessory, adjustable height, detachable armrest, complete assembly, each (Height Adj. Arms (Replacement)	K 1****	Purchase

K0017	NU EP		H 6	Z2195	Detachable, adjustable height armrest, base, each (Receiver for height adj. arms, replacement)	K 1****	Purchase
E0956⁷	NU EP	U2 U2	H 6	Z2201	W/C accessory, lateral trunk or hip support, prefabricated w/fixed mounting hardware, each (Med. Chest Panel Support)	K 1****	Purchase
E1235	NU EP		H 6	Z2204	W/C, pediatric size, rigid, adjustable, with seating system (Snug Seat I Mobility System)	Y*	Purchase
E1070			6	Z2520 #	Fully reclining W/C, detachable arms, desk or full-length, swing-away, detachable footrests	Y	Rental only
K0093	NU EP	U1 U1	H 6	Z2553	Rear wheel zero pressure tire tube (flat free insert) for power W/C, any size, each (Mag. Airless Insert Drive Wheel)	K 1****	Purchase
E2201⁷	NU EP	U1 U1	H 6	Z2555	Manual w/c accessory, nonstandard seat frame width[GREATER THAN]than or equal to 20 inches and [LESS THAN]24 inches (Frame Wdth-14"-15")	K 1****	Manually Priced (21+) Purchase
E2201⁷	NU EP	U2 U2	H 6	Z2557	Manual w/c accessory, nonstandard seat frame width[GREATER THAN]than or equal to 20 inches and [LESS THAN]24 inches (Frame Wdth-19"-20")	K 1****	Manually Priced (21+) Purchase
E2203⁷	NU EP	U2 U2	H 6	Z2558	Manual w/c accessory, nonstandard seat frame depth, 20 to less than 22 inches (Frame Long-16", 17"3, 18", 19"3, 20" Depth)	K 1****	Manually Priced (21+) Purchase
K0056	NU EP	U1 U1	H 6	Z2559	Seat height less than 17 inches or equal to or greater than 21 inches for a high strength, lightweight or ultralightweight W/C (Seat height 19.5"5)	K 1****	Purchase
E1225	NU EP		H 6	Z2560	Manual W/C accessory, semi-reclining back, (recline greater than 15 degrees, but less than 80 degrees), each (Folding Backrest 8 Degree Bend Low 15"-16")	K 1****	Purchase

E1228	NU EP		H 6	Z2561	Special back height for W/C (Folding Backrest Tall 19" - 20")	K 1****	Purchase
E1228	NU EP		H 6	Z2562	Special back height for W/C (Folding Straight Backrest Low (15"-16")	K 1****	Purchase
E1228	NU EP		H 6	Z2563	Special back height for W/C (Folding Straight Backrest Tall (19"-20")	K 1****	Purchase
E0990	EP		6	Z2564	W/C accessory, elevating leg rest, complete assembly, each	K 1****	Purchase
E0990⁷	NU EP	U1 U1	H 6	Z2565	W/C accessory, elevating leg rest, complete assembly, each (Elevating Leg Rest 90 Degree (12"-16" Width)	K 1****	Purchase
E2203⁷	NU EP	U3 U3	H 6	Z2566	Manual w/c accessory, nonstandard seat frame depth, 20 to less than 22 inches (Seat Depth 19"-20")	K 1****	Manually Priced Purchase
E2201⁷	NU EP		H 6	Z2567	Manual w/c accessory, nonstandard seat frame width [GREATER THAN] than or equal to 20 inches and [LESS THAN] 24 inches (Seat Wdth 20")	K 1****	Manually Priced Purchase
E2203⁷	NU EP		H 6	Z2568	Manual w/c accessory, nonstandard seat frame depth, 20 to less than 22 inches (Seat Depth 15")	K 1****	Manually Priced Purchase
E2203⁷	NU EP	U1 U1	H 6	Z2569	Manual w/c accessory, nonstandard seat frame depth, 20 to less than 22 inches (Seat Depth 17"-18")	K 1****	Manually Priced Purchase
E1029⁷	NU EP		H 6	Z2570	Wheelchair accessory, ventilator tray, fixed (Ventilator Tray Wth Battery Tray)	Y	Purchase
K0106	NU EP		H 6	Z2572	Arm trough, each	K 1****	Purchase
K0020	NU EP		H 6	Z2575	Fixed, adjustable height armrest, pair	K 1****	Purchase
K0074	NU EP	U3 U3	H 6	Z2578	Pneumatic caster tire, any size, each (Pneumatic Caster 8 X2 Wth Airless Insert)	K 1****	Purchase

K0067	NU EP		H 6	Z2579	Pneumatic tire, any size,(Pneumatic Caster 8X2 With Airless Insert)	K 1****	Purchase
E0967⁷	NU EP		H 6	Z2583	Manual W/C accessory, hand rim w/projections, each (Projection Vertical or Obilque)	N	Purchase
E0956⁷	NU EP	U3 U3	H 6	Z2584	W/C accessory, lateral trunk or hip support, prefabricated w/fixed mounting hardware, each (Chest/Thoracic Supports)	K 1****	Purchase
E1013	NU EP	U2	H 6	Z2587	Integrated seating system, contoured, for pediatric W/C (Deep Contour Back 14" - 19" Wdth)	K 1****	Purchase
E1020	NU EP		H 6	Z2590	Residual limb support system for W/C (Adjustable Contour Lateral Thigh Support)	K 1****	Purchase
E2363	EP		6	Z2593	Group 24 Gel Batteries	K 1****	Purchase
E1013	EP		6	Z2594	Integrated seating system, contoured, for pediatric W/C (Adjustable Contour Seat 10" -12" Frame)	K 1****	Purchase
E1013	EP	U1	6	Z2595	Integrated seating system, contoured, for pediatric W/C (Adjustable Contour Seat 14" -16" Frame)	K 1****	Purchase
E1026	EP		6	Z2597	Lateral thoracic support, contoured, for pediatric W/C, each (includes hardware) (Adjustable Contour Back 10" -12" Frame)	K 1****	Purchase
E1026	EP	U1	6	Z2598	Lateral thoracic support, contoured, for pediatric W/C, each (includes hardware (Adjustable Contour Back 14" -16" Frame))	K 1****	Purchase
E1228	NU EP	U1 U1	H 6	Z2610	Special back height for W/C (High back contour seat)	K 1****	Purchase
E1235	EP	U1 U1	6	Z2611 ¹'²	W/C, pediatric size, rigid, adjustable with seating system (Rigid W/C Frame)	Y	Purchase
E0950⁷	NU EP	U8 U8	H 6	Z2612	Wheelchair accessory, tray, each (Lap Tray for Switch Array)	Y	Purchase

E0950⁷	NU EP	U6 U6	H 6	Z2613	Wheelchair accessory, tray, each (Lap Tray Switch Array)	K 1****	Purchase
K0014	NU EP	U1 U1	H 6	Z2614¹'²	Other motorized/ power W/C base (Center Drive power base)	Y	Purchase
E0950	NU EP	U3 U3	H 6	Z2617	W/C accessory, tray, each (Custom)	K 1****	Purchase

The following procedure codes may only be billed on paper.

Specialized Wheelchairs and Wheelchair Seating Systems for Individuals Age Two Through

Adult (section 242.191)

No National Code	M1	M2	TOS	Local Code	Description	PA	Capped Rental, Purchase or Rental Only
Bill on paper			H 6	Z1613	One piece footboard (Each)	K 1****	Purchase
Bill on paper			H 6	Z1663	Group 27 deep cycle battery (each)	N	Purchase
Bill on paper			a"	Z1785	W/C Mounting Kit, O.B.	K 1****	Purchase
Bill on paper			H 6	Z1789	Custom Headrest	K 1****	Purchase
Bill on paper			H 6	Z1793	Custom foot platform	K 1****	Purchase
Bill on paper			6	Z1824**	PC Car Seat/Snug Seat	Y	Purchase
Bill on paper			H 6	Z2137	Adjustable Rem. Abductor w/hardware (ea)	K 1****	Purchase
Bill on paper			H 6	Z2138	Adjustable Flip Down Abductor w/hardware (ea)	K 1****	Purchase
Bill on paper			^H6	Z2139	Lateral Hip/Thigh support w/hardware (ea)	K 1****	Purchase
Bill on paper			a"	Z2140	Adductor - no hardware	K 1****	Purchase
Bill on paper			H 6	Z2141	Abductor - no hardware	K 1****	Purchase
Bill on paper			H 6	Z2142	Hip guides - no hardware	N	Purchase
Bill on paper			a"	Z2143	Fluid supplement	N	Purchase

Bill on paper	a^H	Z2145	Laterals - no hardware	K 1****	Purchase
Bill on paper	H 6	Z2157	Standard Seat Cover for Cushion (Replacement)	N	Purchase
Bill on paper	e"	Z2158	Air Exchange Seat Cover for Cushions (Replacement)	N	Purchase
Bill on paper	H 6	Z2159	Fluid Flo-lite pad (Replacement)	N	Purchase
Bill on paper	H 6	Z2175	Power W/C Sleeve Top or Bottom Stem Bearing (Replacement)	K 1****	Purchase
Bill on paper	H 6	Z2178	SWFR Pivot Saddle (Replacement)	N	Purchase
Bill on paper	H 6	Z2180	SWFR Latch Block (Replacement)	N	Purchase
Bill on paper	^H6	Z2181	SWFR Composite Foot Plate (Replacement)	K 1****	Purchase
Bill on paper	H 6	Z2183	Shoe Holders S/M/L/XL	K 1****	Purchase
Bill on paper	H 6	Z2184	X-Tube Assembly Folding W/C (Replacement)	K 1****	Purchase
Bill on paper	H 6	Z2185	Rigid Wheelchair Growth Kit	N	Purchase
Bill on paper	e^H	Z2186	Rigid Side Guard	K 1 ****	Purchase
Bill on paper	H 6	Z2187	Fabric Side Guard	K 1****	Purchase
Bill on paper	H 6	Z2188	Sub Occipital Three Piece Head Set W/REM Hardware	K 1****	Purchase
Bill on paper	H 6	Z2189	Forehead Strap System	K 1****	Purchase
Bill on paper	H 6	Z2190	Regular Links	K 1****	Purchase
Bill on paper	a"	Z2192	Pneumatic or Semi Casters (Replacement) 8 x1 1/4(ea)or8x1 3/4 (ea)	K 1****	Purchase
Bill on paper	H 6	Z2196	Swing Away Adj. Stroller Handles	K 1****	Purchase

Bill on paper	a^H	Z2200	Support Fixture for Head Rest	K 1****	Purchase
Bill on paper	H 6	Z2202	Lg. Chest Panel Support	K 1****	Purchase
Bill on paper	H 6	Z2203	Elbow Block w/Bracket	K 1****	Purchase
Bill on paper	a^H	Z2554	Swing Away Retractable Joystick Mount	K 1****	Purchase
Bill on paper	H 6	Z2571	Power Elevating Leg Rest With Calf Pads	K 1****	Purchase
Bill on paper	H 6	Z2582	Quick Release Axle	K 1****	Purchase
Bill on paper	a^H	Z2585	Growing Seat Pan	K 1****	Purchase
Bill on paper	H	Z2586	Growing Back Upholstery	K 1****	Purchase
Bill on paper	H 6	Z2588	Deep Contour Back 20" Width	K 1****	Purchase
Bill on paper	H 6	Z2589	Adjustable Contour Lateral Pelvic Support	K 1****	Purchase
Bill on paper	a^H	Z2591 ¹	Heavy Duty Motor Pack 350 Pounds	N	Purchase
Bill on paper	H 6	Z2592	Remote Joystick Module	K 1****	Purchase
Bill on paper	H	Z2596	Adjustable Contour Seat Attaching Hardware	K 1****	Purchase
Bill on paper	a"	Z2599	Transit Option	K 1****	Purchase
Bill on paper	H 6	Z2604	Adjustable Back Upholstery	K 1****	Purchase
Bill on paper	H 6	Z2607	Lateral/Posterior Pelvic Support	K 1****	Purchase
Bill on paper	a^H	Z2608	Shoulder Harness Guide Kit	K 1****	Purchase
Bill on paper	H 6	Z2609	Universal Head Rest Kit	K 1****	Purchase
Bill on paper	H 6	Z2615	Remote Joystick Wth 1/8" Jacks	K 1****	Purchase
Bill on paper	H 6	Z2616	Swing Away Mount (Joystick)	K 1****	Purchase

NOTE: Where both a national code and a local code ("Z code") are available, the local

242.192 Specialized Rehabilitative Equipment, All Ages

Additionally, when billing on paper, procedure codes must be billed with a type of service (TOS) code "6" for individuals under 21 years of age or type of service code "H" for individuals age 21 or over.

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

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

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

Specialized Rehabilitative Equipment, All Ages (section 242.192)

National Code

TOS

Description

Capped Rental, Purchase or Rental Only

E0638⁷

NU EP

H 6

Standing frame system, any size, with or without wheels

Purchase

E0638⁷

o_ o_

LU LU

U1 U2

CD CD

Standing frame system, any size, with or without wheels

Purchase

Specialized Rehabilitative Equipment, All Ages (section 242.192)

National Code	M1	M2	TOS	Local Code	Description	PA	Capped Rental, Purchase or Rental Only
E1031	EP	U5	6	Z2037**	Rollabout chair, any and all types with casters five inches or greater (Low Back Activity Chair)	N	Purchase

E1031	EP		6	Z2041**	Rollabout chair, any and all types with casters five inches or greater (Transition Toddler Chair - Sm.)	N	Purchase
E1031	EP		6	Z2042**	Rollabout chair, any and all types with casters five inches or greater (Transition Toddler Chair- Lg.)	Y	Purchase
E0701	NU EP		H 6	Z2053	Helmet with face guard and soft interface material, prefabricated (Soft Shell Helmets)	N	Purchase
E0701	NU EP	U1	H 6	Z2054	Helmet with face guard and soft interface material, prefabricated (Hard Shell Helmets)	N	Purchase
E1035	EP		6	Z2055**	Multi-positional patient transfer system, with integrated seat, operated by care giver (Carrie Seat - Pre School)	Y	Purchase
E1035	EP	U1	6	Z2056**	Multi-positional patient transfer system, with integrated seat, operated by care giver (Carrie Seat - Elementary)	Y	Purchase
E1035	EP	U2	6	Z2057**	Multi-positional patient transfer system, with integrated seat, operated by care giver (Carrie Seat -Jr.)	Y	Purchase

E1035	NU EP	U3 U3	H 6	Z2058	Multi-positional patient transfer system, with integrated seat, operated by care giver (Carrie Seat - Sm. Adult)	Y*	Purchase
E1031	EP	U1	6	Z2059**	Rollabout chair, any and all types with casters five inches or greater (Corner Chair w/Tray & Casters -Sm.)	N	Purchase
E1031	EP	U3	6	Z2060**	Rollabout chair, any and all types with casters five inches or greater (Corner Chair w/Tray & Casters -Lg.)	N	Purchase
E1031	EP	U4	6	Z2061**	Rollabout chair, any and all types with casters five inches or greater (Bolster Chair w/Tray, Chest Support & Casters -Sm.)	N	Purchase
E0245	NU EP	U3 U3	H 6	Z2063	Tub stool or bench (30" Bath Chair)	N	Purchase
E0245	NU EP	U4 U4	H 6	Z2064	Tub stool or bench (38" Bath Chair)	N	Purchase
E0245	NU EP	U5 U5	H 6	Z2065	Tub stool or bench (47" Bath Chair)	N	Purchase
E0245	NU EP	U6 U6	H 6	Z2066	Tub stool or bench (56" Bath Chair)	N	Purchase
E0163	EP		6	Z2067	Commode chair, stationary, with fixed arms (Potty Chair-Sm).	Y	Purchase
E0166	EP	U1	6	Z2068	Commode chair, mobile, with detachable arms (Potty Chair- Lg)	Y	Purchase

E0245	NU EP	U2 U2	H 6	Z2078	Tub stool or bench (Padded Tub Transfer Bench)	N	Purchase
E0245	NU EP	52 52	H 6	Z2079	Tub stool or bench (Non-padded tub transfer bench)	N	Purchase
E0245	NU EP		H 6	Z2080	Tub stool or bench (Adj. Bath Chair w/Back)	N	Purchase
E0241	NU EP		H 6	Z2081	Bathroom wall rail, each (Bolt-on Sm. Grab Bar)	N	Purchase
E0241	NU EP	U1 U1	H 6	Z2082	Bathroom wall rail, each (Bolt-on Lg. Grab Bar)	N	Purchase
E0241	NU EP	U2 U2	H 6	Z2083	Bathroom wall rail, each (Bolt-on Med. Grab Bar)	N	Purchase
E0246	NU EP		H 6	Z2084	Transfer tub rail attachment (Clamp-on Tub Grab Bar)	N	Purchase
E0168	NU	U1	H	Z2085	Commode chair, extra wide and/or heavy duty, stationary or mobile, with or without arms, any type, each (Rehab Shower/Commode Chair)	Y*	Purchase
E0168	EP		6	Z2085	Commode chair, extra wide and/or heavy duty, stationary or mobile, with or without arms, any type, each (Rehab Shower/Commode Chair)	Y*	Purchase

E0168	NU		H	Z2088	Commode chair, extra wide and/or heavy duty, stationary or mobile, with or without arms, any type, each (Adaptive Commode Chair)	N	Purchase
E0168	EP	52	6	Z2088	Commode chair, extra wide and/or heavy duty, stationary or mobile, with or without arms, any type, each (Adaptive Commode Chair)	N	Purchase
E0149	NU EP		H 6	Z2098	Walker, heavy duty, wheeled, rigid or folding, any type (4 Wheel Reverse Walker)	N	Purchase
E0950	NU EP	U1 U1	H 6	Z2600	Wheelchair accessory, tray, each (Tray for gait trainer)	N	Purchase
E0700	NU EP		H 6	Z2601	Safety equipment (e.g., belt, harness or vest (Chin Guard for Safety Helmet sm)	N	Purchase
E0701	NU EP	U2 U2	H 6	Z2603	Helmet with face guard and soft interface material, prefabricated (face guard for safety helmet)	N	Purchase

The following list of codes may only be billed on paper. Specialized Rehabilitative Equipment, All Ages (section 242.192)

No National Code	M1	M2	TOS	Local Code	Local Code Description	PA	Capped Rental, Purchase or Rental Only
Bill on paper			H 6	Z1996	Sm. 51" Supine Stander	Y*	Purchase
Bill on paper			a"	Z1997	Lg. 71" Supine Stander	Y*	Purchase
Bill on paper			6	Z1998**	27" Prone Stander	N	Purchase
Bill on paper			6	Z2000**	42" Prone Stander	Y*	Purchase
Bill on paper			a"	Z2001	50" Prone Stander	Y*	Purchase
Bill on paper			H 6	Z2002	Adj. Abduction Wedge w/hip stabilizer	N	Purchase
Bill on paper			H 6	Z2003	Tray for Stander-Prone	N	Purchase
Bill on paper			H 6	Z2004	Tray for Stander-Supine	N	Purchase
Bill on paper			a"	Z2005	Foot Sandals for Standers	N	Purchase
Bill on paper			6	Z2006**	Up Rite Stander-Sm.	N	Purchase
Bill on paper			6	Z2007**	Up Rite Stander- Med.	N	Purchase
Bill on paper			a"	Z2008	Up Rite Stander- Lg.	N	Purchase
Bill on paper			H 6	Z2009	Caster Base for Up Rite Stander- Sm.	N	Purchase
Bill on paper			H 6	Z2010	Caster Base for Up Rite Stander- Med.	N	Purchase
Bill on paper			a"	Z2011	Caster Base for Up Rite Stander- Lg.	N	Purchase
Bill on paper			6	Z2012**	Tumble Form Tri Stander w/Tray - Sm.	Y*	Purchase
Bill on paper			6	Z2013**	Tumble Form Tri Stander w/Tray - Lg.	Y*	Purchase
Bill on paper			6	Z2015**	48" Side Lyer	N	Purchase
Bill on paper			6	Z2016**	72" Side Lyer	N	Purchase
Bill on paper			6	Z2017**	Tumble Form Feeder Seat -Sm.	N	Purchase

Bill on paper	H 6	Z2018**	Tumble Form Feeder Seat -Med.	N	Purchase
Bill on paper	6	Z2019**	Tumble Form Feeder Seat -Lg.	N	Purchase
Bill on paper	6	Z2020**	Floor Sitter Wedge	N	Purchase
Bill on paper	6	Z2021**	Mobile Floor Sitter Med/Lg.	N	Purchase
Bill on paper	6	Z2022**	Tumble Form Therapy Wedge 4" - Sm.	N	Purchase
Bill on paper	6	Z2023**	Tumble Form Therapy Wedge 6" - Sm.	N	Purchase
Bill on paper	6	Z2026**	Tumble Form Therapy Wedge 8" - Med.	N	Purchase
Bill on paper	6	Z2029**	Tumble Form Therapy Wedge 10" - Lg.	N	Purchase
Bill on paper	6	Z2030**	Tumble Form Therapy Rolls 4"	N	Purchase
Bill on paper	6	Z2031**	Tumble Form Therapy Rolls 6"	N	Purchase
Bill on paper	6	Z2032**	Tumble Form Therapy Rolls 8"	N	Purchase
Bill on paper	6	Z2034**	Tumble Form Therapy Rolls 12"	N	Purchase
Bill on paper	6	Z2035**	Tumble Form Therapy Rolls 14"	N	Purchase
Bill on paper	6	Z2036**	Tumble Form Therapy Rolls 16"	N	Purchase
Bill on paper	6	Z2038**	Therapy Ball - Sm.	N	Purchase
Bill on paper	6	Z2039**	Therapy Ball - Med.	N	Purchase
Bill on paper	6	Z2040**	Therapy Ball - Lg.	N	Purchase
Bill on paper	6	Z2043**	Seat & Back Pad for Toddler Chairs	Y	Purchase
Bill on paper	6	Z2044**	Tray for Toddler Chair	Y	Purchase
Bill on paper	6	Z2045**	14"T&SHigh Back w/Support Activity Chair	Y	Purchase

Bill on paper	6	Z2046**	16"T&SHigh Back w/Support Activity Chair	Y	Purchase
Bill on paper	a"	Z2047	Orthopedic Car Seat	Y	Purchase
Bill on paper	H 6	Z2048	4" Deluxe Wedge w/Strap	N	Purchase
Bill on paper	H 6	Z2072	Lg. Wrap Around Bath Support	N	Purchase
Bill on paper	a"	Z2073	Sm. Wrap Around Back Support	N	Purchase
Bill on paper	H 6	Z2074	Lg. Toilet Support w/Hi Back	N	Purchase
Bill on paper	H 6	Z2075	Sm. Toilet Support w/Hi Back	N	Purchase
Bill on paper	H 6	Z2077	Flexible Shower Hose	N	Purchase
Bill on paper	a"	Z2089	Toilet Seat Reducer Ring (Padded)	N	Purchase
Bill on paper	6	Z2090**	14" Gait Trainer	N	Purchase
Bill on paper	6	Z2091**	19" Gait Trainer	Y*	Purchase
Bill on paper	6	Z2092**	Intermediate Gait Trainer	Y*	Purchase
Bill on paper	H 6	Z2093	Adult Gait Trainer	Y*	Purchase
Bill on paper	6	Z2094**	Tyke Strider Walker w/2 Wheels	N	Purchase
Bill on paper	6	Z2095**	Tweener Strider Walker w/2 Wheels	N	Purchase
Bill on paper	6	Z2096**	Middle Strider Walker w/2 Wheels	N	Purchase
Bill on paper	H 6	Z2097	Adult Strider Walker w/2 Wheels	N	Purchase
Bill on paper	H 6	Z2099	4 Wheel Reverse Walker	N	Purchase
Bill on paper	a"	Z2100	4 Wheel Reverse Walker	N	Purchase
Bill on paper	H 6	Z2101	4 Wheel Reverse Walker	N	Purchase

Bill on paper	H 6	Z2102	4 Wheel Reverse Walker	N	Purchase
Bill on paper	a"	Z2104	4 Wheel Front Swivel Reverse Walker	N	Purchase
Bill on paper	H 6	Z2105	4 Wheel Front Swivel Reverse Walker	N	Purchase
Bill on paper	H 6	Z2106	4 Wheel Front Swivel Reverse Walker	N	Purchase
Bill on paper	H	Z2107	4 Wheel Front Swivel Reverse Walker	N	Purchase
Bill on paper	H 6	Z2239	Bath Chair Headrest	N	Purchase
Bill on paper	H 6	Z2605	Diverter Valve for Handheld Shower	N	Purchase

242.193 Augmentative Communication Device, All Ages

The augmentative communication device is covered for recipients under 21 years of age when prescribed as a result of an EPSDT screen, and for recipients age 21 years and older.

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

Each covered component must be billed using the procedure code assigned to that specific component and billed with a type of service "6" for recipients under 21 and type of service "H" for recipients over 21 years of age. A manufacturer's invoice must accompany the claim. Repairs of the augmentative communication device will also be covered with prior authorization. Refer to section 220.000 of this manual for information.

The Medicaid Program will not cover communication devices that are prescribed solely for social or educational development. Training in the use of the device is not included and is not a covered cost.

The total reimbursement for augmentative components is $7,500.00 per lifetime, per recipient and the devices become the property of the recipient. In cases of extraordinary medical necessity, the provider may apply for an extension of benefits for recipients under 21 years of age. See section 222.410 of this manual.

Additionally, when billing on paper, procedure codes must be billed with a type of service (TOS) "6" for individuals under age 21 or TOS "H" for individuals age 21 and over.

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

⁷ Procedure code became payable July 1, 2004.

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

Augmentative Communication Device, All Ages (section 242.193 )

National Code	M1	M2	TOS	PA	Description	Capped Rental, Purchase or Rental Only
E2512⁷	NU EP		H 6	Y Y	Accessory for speech generating device, mounting system	Manually Priced

Augmentative Communication Device, All Ages (section 242.193 )

National Code	M1	M2	TOS	Local Code	Description	PA	Capped Rental, Purchase or Rental Only
E2599⁷	NU EP		H 6	Z1972	Accessory for speech generating device, not otherwise classified (Switches - used with training aids and augmentative communication devices as a means of access.)	Y*	Manually Priced
E2500⁷	NU EP		H 6	Z1974	Speech generating device, digitized speech, using pre-recorded messages less than or equal to 8 minutes recording time (Light Technology Communication Aids -communication aids that do not have the memory component to store the information. They are often used in conjunction with higher tech devices as part of a multi-modal communication system.)	Y*	Purchase

E2502⁷	NU EP	H 6	Z1975	Speech generating device, digitized speech, using pre-recorded messages, greater than 8 minutes but less than or equal to 20 minutes recording time (Simple	Y*	Purchase
				Voice Output Device -simple devices with limited storage capacity and voice output only.)
E2504⁷	NU EP	H 6	Z1975	Speech generating device, digitized speech, using pre-recorded messages, greater than 20 minutes but less than or equal to 40 minutes recording time (Simple Voice Output Device -simple devices with limited storage capacity and voice output only.)	Y*	Purchase
E2506⁷	NU EP	H 6	Z1975	Speech generating device, digitized speech, using pre-recorded messages, greater than 40 minutes recording time.	Y*	Purchase
				(Simple Voice Output Device - simple devices with limited storage capacity and voice output only.)
E2508⁷	NU EP	H 6	Z1976	Speech generating device, synthesized speech, requiring message formulation by spelling and access by physical contact with the device (More Advanced Voice Output Communication Aids -offer more storage capacity and often have other output methods in addition to voice output (e.g., LED display)	Y*	Purchase

E2510⁷	NU EP	6	Z1977 I I i 1 i i i i i i	Speech generating device synthesized speech, permitting multiple methods of message formulation and multiple methods of device access (Higher Technology Voice Output Communication Aids - offer greater memory capabilities, various types of output, computer interface options, etc.)	Y*	Purchase
E2510⁷	NU EP	H 6	Z1978 I I i 1 i i i 1 1 i i i i i i	Speech generating device synthesized speech, permitting multiple methods of message formulation and multiple methods of device access (State-of-the-Art Voice Output Communication Aids - represents state-of-the-art communication aid technology. Has extensive memory capabilities, various output methods, computer interface options, offer a variety of input methods in a single device and advanced functions, such as: auditory scanning, icon and word prediction, etc.)	Y*	Purchase
E2511⁷	NU EP	H 6	Z1979 I I I i i i 1	Speech generating software program, for personal computer or personal digital assistant (Software - often recommended for augmentative communication device. Software may change as the child matures.)	Y*	Purchase
V5336	NU EP	H 6	Z2260 i i 1 i	Repair/modification of augmentative communicative system or device (excludes adaptive hearing aid)(Augmentative Communication Device Repair- parts only)	Y	Purchase

V5336	NU		H	Z2261	Repair/modification of	Y	Purchase
	EP		6		augmentative communicative system or device (excludes adaptive hearing aid)(Augmentative Communication Device Repair- labor only)

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

242.200 Place of Service, Type of Service and Modifier Codes

Place of Service	Paper Claims	Electronic Claims
Inpatient Hospital	1	21
Outpatient Hospital	2	22
Doctor's Office	3	11
Patient's Home	4	12
Day Care Facility	5	52
Night Care Facility	6	52
Nursing Home	7	33
Skilled Nursing Facility	8	31
Ambulance	9	41
Other Locations	0	99
Independent Laboratory	A	81
Ambulatory Surgical Center	B	24
Residential Treatment Center	C	56
Specialized Treatment Facility	D	56
Comprehensive Outpatient Rehabilitative Facility	E	62
Independent Kidney Disease	Ll_	65

Treatment Center
Inpatient Psychiatric Facility	G	51

Type of Service (paper only)

H-Over 21

U-Used Equipment

I-Initial Rental

6-Under 21

Modifiers

EP- Service provided as part of EPSDT Program

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

NU-New Equipment

RR-Durable Medical Equipment (DME) Rental

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

U2-Medicaid level of Care 2 (defined by state)

U3-Medicaid level of care 3 (defined by state)

U4-Medicaid level of care 4 (defined by state)

U5-Medicaid level of care 5 (defined by state)

UE-Used durable medical equipment (DME)

52-Reduced Services

Notes

016.06.04 Ark. Code R. § 065

11/5/2004

State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.

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