Arkansas Department of uman Services Division of Medical Services Donaghey Plaza South P.O. Box 1437 Little Rock, Arkansas 72203-1437 Internet Website: www.medicaid.state.ar.us Telephone (501) 82-8292 TDD (501) 82-789 or 1-877-708-8191 FAX (501) 82-1197 TO: Arkansas Medicaid Prosthetics ealth Care Providers DATE: September 1, 2004 SBJECT: Provider Manual pdate Transmittal o. 0 REMOVE ISERT Section Date Section Date 242.110 242.200 10-13-03 242.170 242.200 9-1-04 Provider Manual pdate Transmittal o. 0 is being reissued. Explanation of pdates Please ote: All sections included in this update are revised retroactively to 10-13-03 and July 2004 revisions are also included. Procedure code descriptions have been added to all sections for ease of reference. Sections 242.100 through 242.112 have been revised to include the correct procedure codes, modifiers, procedure code descriptions and type of service (TOS) codes used in the sections. Section 242.113 has been deleted. The information from this section was incorporated into section 242.112 and the title has been changed from Durable Medical Equipment, Pregnant Women All Ages to ome Blood Glucose Monitor and Supplies-Pregnant Women All Ages. Modifiers, procedure code descriptions and type of service (TOS) codes have been added to the section. Section 242.120 has been revised to include the correct procedure codes, modifiers, procedure code descriptions and type of service (TOS) codes used in the section. Effective on July 1, 2004, several national procedure codes within the section became non payable. The codes are: A421, A422, A424, A42, A428, A430, A432, A434, and A43. Arkansas Medicaid has replaced the codes with new national codes that became effective July 1, 2004. Section 242.130 has been revised to include the correct procedure codes, modifiers, procedure code descriptions and type of service (TOS) codes used in the section. Effective on July 1, 2004, procedure code A452 replaced A4527 which had been cross-walked to Z2720. Arkansas Medicaid has replaced the codes with new national codes that became effective July 1, 2004. Sections 242.140 and 242.150 have been revised to include the correct procedure codes, modifiers, procedure code descriptions and type of service (TOS) codes used in the section. Section 242.152 has been revised to include the correct procedure codes, modifiers, procedure code descriptions and type of service (TOS) codes used in the section. Alpha sub-section headings have been included within the section for ease of usage. Section 242.153 has been revised to remove obsolete information from the section. The Department of uman Services is in compliance with Titles VI and VII of the Civil Rights Act.
Arkansas Medicaid Prosthetics Providers pdate Transmittal o. 0 Page 2 Section 242.10 has been revised to include correct procedure codes, modifiers, procedure code descriptions and type of service (TOS) codes used in the section. Information has been merged into the section from 242.11, which was also titled Durable Medical Equipment, All Ages. The new title for section 242.11 is sed Durable Medical Equipment, Age 21 and Over. Section 242.11 has been revised. The title has been revised and information found in the section has been merged into section 242.10. The new title for section 242.11 is sed Durable Medical Equipment, Age 21 and Over. Section 242.12 has been deleted. Information that was included in the section has been transferred to Section 242.11. Section 242.170 has been revised to include the correct procedure codes, modifiers, procedure code descriptions and type of service (TOS) codes used for the section. Section 242.180, previously titled Orthotic Appliances, nder 21 ears of Age has been re-titled Orthotic Appliances, All Ages. Information found in the section has been merged with information previously located in section 242.181 and section 242.182. Information has been revised to include the correct procedure codes, modifiers, procedure code descriptions and type of service (TOS) codes used in the sections. Section 242.181, titled Orthotic Appliances, Age 21 and Over has been deleted and information from the section has been merged with Section 242.180, titled Orthotic Appliances, All Ages. Section 242.182, titled Payable Orthotic Appliance Procedure Codes Age 21 and Over has been deleted and information contained in the section has been merged into section 242.180. Section 242.190, previously titled Prosthetic Devices, nder 21 ears of Age has been re-titled Prosthetic Devices, All Ages. Information found in the section has been merged with information previously located in Sections 242.191 and 242.192. Information has been revised to include the correct procedure codes, modifiers, procedure code descriptions and type of service (TOS) codes used in the sections. Section 242.191, titled Prosthetic Devices, Age 21 and Over has been revised and information found in the section has been merged into section 242.190. The section has been renamed Specialized Wheelchairs and Wheelchair Seating Systems for Individuals Age Two Through Adult. Information has been revised to include the correct procedure codes, modifiers, procedure code descriptions and type of service (TOS) codes used in the section. Effective July 1, 2004, several national procedure codes became non-payable. The codes include: E0993, E1150, E1210, E1212, E12, K0004, K0014, K001, K0025, K0030, K0048, K0054, K0055, K0057, K0058, K002, K0082, K0084, K0085, K008, K0088, K0089, K0087, K0083, K0100, K0107, K0108, K0112, K0113 and K0115. Arkansas Medicaid has replaced the codes with new national codes that became effective July 1, 2004. Section 242.192, titled Payable Prosthetic Device Procedure Codes, Age 21 and Over has been revised and information previously found in the section has been merged into section 242.190. The title of the section has been changed to Specialized Rehabilitative Equipment, All Ages. Information has been revised to include the correct procedure codes, modifiers, procedure code descriptions and type of service (TOS) codes used in the section.
Arkansas Medicaid Prosthetics Providers pdate Transmittal o. 0 Page 3 Section 242.193 has been revised. The section previously titled Specialized Wheelchairs and Wheelchair Seating Systems for Individuals Age Two Through Adult. That information has been transferred to Section 242.191. The current title for the section is Augmentative Communication Device, All Ages. Information has been revised to include correct procedure codes, modifiers, procedure code descriptions type of service (TOS) codes to the section. Several national procedure codes became non-payable on July 1, 2004. The procedure codes include: K0541, K0542, K0543, K0544, K0545 and K0547. Arkansas Medicaid has replaced the procedure codes with new national codes that became effective July 1, 2004. Section 242.194 has been deleted. Information from the section has been transferred to section 242.192. Section 242.195 has been deleted. Information from the section has been transferred to section 242.193. Section 242.200 has been revised. The heading has been renamed Place of Service, Type of Service and Modifier Codes. Modifiers and their definitions used in the Prosthetics Program have been added to the sections. Paper versions of this update transmittal have updated pages attached to file in your provider manual. See Section I for instructions on updating the version of the manual. For electronic versions, these changes will be automatically incorporated. If you need this material in an alternative format, such as large print, please contact our Americans with Disabilities Act Coordinator at (501) 82-789 or 1-877-708-8191. Both telephone numbers are voice and TDD. If you have questions regarding this transmittal, please contact the EDS Provider Assistance Center at 1-800-457-4454 (Toll-Free) within Arkansas or locally and Out-of-State at (501) 37-2211. Thank you for your participation in the Arkansas Medicaid Program. Roy Jeffus, Director Arkansas Medicaid provider manuals (including update transmittals), official notices and remittance advice (RA) messages are available for downloading from the Arkansas Medicaid website: www.medicaid.state.ar.us.
242.110 Respiratory and Diabetic Equipment All Ages 9-1-04 Effective for dates of service on and after October 13, 2003, when billing either electronically or on, procedure codes found in this section must be billed with modifier for recipients under 21 years of age or modifier for recipients age 21 and over. When a second modifier is listed, that modifier must be used in conjunction with either or. Additionally, when billing on, procedure codes must be billed with a type of service (TOS) code for individuals under age 21 or TOS 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 in the column, if not, an 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) ational Code M1 M2 TOS Description PA E0424 E0430 E0435 E0439 EO441 E0442 Stationary compressed gaseous oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing Portable gaseous oxygen system, purchase, includes regulator, flowmeter, humidifier, cannula or mask, and tubing Portable liquid oxygen system, purchase; includes portable container, supply reservoir, flowmeter, humidifier, contents gauge, cannula or mask, tubing and refill adapter Stationary liquid oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing 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 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 Rental Rental Rental Rental
Respiratory and Diabetic Equipment All Ages (section 242.110) ational Code M1 M2 TOS Description PA E0443 E0444 E0470 7 E0471 7 E0472 7 E050 E051 7 E052 7 RR RR RR RR RR RR 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 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 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) 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) 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) umidifier, durable for supplemental humidification during IPPB treatment or oxygen delivery umidifier, non-heated, used w/positive airway pressure device umidifier, heated, used w/positive airway pressure device Rental Rental Rental E0570 ebulizer, with compressor E0575 ebulizer, ultrasonic, large volume Rental E000 E1390 Respiratory suction pump, home model, portable or stationary, electric Oxygen concentrator, single delivery port, capable of delivering 85 % or greater oxygen concentration at the prescribed flow rate Rental Rental
Respiratory and Diabetic Equipment All Ages (section 242.110) ational Code M1 M2 TOS Description PA E1391 7 O2 concentrator, dual delivery port, capable of delivering 85% or > O2 concentration at the prescribed flow rate, each E1391 7 I O2 concentrator, dual delivery port, 85% or > O2 concentration at the prescribed flow rate, each Respiratory and Diabetic Equipment All Ages (section 242.110) ational Code M1 M2 TOS Local Code Description PA E1340 Z0425 Repair or nonroutine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes (DME Repair: Parts 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.) A9999 7 Z0428 Misc. DME supply or accessory, not otherwise specified nlisted Durable Medical Equipment. (The manufacturer s invoice must be attached to the claim form.) E0779 RR Z159 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). Rental
Respiratory and Diabetic Equipment All Ages (section 242.110) ational Code M1 M2 TOS Local Code Description PA A7034 RR Z1579 asal interface (mask or cannula type) used with positive airway pressure device, with or without head strap (CPAP Device asal Continuous Positive Airway Pressure (CPAP) Device (includes necessary accessory items) OTE: Complete Medical data pertinent to the request must be submitted with the prior authorization request. OTE: Bill A7034 as the Global Monthly Rental Service. E0483 RR Z1705 igh frequency chest wall oscillation air-pulse generator system, (includes hoses and vest), each (Bronchial Drainage System) E0483 52 Z170 igh 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.) E1340 4 Z1719 Repair or nonroutine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes (Maintenance for Rental items) E1340 Z1758 Repair or nonroutine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes (Labor (a maximum of twenty (20) units (20 units = 5 hours of labor) per date of service is allowable.) E1340 Z1758 Labor (a maximum of twenty (20) units (20 units = 5 hours of labor) per date of service is allowable.) Rental Rental /A
Respiratory and Diabetic Equipment All Ages (section 242.110) ational Code M1 M2 TOS Local Code Description PA E0470 RR Z1983 BIPAP Device asal Bilevel Positive Airway support system (includes necessary accessory items) OTE: Complete medical data pertinent to the request must be submitted with the prior authorization request. E0784 Z2205 External ambulatory infusion pump, insulin A4230 Z2208 Infusion set for external insulin pump, nonneedle cannula type (each) A4231 Z2209 Infusion set for external insulin pump, needle type, (each) A4232 Z2210 Syringe with needle for external insulin pump, sterile, 3cc (each) A432 Z2211 Replacement battery for external infusion pump, any type, each A021 Z2212 Collagen dressing, pad size 1 sq. in. or less, each A022 Z2212 Collagen dressing, pad size more than 1 sq. in. but less than or equal to 48 sq. in., each A023 Z2212 Collagen dressing, pad size more than 48 sq. in., each A024 Z2212 Collagen dressing wound filler, per in A427 52 Z2240 Spacer bag or reservoir without mask, for use with metered dose inhaler. A427 Z2241 Spacer bag or reservoir with mask, for use with metered dose inhaler. Global Code for BIPAP OTE: 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 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 claim. Where only a national code is available, it can be used indefinitely for both electronic and claims. 242.111 Initial Rental of a DME Item for Individuals of All Ages 9-1-04
Effective for dates of service on and after October 13, 2003, when billing either electronically or on, procedure codes found in this section must be billed with modifier K to indicate an initial rental of an item. Modifiers are indicated below with the heading of M1 and M2. Additionally, when billing on, 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 (21) or for only individuals age 21 and over (). 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) ational Code M1 M2 TOS Description E01 Commode chair, mobile, with detachable arms 21 E0181 Pressure pad, alternating with pump, heavy duty 21 E0200 E0205 eat lamp, without stand (table model), includes bulb, or infrared element eat lamp, with stand includes bulb, or infrared element E0217 Water circulating heat pad with pump 21 E0225 ydrocollator unit, includes pad 21 E023 Pump for water circulating pad 21 E0239 ydrocollator unit, protable 21 E0250 ospital bed, fixed height, with any type side rails, with mattress E0255 ospital bed, variable height; hi-lo, with any type side rails, with mattress E020 I ospital bed, semi-electric, (head and foot adjustment), with any type side rails with mattress E0271 Mattress, inner spring 21 E0272 Mattress, foam rubber 21 All 21 21 21 21 21 21 E0303 7 I ospital bed, heavy duty, extra wide, with weight capacity > 350 but < or = 00, 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
Initial Rental of a DME Item for Individuals of All Ages (section 242.111) ational Code M1 M2 TOS Description E0435 Portable liquid oxygen system, purchase; includes portable container, supply reservoir, flowmeter, humidifier, contents gauge, cannula or mask, tubing and refill adapter All 21 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 21 E055 Compressor, air power source for equipment which is not self-contained or cylinder driven 21 E0575 ebulizer, ultrasonic, large volume AA E0585 ebulizer, with compressor and heater 21 E000 Respiratory suction pump, home model, portable or stationary, electric AA E00 Vaporizer, room type 21 E030 Patient lift, hydraulic, with seat or sling 21 E050 Pneumatic compressor, nonsegmental home model 21 E07 Segmental pneumatic appliance for use with pneumatic compressor, full leg E08 Segmental pneumatic appliance for use with pneumatic compressor, full arm E091 ltraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; treatment area two square feet or less E092 I ltraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; four foot panel E093 I ltraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; six foot panel E094 I ltraviolet multidirectional light therapy system in six foot cabinet includes bulbs/lamps, timer and eye protection E0720 TES, two lead, localized stimulation 21 E0730 Transcutaneous electrical nerve stimulation device four or more leads, for multiple nerve stimulation E0745 I euromuscular stimulator, electronic shock unit 21 E0747 Osteogenesis stimulator, electrical noninvasive, other than spinal applications E0910 Trapeze bars, also known as Patient elper, attached to bed, with grab bar E0920 Fracture frame, attached to bed, includes weights 21 21 21 21 21 21 21 21 21 21
Initial Rental of a DME Item for Individuals of All Ages (section 242.111) ational Code M1 M2 TOS Description E0930 Fracture frame, freestanding, includes weights 21 E0935 Passive motion exercise device 21 E0940 Trapeze bar, freestanding, complete with grab bar 21 E0941 Gravity assisted traction device, any type 21 E1130 Standard wheelchair, fixed full-length arms, fixed or swing away, detachable footrests E1224 Wheelchair with detachable arms, elevating leg rests 21 All 21 21 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) ational Code M1 M2 TOS Local Code Description All 21 E0779 I Z159 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) A7034 I Z1579 asal interface (mask or cannula type) used with positive airway pressure device, with or without head strap (CPAP Device asal Continuous Positive Airway Pressure (CPAP) Device (includes necessary accessory items) OTE: For, complete medical data pertinent to the request must be submitted with the prior authorization request. S8105 Z1588 Oximeter for measuring blood oxygen levels noninvasively E0250 I Z234 ospital bed, fixed height, with any type side rails, with mattress E0255 K I Z2347 ospital bed, variable height; hi-lo, with any type side rails, with mattress E020 K I Z2348 ospital bed, semi-electric, (head and foot adjustment), with any type side rails with mattress E0910 K I Z2353 Trapeze bars, also known as Patient elper, attached to bed, with grab bar AA AA 21
Initial Rental of a DME Item for Individuals of All Ages (section 242.111) ational Code M1 M2 TOS Local Code Description E1130 K I Z2355 Standard wheelchair, fixed full-length arms, fixed or swing away, detachable footrests E1224 I Z235 Wheelchair with detachable arms, elevating legrests E0143 I Z2359 Walker, folding, wheeled, adjustable or fixed height E030 K I Z2374 Patient lift, hydraulic, with seat or sling E0730 K I Z2380 Transcutaneous electrical nerve stimulation device four or more leads, for multiple nerve stimulation OTE: 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 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 claim. Where only a national code is available, it can be used indefinitely for both electronic and 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. All 21 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 ome Blood Glucose Monitor and Supplies - Pregnant Women, All Ages 9-1-04 Effective for dates of service on and after October 13, 2003, when billing either electronically or on, procedure codes found in this section must be billed with modifier for individuals of all ages. When a second modifier is listed, that modifier must be used in conjunction with the modifier. Additionally, when billing on, procedure codes must be billed with a type of service (TOS) code 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. ational Code M1 M2 TOS Local Code Description PA or Rental E007 Z2272 ome Blood Glucose Monitor A4253 Z2285 Blood glucose test or reagent strips for home glucose monitor, per 50 strips A4259 2 Z2337 Lancets, per box of 100
OTE: 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 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 claim. Where only a national code is available, it can be used indefinitely for both electronic and claims. 242.120 Medical Supplies, All Ages 9-1-04 Effective for dates of service on and after October 13, 2003, when billing either electronically or on, procedure codes found in this section must be billed with modifier for individuals of all ages. When a second modifier is listed, that modifier must be used in conjunction with the modifier. Additionally, when billing on procedure codes must be billed with a type of service (TOS) code 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-79 may be used for the request for prior authorization. View or print form DMS-79 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) ational Code M1 M2 TOS Description A420 Syringe with needle, sterile 1 cc, ea A421 7 Sterile water/saline, 10 ml A4217 7 Sterile water/saline, 500 ml A4221 1 Supplies for maintenance of drug infusion catheter, per week (list drug separately) A4222 1 Supplies for external drug infusion pump, per cassette or bag (list drug separately) A4253 Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips A425 ormal, low, and high calibrator solution/chips A4259 Lancets, per box of 100 A425 Paraffin, per pound A4310 Insertion tray without drainage bag and without catheter (accessories only) A4311 Insertion tray without drainage bag with indwelling catheter, Foley type, two-way latex with coating (Teflon, silicone, silicone elastomer or hydrophilic, etc.)
Medical Supplies, All Ages (section 242.120) ational Code M1 M2 TOS Description A4312 Insertion tray without drainage bag with indwelling catheter, Foley type, two-way, all silicone A4313 Insertion tray without drainage bag with indwelling catheter, Foley type, three-way, for continuous irrigation A4314 Insertion tray with drainage bag with indwelling catheter, Foley type, two-way latex with coating (Teflon, silicone, silicone elastomer or hydrophilic, etc. A4315 Insertion tray with drainage bag with indwelling catheter, Foley type, two-way, all silicone A431 Insertion tray with drainage bag with indwelling catheter, Foley type, three-way, for continuous irrigation A4320 Irrigation tray with bulb or piston syringe, any purpose A4322 Irrigation syringe, bulb or piston, each A432 Male external catheter specialty type with intergral collection chamber, each A4327 Female external urinary collection device; metal cup, each A4328 Female external urinary collection device; pouch, each A4330 Perianal fecal collection pouch with adhesive, each A4338 Indwelling catheter, Foley type, two-way latex with coating (Teflon, silicone, silicone elastomer or hydrophilic, etc), each A4340 Indwelling catheter; specialty type, (e.g., coude, mushroom, wing, etc.), each A4344 Indwelling catheter, Foley type, two-way, all silicone, each A434 Indwelling catheter, Foley type, three-way for continuous irrigation, each A4347 Male external catheter with or without adhesive, with or without anti-reflux device; per dozen A4348 Male external catherter with intergral collection compartment, extended wear, each (e.g., 2 per month) A4351 Intermittent urinary catheter; straight tip, with or without coating (Teflon, silicone, silicone elastomer or hydrophilic, etc.), each A4351 Intermittent urinary catheter; straight tip, with or without coating (Teflon, silicone, silicone elastomer or hydrophilic, etc.), each A4352 Intermittent urinary catheter; coude (curved) tip, with or without coating (Teflon, silicone, silicone elastomeric or hydrophilic, etc.), each
Medical Supplies, All Ages (section 242.120) ational Code M1 M2 TOS Description A4352 Intermittent urinary catheter; coude (curved) tip, with or without coating (Teflon, silicone, silicone elastomeric or hydrophilic, etc.), each A4354 Insertion tray with drainage bag but without catheter A4355 Irrigation tubing set for continuous bladder irrigation through a three-way indwelling Foley catheter, each A435 External urethral clamp or compression device (not to be used for catheter clamp), each A4357 Bedside drainage bag, day or night, with or without anti-reflux device, with or without tube, each A4358 rinary drainage bag, leg or abdomen, vinyl, with or without tube, with straps, each A4359 rinary suspensory without leg bag, each A431 Ostomy faceplate, each A432 Skin barrier; solid, four by four or equivalent; each A434 Adhesive, liquid, or equal, any type, per ounce A437 Ostomy belt, each A439 Ostomy skin barrier, liquid, (spray, brush, etc), per oz A4371 Ostomy skin barrier, power, per oz A4397 Irrigation supply; sleeve, each A4398 Ostomy irrigation supply; bag, each A4399 Ostomy irrigation supply; cone/catheter, including brush A4400 Ostomy irrigation set A4402 Lubricant, per ounce A4404 Ostomy ring, each A4405 Ostomy skin barrier, non-pectin based, paste, per ounce A440 Ostomy skin barrier, pectin based, paste, per ounce A4414 Ostomy skin barrier, with flange (solid, flexible or accordion), without built-in convexity, 4 x 4 inches or smaller, each A4450 Tape, non-waterproof, per 18 square inces A4452 Tape, waterproof, per 18 square inces A4455 Adhesive remover or solvent (for tape, cement or other adhesive), per ounce
Medical Supplies, All Ages (section 242.120) ational Code M1 M2 TOS Description A4558 Conductive paste or gel A451 Pessary, rubber, any type A452 Pessary, non rubber, any type A423 Tracheostomy, inner cannula A425 Tracheostomy care kit for new tracheostomy A42 Tracheostomy cleaning brush, each A428 Oropharyngeal suction catheter, each A429 Tracheostomy care kit for established tracheostomy A4772 Blood glucose test strips, for dialysis, per 50 A4927 Gloves, non-sterile, per 100 A5051 Ostomy pouch, closed; with barrier attached (one piece), each A5052 Ostomy pouch, closed; without barrier attached (one piece), each A5053 Ostomy pouch, closed; for use on faceplate, each A5054 Ostomy pouch, closed; for use on barrier with flange (two piece), each A5055 Stoma cap A501 Ostomy pouch, drainable; with barrier attached (one piece), each A502 Ostomy pouch, drainable; without barrier attached (one piece), each A503 Ostomy pouch, drainable; for use on barrier with flange (two piece system), each A5071 Ostomy pouch, urinary; with barrier attached (one piece), each A5072 Ostomy pouch, urinary; without barrier attached (one piece), each A5073 Ostomy pouch, urinary; for use on barrier with flange (two piece), each A5081 Continent device; plug for continent stoma A5082 Continent device; catheter for continent stoma A5093 Ostomy accessory; convex insert A5102 Bedside drainage bottle, with or without tubing, rigid or expandable, each A5105 rinary suspensory; with leg bag, with or without tube
Medical Supplies, All Ages (section 242.120) ational Code M1 M2 TOS Description A5112 rinary leg bag; latex A5113 Leg strap; latex, replacement only, per set A5114 Leg strap; foam or fabric, replacement only, per set A5119 Skin barrier; wipes, box per 50 A5121 Skin barrier; solid, x or equivalent, each A5122 Skin barrier; solid, 8 x 8 or equivalent, each A512 Adhesive or non-adhesive; disk or foam pad A5131 Appliance cleaner, incontinence and ostomy appliances, per 1 oz. A154 Wound pouch, each A234 ydrocolloid dressing, wound cover, pad size 1 sq. in. or less, without adhesive border, each dressing A241 ydrocolloid dressing, wound filler, dry form, per gram A242 ydrocolloid dressing, wound cover, pad size 1 sq. in. or less, without adhesive border, each dressing A242 ydrocolloid dressing, wound cover, pad size 1 sq. in. or less, without adhesive border, each dressing A248 ydrogel dressing, wound filler, gel, per fluid ounce A248 ydrogel dressing, wound filler, gel, per fluid ounce A442 7 Conforming bandage, non-elastic, knitted/woven, non-sterile, width < 3 in, per yd A445 7 Conforming bandage, non-elastic, knitted/woven sterile, width <3 in, per yd A448 7 Light compression bandage, elastic, knitted/woven width<3in, per yd A453 7 Self-adherent bandage, elastic, non-knitted/non-woven, width<3in, per yd A454 7 Self-adherent bandage, elastic, non-knitted/non-woven, width > or = 3 in & < 5 in, per yd A455 7 Self-adherent bandage, elastic, non-knitted/non-woven, width > or = 5 in, per yd A501 1,7 Compression burn garment, body suit (head to foot), custom fabricated A502 1,7 Compression burn garment, chin strap, custom fabricated
Medical Supplies, All Ages (section 242.120) ational Code M1 M2 TOS Description A503 1,7 Compression burn garment, facial hood, custom fabricated A504 1,7 Compression burn garment, glove to wrist, custom fabricated A505 1,7 Compression burn garment, glove to elbow, custom fabricated A50 1,7 Compression burn garment, glove to axilla, custom fabricated A507 1,7 Compression burn garment, foot to knee length, custom fabricated A508 1,7 Compression burn garment, foot to thigh length, custom fabricated A509 1,7 Compression burn garment, upper trunk to waist including arm openings (vest), custom fabricated A510 1,7 Compression burn garment, trunk including arms down to leg openings (leotard), custom fabricated A511 1,7 Compression burn garment, lower trunk including leg openings (panty), custom fabricated A512 1,7 Compression burn garment, not otherwise classified A7520 7 Trachestomy/Laryngectomy tube, non-cuffed, PVC, silicone or equal, each A7521 7 A7522 7 A7524 7 A7525 7 Trachestoomy/Laryngectomy tube, cuffed, PVC, silicone or equal, each Trachestomy/Laryngectomy tube, stainless steel or equal, (sterilizable and reusable), each PO-Tracheostoma stent/stud/button, each Tracheostomy mask, each B408 Gastrostomy/jejunostomy tube, any material, any type, (standard or low profile), each E077 IV pole Medical Supplies, All Ages (section 242.120) ational Code M1 M2 TOS Local Code Description A257 Z1938 Transparent film, 1 sq. in. or less, each dressing A258 Z1939 Transparent film, more than 1 sq. in., but less than or equal to 48 sq. in., each dressing A259 Z1940 Transparent film, more than 48 sq. in., each dressing
Medical Supplies, All Ages (section 242.120) ational Code M1 M2 TOS Local Code Description A21 Z1941 Gauze, non-impregnated, non-sterile, pad size 1 sq. in. or less, without adhesive border, each dressing A219 Z1941 Gauze, non-impregnated, 1 sq. in. or less with any size adhesive border, each dressing A228 Z1941 Gauze, impregnated, water or normal saline, pad, size 1 sq. in. or less, without adhesive border, each dressing A220 Z1942 Gauze, non-impregnated, pad more than 1 sq. in., but less than or equal to 48 sq. in., with any size adhesive border, each dressing A229 Z1942 Gauze, impregnated, water or normal saline, pad size more than 1 sq. in., but less than or equal to 48 sq. in., without adhesive border, each dressing A403 Z1942 Gauze, non-impregnated, sterile, pad size more than 1 sq. in. but less than 48 sq. in., without adhesive border, each dressing A221 Z1943 Gauze, non-impregnated, pad size more than 48 sq. in., with any size adhesive border, each dressing A230 Z1943 Gauze, impregnated, water or normal saline, pad more than 48 sq. in., without adhesive border, each dressing A404 Z1943 Gauze, non-impregnated, sterile, pad size more than 48 sq. in., without adhesive border, each dressing A4450 Z1944 Tape, non-waterproof, per 18 square inches A441 7 Z1944 Padding bandage, non-elastic, non-woven/nonknitted, width > or = 3 inches & < 5 in, per yd A443 7 Z1944 Conforming bandage, non-elastic, knitted/woven, non-sterile, width > or = 3 in & < 5 in, per yd A444 7 Z1944 Conforming bandage, non-elastic, knitted/woven, non-sterile, width > or = 5 in, per yd A44 7 Z1944 Conforming bandage, non-elastic, knitted/woven, sterile, width > or = 3 in & < 5 in, per yd A447 7 Z1944 Conforming bandage, non-elastic, knitted/woven, sterile, width > or = 5 in, per yd A245 Z1945 ydrogel dressing, wound cover, pad size 1 sq. in. or less, with any size adhesive border, each dressing A242 Z1945 ydrogel dressing, wound cover, pad size 1 sq. in. or less, without adhesive border, each dressing
Medical Supplies, All Ages (section 242.120) ational Code M1 M2 TOS Local Code Description A243 Z194 ydrogel dressing, wound cover, pad size more than 1 sq. in., but less than or equal to 48 sq. in., without adhesive border, each dressing A24 Z194 ydrogel dressing, wound cover, pad size more than 1 sq. in., but less than or equal to 48 sq. in., with any size adhesive border, each dressing A244 Z1947 ydrogel dressing, wound cover, pad size more than 48 sq. in. without adhesive border, each dressing A247 Z1947 ydrogel dressing, wound cover, pad size more than 48 sq. in. with any size adhesive border, each dressing A248 Z1948 ydrogel dressing, wound filler, gel, per fluid ounce A234 Z1949 ydrocolloid dressing, wound cover, pad size 1 sq. in. or less, without adhesive border, each dressing A237 Z1949 ydrocolloid dressing, wound cover, pad size 1 sq. in. or less, with any size adhesive border, each dressing A235 Z1950 ydrocolloid dressing, wound cover, pad size more than 1 sq. in., but less than or equal to 48 sq. in., without adhesive border, each dressing A238 Z1950 ydrocolloid dressing, wound cover, pad size more than 1 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing A23 Z1951 ydrocolloid dressing, wound cover, pad size more than 48 sq. in., without adhesive border, each dressing A238 Z1951 ydrocolloid dressing, wound cover, pad size more than 1 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing A239 Z1951 ydrocolloid dressing, wound cover, pad size more than 48 sq. in., with any size adhesive border, each dressing A19 Z1952 Alginate or other fiber gelling dressing, wound cover, pad size 1 sq. in. or less, each dressing A197 52 Z1953 Alginate or other fiber gelling dressing, wound cover, pad size more than 1 sq. in. but less than or equal to 48 sq. in, each dressing A198 Z1954 Alginate or other fiber gelling dressing, wound cover, pad size more than 48 sq. in., each dressing A197 52 Z1955 Alginate or other fiber gelling dressing, wound cover, pad size more than 1 sq. in. but less than or equal to 48 sq. in, each dressing (1 linear yard)
Medical Supplies, All Ages (section 242.120) ational Code M1 M2 TOS Local Code Description A212 Z195 Foam dressing, wound cover, pad size 1 sq. in. or less, with any size adhesive border, each dressing A213 Z1957 Foam dressing, wound cover, pad size more than 1 sq. in but less than or equal to 48 sq. in., with any size adhesive border, each dressing A211 Z1958 Foam dressing, wound cover, pad size more than 48 sq. in., without adhesive border, each dressing A203 Z1959 Composite dressing, pad size 1 sq. in. or less, with any size adhesive border, each dressing A204 Z190 Composite dressing, pad size more than 1 sq. in. but less than 48 sq. in., with any size adhesive border, each dressing A205 Z191 Composite dressing, pad size more than 48 sq. in., with any size adhesive border, each dressing A4253 52 Z193 Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips A4353 2 Z194 Intermittent urinary catheter, with insertion supplies (tray) A4394 Z195 Ostomy deodorant for use in ostomy pouch, liquid, per fluid ounce A435 Z19 Adhesive remover wipes, any type, per 50 A438 Z197 Ostomy filter, any type, each A449 7 Z199 Light compression bandage, elastic, knitted/woven, width > or = 3 in & < 5 in, per yd A450 7 Z199 Light compression bandage, elastic, knitted/woven, width > or = 5 in, per yd A451 7 Z199 Moderate compress bandage, elastic, knitted/woven load resistance of 1.25 to 1.34 foot pounds at 50% maximum stretch, width > or = 3 in & < 5 in, per yd A452 7 Z199 igh compress bandage, elastic, knitted/woven, load resistance greater than or equal to 1.35 foot pounds at 50 % maximum stretch, width > or = 3 in & < 5 in, per yd A4483 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) ational Code M1 M2 TOS Local Code Description Maximum nits Z2481 Thick-It per 8 oz. can 1 unit = 1 can Maximum 4 units per date of service
The following items are not subject to the $250 benefit limit. Medical Supplies, All Ages (section 242.120) ational Code M1 M2 TOS Local Code Description Maximum nits L8239 Z2483* Gradient compression stocking, OS (Jobst) 1 unit = 1 stocking Maximum 2 units per date of service *OTE: L8239 (Z2483) must be prior authorized. Form DMS-79 may be used for the request for prior authorization. View or print form DMS-79 and instructions for completion. OTE: 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 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 claim. Where only a national code is available, it can be used indefinitely for both electronic and claims. 242.130 Diapers and nderpads, 3 ears Old and Older 9-1-04- Effective for dates of service on and after October 13, 2003, when billing either electronically or on, procedure codes found in this section must be billed with modifier for recipients under 21 years of age or modifier for recipients age 21 and over. When a second modifier is listed, that modifier must be used in conjunction with either or. Additionally, when billing on, procedure codes must be billed with a type of service (TOS) code for individuals under age 21 or TOS 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 in the column, or if not, an is shown. Diapers and nderpads, 3 ears Old and Older (section 242.130) ational Code M1 M2 TOS Local Code Description PA or Rental A4554 Z1721 Disposable underpads, all sizes (e.g., Chux s) A4521 Z1722 Adult- sized incontinence product, diaper, small size, each A4522 Z1723 Adult-sized incontinence product, diaper, medium size, each A4523 Z1724 Adult-sized incontinence product, diaper, large size, each A4335 Z1830 Incontinence supply; miscellaneous (Small Child Size Diaper) A4335 Z1831 Incontinence supply; miscellaneous (Medium Child Size Diaper)
Diapers and nderpads, 3 ears Old and Older (section 242.130) ational Code M1 M2 TOS Local Code Description PA A4335 2 Z1832 Incontinence supply; miscellaneous (Large Child Size Diaper) A4533 Z2718 outh-sized incontinence product, diaper, each (outh adult Diaper 45-0 lbs.) A4524 Z2719 Adult-sized incontinence product, diaper, extra large size, each (Extra Large Adult Diaper (over 170 lbs.) A452 A4527 A4528 A4535 52 Z2720 Z2721 Z2721 Z2722 Adult-sized incontinence product, brief, medium size, each (Over- ight Brief Medium 33-41 waist/hip, 110 170 lbs.) Adult-sized incontinence product, brief, large size, each (Over-ight Brief Large 42-54 waist/hip, over 170 lbs.) Adult-sized incontinence product, brief, extra-large size, each (Over- ight Brief Large 42-54 waist/hip, over 170 lbs.) Disposable liner/shield for incontinence, each (Panty Liners/Bladder Pads/Diaper Doublers) A4531 Z2723 Child-sized incontinence product, brief, small/medium size, each (Pull-ups nisex up to 34 lbs.) A4531 Z2724 Child-sized incontinence product, brief, small/medium size, each (Pull-ups nisex over 34 lbs.) A4532 Z2725 Child-sized incontinence product, brief, large size, each (Pull-ups nisex 45-5 lbs.) A4532 Z272 Child-sized incontinence product, brief, large size, each (Pull-ups nisex 5-80 lbs.) A4335 3 Z2727 Incontinence supply; miscellaneous (nder-garment One size fits all) or Rental OTE: 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 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 claim. Where only a national code is available, it can be used indefinitely for both electronic and 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 9-1-04 Effective for dates of service on and after October 13, 2003, when billing either electronically or on, the procedure code found in this section must be billed using modifier for individuals of all ages. Additionally, when billing on, the procedure code must be billed with a type of service (TOS) 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 in the column, if not an is shown. Prior authorization is not required when another insurance pays at least 50% of the Medicaid maximum allowable reimbursement amount. ational Code M1 M2 TOS Local Code Description PA A470 Z190 Automatic blood pressure monitor Rental OTE: 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 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 claim. Where only a national code is available, it can be used indefinitely for both electronic and claims. 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 utritional Formulae, for Child ealth Services (SDT) Recipients nder 21 ears of Age 9-1-04 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 ealth Services (SDT) screening/referral. Effective for dates of service on and after October 13, 2003, when billing either electronically or on, procedure codes found in this section must be billed with modifier for recipients
under 21 years of age. When a second modifier is listed, that modifier must be used in conjunction with. Additionally, when billing on, procedure codes must be billed with a type of service (TOS) code 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. utritional Formulae, for Child ealth Services (SDT) Recipients nder 21 ears of Age (section 242.150) ational Code M1 M2 TOS Local Code Description Covered Formulae B4150 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) Covered Formulae: Attain Attain LS Boost Boost Powder Boost w/fiber Ceralyte Enfamil Enfamil with Iron Enfamil ext Step-Soy Enlive Ensure Ensure igh Fiber Ensure Ensure Powder Ensure w/fiber Entra Entrition Fibersource Fibersource Fortison Impact w/or without Fiber Intraolite Isocal Isomil IsoSource IsoSource Jevity (1.0 CAL) KinderCal Lactofree Lonalac Powder Meritene Meritene Powderewtrition ubasics ubasics Juice utrapack utrapack Isotonic utren w/without Fiber utren Jr Osmolite B4151 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- aturalized) See list below Osmolite (1.0 CAL) PediaSure w/or without Fiber Pre Attain Profiber Promote w/or without Fiber Prosobee Protain XL Renu Resource Diabetic Resource for Kids Resource Fruit Beverage Resource Liquid Sustagen Powder Travasorb ltracal Compleat ProBalance Vitaneed
utritional Formulae, for Child ealth Services (SDT) Recipients nder 21 ears of Age (section 242.150) ational Code M1 M2 TOS Local Code Description Covered Formulae B4152 Z1503 Enteral formulae; category II: Intact protein/protein isolates (calorically dense), administered through an enteral feeding tube, 100 calories = 1 unit (Category II- Intact Protein/ Protein Isolates - Calorically Dense) B4153 Z1504 Enteral formulae; category III: hydrolyzed protein/amino acids, administered through an enteral feeding tube, 100 calories = 1 unit (Category III- ydrolyzed Protein/Amino Acids) Covered Formulae: Accupep PF Alimentum Alitraq Criticare Isotein eocate eocate 1+ eocate Jr. utramigen Peptamen Peptamen 1.5 Diet Peptamen Junior Peptamen VP Peptamen with Prebio 1 Pepti Precision Powder Precision Isotonic Powder Pregestimal B4153 Z1504 Enteral formulae; category III: hydrolyzed protein/amino acids, administered through an enteral feeding tube, 100 calories = 1 unit (Category III- ydrolyzed Protein/Amino Acids) Covered Formulae: Accupep PF Alimentum Alitraq Criticare Isotein eocate eocate 1+ eocate Jr. utramigen Peptamen Peptamen 1.5 Diet Peptamen Junior Peptamen VP Peptamen with Prebio 1 Pepti Precision Powder Precision Isotonic Powder Pregestimal Boost Plus Comply Deliver 2 Ensure Plus Ensure Plus Magnacal ubasics Plus utren 1.5 utren 2.0 Resource Plus Scandishake Two-Cal See list below Reabilan Reabilan SandoSource Peptide Travasorb Powder Vital Powder Vivonex Pediatric Vivonex Plus Vivonex TE Powder See list below Reabilan Reabilan SandoSource Peptide Travasorb Powder Vital Powder Vivonex Pediatric Vivonex Plus Vivonex TE Powder
utritional Formulae, for Child ealth Services (SDT) Recipients nder 21 ears of Age (section 242.150) ational Code M1 M2 TOS Paper (Indicate specific name of formula on claims.) Local Code Description Covered Formulae B4154 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 eeds) Covered formulae: Advera AminAid Powder Analog MSD 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 utriep Perative Periflex Phenex I Phenex II Phenyl-Free PK 1, 2 & 3 Portagen Powder Product 8005 Propimax I Propimax II Pulmocare epatic Aid Powder ominex 1 & 2 IsoSource V Ketocal Powder Ketonex 1 Ketonex 2 Lofenalac B4155 Z150 Enteral formulae; category V: modular components, administered through an enteral feeding tube, 100 calories = 1 unit Category V - Modular Components (Protein, Carbohydrates, Fat) B415 Z1507 Enteral formulae: category VI: standardized nutrients, administered through an enteral feeding tube, 100 calories = 1 unit. (Category VI Standard) See list below Low Phe/Tyr Diet Powder Maxamaid MSD Maxamaid XP Maxamaid XLS-TR Maxamaid X Phen, Tyr Maxamum MSD Maxamum XP MSD 1, 2 & Powder epro RCF Respalor Similac 0/40 Suplena Traumacal TraumAid Powder Travasorb MCT Powder Travasorb Renal Powder TR 1 & 2 Casec Powder Fructose Powder Gevral Protein MCT Oil MCT Powder Moducal Polycose Liquid Promod Provimin Sumacal Precision LR Powder Enfamil Premature 24 CAL with/without IronSimalac eosure Special Care - 20 & 24 K Calorie/ounce with Iron Tolerex Travasorb STD Powder
utritional Formulae, for Child ealth Services (SDT) Recipients nder 21 ears of Age (section 242.150) ational Code M1 M2 TOS Local Code Description Covered Formulae B4155 Z224 Enteral formulae; category V: modular components, administered through an enteral feeding tube, 100 calories = 1 unit (Calorie Boosters) B4155 2 Z2273 Enteral formulae; category V: modular components, administered through an enteral feeding tube, 100 calories = 1 unit B4154 Z2500 Enteral formulae; category IV: defined formula for special metabolic need, administered through an enteral feeding tube, 100 calories = 1 unit Polycose Powder Dextrose Scandical Microlipids XMTVI Maxamaid OTE: 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 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 claim. Where only a national code is available, it can be used indefinitely for both electronic and claims. Providers must bill the formula procedure codes with a type of service code. 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. OTE: 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. OTE: 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 9-1-04 Effective for dates of service on and after October 13, 2003, when billing either electronically or on, the procedure code found in this section must be billed with modifier. Additionally, when billing on, procedure code must be billed with a type of service (TOS) code. 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. ational Code M1 M2 TOS Local Code Local Code Description Z2487 Pedia-Pop 1 unit = 1 box Maximum nits 2 units per date of service OTE: 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 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 claim. Where only a national code is available, it can be used indefinitely for both electronic and claims. 242.152 Enteral utrition Infusion Pump and Enteral Feeding Pump Supply Kit 9-1-04 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, procedure codes found in this section must be billed with modifier for recipients under 21 years of age. When a second modifier is listed, that modifier must be used in conjunction with. Additionally, when billing on, procedure codes must be billed with a type of service (TOS) code for individuals under age 21. The procedure codes will require prior authorization from the tilization 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 in the column, if not, an is shown. ational Code M1 M2 TOS Local Code Description B4035 Z1509 Enteral feeding supply kit, pump fed, per day (1 unit = 1 day) Maximum nits PA 1 per day
E1340 2 Z1510 Repair or nonroutine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes (Repair Enteral utrition Infusion Pump) B9000 Z1525 Enteral nutrition infusion pump without alarm (1 day = 1 unit) /A 1 per day OTE: 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 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 claim. Where only a national code is available, it can be used indefinitely for both electronic and claims. A. Enteral utrition 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. sed equipment will not be prior authorized. Code B9000 (Z1525) Enteral utrition Infusion Pump, represents a new piece of equipment being reimbursed by Medicaid on the rent-topurchase 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 tilization 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 tilization 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. ational Code M1 M2 TOS Local Code Description E1340 2 Z1510 Repair or nonroutine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes (Repair-Enteral utrition Infusion Pump) OTE: 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 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 claim. Where only a national code is available, it can be used indefinitely for both electronic and claims. 242.153 MIC-KE Skin Level Gastrostomy Tube (Mic-Key Button) and Supplies 9-1-04 The Arkansas Medicaid Program reimburses for the MIC-KE Skin Level Gastrostomy Tube (Mic-Key Button) and supplies for Medicaid-eligible individuals under age 21. Prior authorization (PA) from the tilization Review Section will be required. When billing the procedure codes, providers must use type of service. 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 tilization Review Section must be contacted to receive the prior authorization. To request prior authorization, complete and forward Form DMS-79, titled Medical Equipment Request for Prior Authorization and Prescription, along with sufficient medical documentation, to the tilization Review Section. View or print the tilization Review Section contact information. View or print form DMS-79 and instructions for completion. The MIC-KE Kit will be benefit limited to 2 per state fiscal year (SF). 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 tilization Review Section for any extensions using the DMS-79. Procedure codes listed are individually priced. ational Code Local Code Z298 Z299 Z2700 Local Code Description MIC-KE Kit SECR-LOK Extension Set with 2 Port and Clamp 12 Length SECR-LOK Extension Set with 2 Port and Clamp 24 Length
Z2702 Z2703 Z2704 Z2705 Z270 Z2714 Bolus Extension Set with Single Port Clamp 12 Length Bolus Extension Set with Single Port Clamp 24 Length Bolus SECR-LOK Extension Set Single Port w/clamp 12 Length Bolus SECR-LOK Extension Set Single Port w/clamp 24 Length Microvasive Adapter Microvasive Decompression Tube OTE: 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 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 claim. Where only a national code is available, it can be used indefinitely for both electronic and claims. 242.10 Durable Medical Equipment, All Ages 9-1-04 Effective for dates of service on and after October 13, 2003, when billing either electronically or on, procedure codes found in this section must be billed with modifier for recipients under 21 years of age or modifier for recipients age 21 and over. When a second modifier is listed, that modifier must be used in conjunction with either or. Modifier must be used when billing for used equipment. Additionally, when billing on, procedure codes must be billed with a type of service (TOS) code for individuals under age 21 and TOS for individuals age 21 and over. TOS 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 in the column, if not, an 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 (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 242.10) ational Code M1 M2 TOS PA Description A435 A43 A437 E0100 E0105 E0110 E0111 E0112 E0113 E0114 E011 E0130 E0135 E0140 7 E0141 or Rental nderarm pad, crutch, replacement, each Replacement, handgrip, cane, crutch, or walker, each Replacement, tip, cane, crutch, walker, each Cane, includes canes of all materials, adjustable or fixed, with tip Cane, quad or three-prong, includes canes of all materials, adjustable or fixed, with tips Crutches, forearm, includes crutches of various materials, adjustable or fixed, pair, complete with tips and handgrips Crutch, forearm, includes crutches of various materials, adjustable or fixed, each, with tip and handgrip Crutches, underarm, wood, adjustable or fixed, pair, with pads, tips and handgrips Crutch, underarm, wood, adjustable or fixed, each, with pad, tip and handgrip Crutches, underarm, other than wood, adjustable or fixed, pair, with pads, tips and handgrips Crutch, underarm, other than wood, adjustable or fixed, each, with pad, tip and handgrip Walker, rigid (pickup), adjustable or fixed height Walker, folding (pickup), adjustable or fixed height Walker, w/trunk support, adjustable or fixed height, any type Walker, rigid, wheeled, adjustable or fixed height
Durable Medical Equipment, All Ages (section 242.10) ational Code M1 M2 TOS PA Description E0143 E0147 E0153 E0154 E0155 E015 7 E0157 E0158 E0159 7 E010 E011 E013 E014 E01 E01 2 2 2 Walker, folding, wheeled, adjustable or fixed height Walker, heavy duty, multiple braking system, variable wheel resistance or Rental Platform attachment, forearm crutch, each Platform attachment, walker, each Wheel attachment, rigid pick-up walker, per pair seat attachment, walker Seat attachment, walker Crutch attachment, walker, each Leg extensions for walker, per set of four (4) Brake attachment for wheeled walker, replacement, each Sitz type bath or equipment, portable, used with or without commode Sitz type bath or equipment, portable, used with or without commode, with faucet attachment(s) Commode chair, stationary, with fixed arms Commode chair, mobile, with fixed arms PO-Commode chair, mobile, w/detachable arms PO-Commode chair, mobile, w/detachable arms Rental
Durable Medical Equipment, All Ages (section 242.10) ational Code M1 M2 TOS PA Description E017 E0175 E0178 E0180 E0181 E0182 E0184 E0185 E0189 E0190 7 E0191 E0192 E019 7 E0197 E0200 4 or Rental Pail or pan for use with commode chair Foot rest, for use with commode chair, each Gel or gel-like pressure pad or cushion, nonpositioning Pressure pad, alternating with pump Pressure pad, alternating with pump, heavy duty Rental Pump for alternating pressure pad Dry pressure mattress Gel or gel-like pressure pad for mattress, standard mattress length and width Lambswool sheepskin pad, any size Positioning cushion/pillow/wedge, any shape or size eel or elbow protector, each Low pressure and positioning equalization pad, for wheelchair Gel pressure mattress Air pressure pad for mattress, standard mattress length and width eat lamp, without stand (table model), includes bulb, or infrared element Rental
Durable Medical Equipment, All Ages (section 242.10) ational Code M1 M2 TOS PA Description E0202 E0205 E0217 E0225 E0235 E023 E0238 E0239 E0240 7 E0247 7 E0248 7 E0249 2 2 3 3 Phototherapy (bilirubin) light with photometer eat lamp, with stand includes bulb, or infrared element or Rental Rental Rental Water circulating heat pad with pump Rental ydrocollator unit, includes pad Rental Paraffin bath unit, portable (see medical supply code A425 for paraffin) Pump for water circulating pad Rental onelectric heat pad, moist ydrocollator unit, portable Rental Bath/shower chair w/wo wheels, any size Transfer bench, tub/toilet, w/wo commode opening Transfer bench, heavy duty, tub/toilet w/wo commode opening Pad for water circulating heat unit E0250 ospital bed, fixed height, with any type side rails, with mattress Rental
Durable Medical Equipment, All Ages (section 242.10) ational Code M1 M2 TOS PA Description E0255 ospital bed, variable height; hi-lo, with any type side rails, with mattress E020 E0271 E0272 E0273 E0275 E027 E0280 E0300 7 RR RR ospital bed, semi-electric, (head and foot adjustment), with any type side rails with mattress or Rental Rental Rental Mattress, inner spring Rental Mattress, foam rubber Rental Bed board Bed pan, standard, metal or plastic Bed pan, fracture, metal or plastic Bed cradle, any type Pediatric crib, hospital grade, fully enclosed RR Pediatric crib, hospital grade, fully enclosed Rental E0303 7 ospital bed, heavy duty, extra wide, with weight capacity > 350 but < or = 00, any type side rails, w/mattress Rental (Rent to ) E0325 rinal; male, jug-type, any material E032 rinal; female, jug-type, any material E0480 Percussor, electric or pneumatic, home model Rental E055 Compressor, air power source for equipment which is not self-contained or cylinder driven Rental
Durable Medical Equipment, All Ages (section 242.10) ational Code M1 M2 TOS PA Description E0570 E0585 E005 E00 E007*** or Rental ebulizer, with compressor ebulizer, with compressor and heater Rental Vaporizer, room type Postural drainage board Rental ome blood glucose monitor E030 Patient lift, hydraulic, with seat or sling Rental E050 Pneumatic compressor, nonsegmental home model Rental E07 Segmental pneumatic appliance for use with pneumatic compressor, full leg Rental E08 Segmental pneumatic appliance for use with pneumatic compressor, full arm Rental E091 ltraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; treatment area two square feet or less Rental E092 ltraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; four foot panel Rental E093 ltraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; six foot panel Rental E094 ltraviolet multidirectional light therapy system in six foot cabinet includes bulbs/lamps, timer and eye protection Rental E0720 TES, two lead, localized stimulation Rental
Durable Medical Equipment, All Ages (section 242.10) ational Code M1 M2 TOS PA Description E0730 E0740 E0745 E0747 E0748 Transcutaneous electrical nerve stimulation device four or more leads, for multiple nerve stimulation Incontinence treatment system, pelvic floor stimulator, monitor, sensor and/or trainer euromuscular stimulator, electronic shock unit Osteogenesis stimulator, electrical noninvasive, other than spinal applications Osteogenesis stimulator, electrical noninvasive, spinal applications or Rental Rental Rental Rental E0749 Osteogenesis stimulator, electrical, surgically implanted E0840 Traction frame, attached to headboard, cervical traction E0850 Traction stand, freestanding, cervical traction E080 Traction equipment, overdoor, cervical E0870 Traction frame, attached to footboard, extremity traction (e.g., Buck s) E0880 Traction stand, freestanding, extremity traction (e.g., Buck s) E0890 Traction frame, attached to footboard, pelvic traction E0900 Traction stand, freestanding, pelvic traction (e.g., Buck s) E0910 Trapeze bars, also known as Patient elper, attached to bed, with grab bar Rental
Durable Medical Equipment, All Ages (section 242.10) ational Code M1 M2 TOS PA Description E0920 E0930 E0935 E0940 E0941 E0942 E0944 E0945 E094 E0947 E0948 E0950 E1130* E1140* Fracture frame, attached to bed, includes weights Fracture frame, freestanding, includes weights or Rental Rental Rental Passive motion exercise device Rental Trapeze bar, freestanding, complete with grab bar Rental Gravity assisted traction device, any type Rental Cervical head harness/halter Pelvic belt/harness/boot Extremity belt/harness Fracture frame, dual with cross bars, attached to bed (e.g., Balken, Four Poster) Fracture frame, attachments for complex pelvic traction Fracture frame, attachments for complex cervical traction Wheelchair accessory, tray, each Standard wheelchair, fixed full-length arms, fixed or swing away, detachable footrests Wheelchair, detachable arms, desk or fulllength, swing away, detachable footrests Rental Rental
Durable Medical Equipment, All Ages (section 242.10) ational Code M1 M2 TOS PA Description E1150* E110* E1224* Wheelchair; detachable arms, desk or full-length, swing away, detachable, elevating legrests Wheelchair; fixed full-length arms, swing away, detachable, elevating legrests Wheelchair with detachable arms, elevating leg rests or Rental Rental Rental Rental Durable Medical Equipment, All Ages (section 242.10) ational Code M1 M2 TOS Local Code Description PA E1340 Z0425 Repair or nonroutine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes (DME Repairs/Parts 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.) E0779 Z159 Ambulatory infusion pump, mechanical, reusable, for infusion 8 hours or greater or Rental Rental (Ambulatory infusion device payable only when services are provided to patients receiving chemotherapy, pain management or antibiotic treatment in the home.) S8105 Z1588*** Oximeter for measuring blood oxygen levels noninvasively (Pulse oximeter (including 4 disposable probes) Rental
Durable Medical Equipment, All Ages (section 242.10) ational Code M1 M2 TOS E1340 E0245 S809 E0250 E0255 E020 Local Code Description PA Z1758*** Z1822*** Z1828*** Z1892 Z1893 Z1894 Repair or non routine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes (Labor (a maximum of twenty (20) units (20 units = 5 hours of labor) per date of service is allowable.) Tub stool or bench (Bath Frame Support, Large) Portable peak flow meter (used by asthmatic patients) ospital bed, fixed height, with any type side rails, with mattress ospital bed, variable height; hi-lo, with any type side rails, with mattress ospital bed, semi-electric, (head and foot adjustment), with any type side rails with mattress or Rental OTE: 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 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 claim. Where only a national code is available, it can be used indefinitely for both electronic and claims. Procedure codes E0250 (Z1892 ), E0255 (Z1893 ) and E020 (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 for individuals age 21 and over, or modifier when billing for individuals under the age of 21. A type of service code must be used for billing claims for recipients under age 21 and type of service code 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 E020 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. 242.11 sed Durable Medical Equipment, Age 21 and Over 9-1-04
Effective for dates of service on and after October 13, 2003, when billing either electronically or on, procedure codes found in this section must be billed with modifier for used equipment. Additionally, when billing on, bill for recipients age 21 and over using these procedure codes with a type of service code, 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 in the column, if not, an 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. sed Durable Medical Equipment, Age 21 and Over (section 242.11) ational Code M1 M2 TOS Local Code Description PA E013 Z2344 Commode chair, stationary with fixed arms E0255 Z2347 ospital bed, variable height; hi-lo, with any type side rails, with mattress E020 Z2348 ospital bed, semi-electric, (head and foot adjustment), with any type side rails with mattress E0910 Z2353 Trapeze bars, also known as Patient elper, attached to bed, with grab bar E1130 Z2355* Standard wheelchair; fixed full-length arms, fixed or swing away, detachable footrests E1224 Z235* Wheelchair with detachable arms, elevating legrests E0143 Z2359 Walker, folding, wheeled, adjustable or fixed height E030 Z2374 Patient lift, hydraulic, with seat or sling E0730 Z2380 Transcutaneous electrical nerve stimulation device four or more leads, for multiple nerve stimulation E0105 Z2387 Cane, quad or three-prong, includes canes of all materials, adjustable or fixed, with tips or Rental Rental Rental Rental Rental Rental Rental Rental Rental
sed Durable Medical Equipment, Age 21 and Over (section 242.11) ational Code M1 M2 TOS Local Code Description PA E0143 Z2395 Walker, folding, wheeled, adjustable or fixed height E0180 Z2410 Pressure pad, alternating with pump or Rental E0191 Z241 eel or elbow protector, each E0192 Z2417 Low pressure and positioning equalization pad for wheelchair E0202 Z2419 Phototherapy (bilirubin) light with photometer Rental OTE: 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 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 claim. Where only a national code is available, it can be used indefinitely for both electronic and claims. 242.170 Apnea Monitors for Individuals nder 1 ear of Age 9-1-04 Effective for dates of service on and after October 13, 2003, when billing either electronically or on, procedure codes found in this section must be billed with modifier for recipients under 21 years of age. Modifier must be used when billing for used equipment. Additionally, when billing on, procedure codes must be billed with a type of service (TOS) code for individuals under 21 years of age or type of service, 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 in the column, if not, an 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. ational Code M1 M2 TOS E018 Local Code Description PA Apnea monitor, without recording feature E019 E008 Apnea monitor, with recording feature (on 31st day) (on 31st day) or Rental Rental (Daily Rental) Rental (Daily Rental)
ational Code M1 M2 TOS E018 Local Code Description PA Z184 Technical and lab services for setting up pneumogram or event recording (not including professional services) I I Z185 Apnea monitor, without recording feature (Initial set up of apnea monitor includes 30 days rental) E019 Z185 Apnea monitor, with recording feature (Initial set up of apnea monitor includes 30 days rental) or Rental First Month s Rental First Month s Rental OTE: 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 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 claim. Where only a national code is available, it can be used indefinitely for both electronic and claims. 242.180 Orthotic Appliances, All Ages 9-1-04 Effective for dates of service on and after October 13, 2003, when billing either electronically or on, procedure codes found in this section must be billed with modifier for recipients under 21 years of age or modifier for recipients age 21 and over. When a second modifier is listed, that modifier must be used in conjunction with either or. Additionally, when billing on, procedure codes must be billed with a type of service (TOS) code for individuals under age 21 or TOS code 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 in the column, if not, an is shown. When prior authorization is not applicable (for 21) that information is shown with an /A in the column. When codes are payable for all ages, All is indicated in the column, 21 is shown when the code is payable only for individuals under age 21 and 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) ational Code M1 M2 TOS Description A5500 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 A5501 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 A5503 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 A5504 For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with wedge(s), per shoe A5505 For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with metatarsal bar, per shoe A550 For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with off-set heel(s), per shoe A5507 For diabetics only, not otherwise specified modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe, per shoe A5509 For diabetics only, direct formed, molded to foot with external heat source (i.e., heat gun) multiple density inserts(s), prefabricated, per shoe A5510 For diabetics only, direct formed, compression molded to patient s foot without external heat source, multiple-density insert(s) prefabricated, per shoe All 21 PA
Orthotic Appliances, All Ages (section 242.180) ational Code M1 M2 TOS Description A5511 For diabetics only, custom-molded from model of patient s foot multiple-density insert(s) customfabricated, per shoe L0100 L0110 L0120 L0130 L0140 L0150 L010 L0170 L0172 L0174 L0180 L0190 L0200 L0210 L0220 Cranial orthosis (helmet), with or without soft interface, molded to patient model Cranial orthosis (helmet), with or without soft interface, non-molded Cervical, flexible, nonadjustable (foam collar) Cervical, flexible, thermoplastic collar, molded to patient Cervical, semi-rigid, adjustable (plastic collar) Cervical, semi-rigid, adjustable molded chin cup (plastic collar with mandibular/occipital piece) Cervical, semi-rigid wire frame occipital/mandibular support Cervical, collar, molded to patient model Cervical, collar, semi-rigid thermoplastic foam, two piece Cervical, collar, semi-rigid thermoplastic foam, two piece with thoracic extension Cervical, multiple post collar, occipital/mandibular supports, adjustable Cervical, multiple post collar, occipital/mandibular supports, adjustable cervical bars (Somi, Guilford, Taylor types) Cervical, multiple post collar, occipital/mandibular supports, adjustable cervical bars, and thoracic extension All 21 PA All All All All All All All All All All All All All Thoracic, rib belt All Thoracic, rib belt, custom fabricated All
Orthotic Appliances, All Ages (section 242.180) ational Code M1 M2 TOS Description L0450 L0452 L0454 L045 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 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 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 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 21 PA All All All All
Orthotic Appliances, All Ages (section 242.180) ational Code M1 M2 TOS Description L0458 L040 L042 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 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 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 21 PA All All All
Orthotic Appliances, All Ages (section 242.180) ational Code M1 M2 TOS Description L044 L04 L048 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 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 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 21 PA All All All
Orthotic Appliances, All Ages (section 242.180) ational Code M1 M2 TOS Description L0470 L0472 L0474 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 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 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 21 PA All All All
Orthotic Appliances, All Ages (section 242.180) ational Code M1 M2 TOS Description L047 L0478 L0480 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 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 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 21 PA All All All
Orthotic Appliances, All Ages (section 242.180) ational Code M1 M2 TOS Description L0482 L0484 L048 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 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 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 21 PA All All All
Orthotic Appliances, All Ages (section 242.180) ational Code M1 M2 TOS Description L0488 L0490 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 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 L0500 Lumbar-sacral-orthosis (LSO), flexible, (lumbo-sacral support) L0510 LSO, flexible, (lumbo-sacral support), custom fabricated L0515 LSO, anterior-posterior control, with rigid or semi-rigid posterior panel, prefabricated L0520 L0530 L0540 L0550 L050 LSO, anterior-posterior-lateral control, (Knight, Wilcox types), with apron front LSO, anterior-posterior control (Macausland type), with apron front LSO, lumbar flexion (Williams flexion type) LSO, anterior-posterior-lateral control, molded to patient model LSO, anterior-posterior-lateral control, molded to patient model, with interface material All 21 PA All All All All All All All
Orthotic Appliances, All Ages (section 242.180) ational Code M1 M2 TOS Description L055 L000 L010 L020 L0700 L0710 L0810 L0820 L0830 L080 L090 L0970 L0972 L0974 L097 L0978 L0980 LSO, anterior-posterior-lateral control, custom fitted Sacroiliac, flexible (sacroiliac surgical support) Sacroiliac, flexible (sacroiliac surgical support, custom fabricated Sacroiliac, semi-rigid (Goldthwaite, Osgood types), with apron front Cervical-thoracic-lumbar-sacralorthoses (CTLSO), anteriorposterior- lateral control, molded to patient model, (Minerva type) CTLSO, anterior-posterior-lateralcontrol, molded to patient model, with interface material, (Minerva type) alo procedure, cervical halo incorporated into jacket vest alo procedure, cervical halo incorporated into plaster body jacket alo procedure, cervical halo incorporated into Milwaukee type orthosis Addition to halo procedure, magnetic reasonance image compatible system Torso support, post surgical support, pads for post surgical support All 21 PA All All All All All All All All All All All TLSO, corset front All LSO, corset front All TLSO, full corset All LSO, full corset All Axillary crutch extension All Peroneal straps, pair All
Orthotic Appliances, All Ages (section 242.180) ational Code M1 M2 TOS Description L0982 Stocking supporter grips, set of four (4) All 21 PA All L0984 Protective body sock, each L1000 L1010 L1020 L1025 L1030 L1040 L1050 L100 L1070 L1080 L1085 L1090 L1100 L1110 L1120 L1200 CTLSO (Milwaukee), inclusive of furnishing initial orthosis, including model TLSO or scoliosis orthosis, axilla sling Addition to CTLSO or scoliosis orthosis, kyphosis pad Addition to CTLSO or scoliosis orthosis, kyphosis pad, floating Addition to CTLSO or scoliosis orthosis, lumbar bolster pad Addition to CTLSO or scoliosis orthosis, lumbar or lumbar rib pad Addition to CTLSO or scoliosis orthosis, sternal pad Addition to CTLSO or scoliosis orthosis, thoracic pad Addition to CTLSO or scoliosis orthosis, trapezius sling Addition to CTLSO or scoliosis orthosis, outrigger Addition to CTLSO or scoliosis orthosis, outrigger, bilateral with vertical extensions Addition to CTLSO or scoliosis orthosis, lumbar sling Addition to CTLSO or scoliosis orthosis, ring flange, plastic or leather Addition to CTLSO or scoliosis orthosis, ring flange, plastic or leather, molded to patient model Addition to CTLSO, scoliosis orthosis, cover for upright, each Thoracic-lumbar-sacral-orthosis (TLSO), inclusive of furnishing initial orthosis only All All All All All All All All All All All All All All All All
Orthotic Appliances, All Ages (section 242.180) ational Code M1 M2 TOS Description L1210 L1220 L1230 L1240 L1250 L120 L1270 L1280 L1290 L1300 L1310 L1499 L1500 L1510 L1520 L100 L110 Addition to TLSO, (low profile), lateral thoracic extension Addition to TLSO, (low profile), anterior thoracic extension Addition to TLSO, (low profile), Milwaukee type superstructure Addition to TLSO, (low profile), lumbar derotation pad Addition to TLSO, (low profile), anterior ASIS pad Addition to TLSO, (low profile), anterior thoracic derotation pad Addition to TLSO, (low profile), abdominal pad Addition to TLSO, (low profile), rib gusset (elastic), each Addition to TLSO, (low profile), lateral trochanteric pad Other scoliosis procedure, body jacket molded to patient model Other scoliosis procedure, postoperative body jacket Spinal orthosis, not otherwise specified TKAO, mobility frame (ewington, Parapodium types) TKAO, standing frame, with or without tray and accessories All 21 PA All All All All All All All All All All All All All All TKAO, swivel walker All O, abduction control of hip joints, flexible, Frejka type with cover, prefabricated, includes fitting and adjustment O, abduction control of hip joints, flexible, (Frejka cover only) prefabricated, includes fitting and adjustment All All
Orthotic Appliances, All Ages (section 242.180) ational Code M1 M2 TOS Description L120 L130 L140 L150 L10 L180 L185 L18 O, abduction control of hip joints, flexible, (Pavlik harness), prefabricated, includes fitting and adjustment O, abduction control of hip joints, semi-flexible (Von Rosen type), custom fabricated O, abduction control of hip joints, static, pelvic band or spreader bar, thigh cuffs, custom fabricated O, abduction control of hip joints, static, adjustable, custom fitted (Ilfled type), prefabricated, includes fitting and adjustment O, abduction control of hip joints, static, plastic, prefabricated, includes fitting and adjustment O; abduction control of hip joints, dynamic, pelvic control, adjustable hip motion control, thigh cuffs (Rancho hip action type), custom fabricated O, abduction control of hip joint, post operative hip abduction type, custom fabricated O, abduction control of hip joint, post operative hip abduction type, prefabricated, includes fitting and adjustments L190 Combination, bilateral, lumbosacral, hip, femur orthosis providing adduction and internal rotation control, prefabricated, includes fitting and adjustment L1700 L1710 L1720 L1730 Legg Perthes orthosis, (Toronto type), custom fabricated Legg Perthes orthosis, (ewington type), custom fabricated Legg Perthes orthosis, trilateral, (Tachdijan type), custom fabricated Legg Perthes orthosis, (Scottish Rite type) custom fabricated All 21 PA All All All All All All All All All All All All
Orthotic Appliances, All Ages (section 242.180) ational Code M1 M2 TOS Description L1750 L1755 L1800 L1810 L1815 L1820 L1825 L1830 L1832 L1834 L1840 Legg Perthes orthosis, Legg Perthes sling (Sam Brown type), prefabricated, includes fitting and adjustment Legg Perthes orthosis, (Patten bottom type), custom fabricated KO, elastic with stays, prefabricated, includes fitting and adjustment KO, elastic with joints, prefabricated, includes fitting and adjustment KO, elastic or other elsastic type material with condylar pad(s), prefabricated, includes fitting and adjustment KO, elastic with condyle pads and joints, prefabricated, includes fitting and adjustment KO, elastic knee cap. prefabricated, includes fitting and adjustment KO, immobilizer, canvas longitudinal, prefabricated, includes fitting and adjustment KO, adjustable knee joints, positional orthosis, rigid support, prefabricated, includes fitting and adjustment rigid support KO, without knee joint, rigid, custom fabricated KO, derotation, medial-lateral, anterior cruciate ligament, custom fabricated L1843 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 All 21 PA All All All All All All All All All All All
Orthotic Appliances, All Ages (section 242.180) ational Code M1 M2 TOS Description L1844 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 L1845 L184 KO, double upright, thigh and calf, with adjustable flexion and extension joint, medial-lateral and rotation control, prefabricated, includes fitting and adjustment KO, double upright, thigh and calf, with adjustable flexion and extension joint, medial-lateral and rotation control, custom fabricated L1847 Knee orthosis, double upright with adjustable joint, with inflatable air support chamber(s) prefabricated, includes fitting and adjustment L1850 L1855 L1858 L180 L1870 L1880 L1900 L1902 L1904 KO, Swedish type, prefabricated, includes fitting and adjustment KO, molded plastic, thigh and calf sections, with double upright knee joints, custom fabricated KO, molded plastic, polycentric knee joints, pneumatic knee pads (CTI), custom fabricated KO, modification of supracondylar prosthetic socket, custom fabricated (SK) KO, double upright, thigh and calf lacers, with knee joints, custom fabricated KO, double upright, nonmolded thigh and calf cuff/lacers with knee joints, custom fabricated AFO, spring wire, dorsiflexion assist calf band, custom fabricated AFO, ankle gauntlet, prefabricated, includes fitting and adjustment AFO, molded ankle gauntlet, custom fabricated All 21 PA All All All All All All All All All All All
Orthotic Appliances, All Ages (section 242.180) ational Code M1 M2 TOS Description L190 L1910 L1920 L1930 L1940 L1945 L1950 L190 L1970 L1980 L1990 L2000 L2010 AFO, multigamentus ankle support, prefabricated, includes fitting and adjustment AFO, posterior, single bar, clasp attachment to shoe counter prefabricated, includes fitting and adjustment, AFO, single upright with static or adjustable stop (Phelps or Perlstein type, custom fabricated AFO, plastic or other material, prefabricated, includes fitting and adjustment AFO, plastic or other material, custom-fabricated AFO, molded to patient model, plastic, rigid anterior tibial section (floor reaction), custom fabricated AFO, spiral, (Institute of Rehabilitative Medicine type), plastic, custom fabricated AFO, posterior solid ankle, plastic, custom fabricated AFO, plastic, with ankle joint, custom fabricated AFO, single upright free plantar dorsiflexion, solid stirrup, calf band/cuff (single bar BK orthosis), custom fabricated AFO, double upright free plantar dorsiflexion, solid stirrup, calf band/cuff (double bar BK orthosis), custom fabricated KAFO, single upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar AK orthosis), custom fabricated KAFO, single upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar AK orthosis), without knee joint, custom fabricated All 21 PA All All All All All All All All All All All All All
Orthotic Appliances, All Ages (section 242.180) ational Code M1 M2 TOS Description L2020 L2030 KAFO, double upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (double bar AK orthosis), custom fabricated KAFO, double upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs, (double bar AK orthosis), without knee joint, custom fabricated L2035 KAFO, full plastic, static prefabricated (pediatric size) prefabricated, includes fitting and adjustment L203 L2037 L2038 KAFO, full plastic, double upright, free knee, custom fabricated KAFO, full plastic, single upright, free knee, custom fabricated KAFO, full plastic, without knee joint, multi-axis ankle, (Lively orthosis or equal), custom fabricated L2039 KAFO, full plastic, single upright, poly-axial hinge, medial lateral rotation control, custom fabricated L2040 L2050 L200 L2070 L2080 L2090 KAFO, torsion control, bilateral rotation straps, pelvic band/belt, custom fabricated KAFO, torsion control, bilateral torsion cables, hip joint, pelvic band/belt, custom fabricated KAFO, torsion control, bilateral torsion cables, ball bearing hip joint, pelvic band/belt, custom fabricated KAFO, torsion control, unilateral rotation straps, pelvic band/belt, custom fabricated KAFO, torsion control, unilateral torsion cable, hip joint, pelvic band/belt, custom fabricated KAFO, torsion control, unilateral torsion cable, ball bearing hip joint, pelvic band/belt, custom fabricated All 21 PA All All All All All All All All All All All
Orthotic Appliances, All Ages (section 242.180) ational Code M1 M2 TOS Description L210 L2108 L2112 L2114 L211 L212 L2128 L2132 L2134 L213 L2180 L2182 L2184 L218 AFO, fracture orthosis, tibial fracture cast orthosis, thermoplastic type casting material, custom fabricated AFO, fracture orthosis, tibial fracture cast orthosis, custom fabricated AFO, fracture orthosis, tibial fracture orthosis, soft, prefabricated, includes fitting and adjustment AFO, fracture orthosis, tibial fracture orthosis, semi-rigid, prefabricated, includes fitting and adjustment AFO, fracture orthosis, tibial fracture orthosis, rigid, prefabricated, includes fitting and adjustment KAFO, fracture orthosis, femoral fracture cast orthosis, thermoplastic type casting material, molded to patient KAFO, fracture orthosis, femoral fracture cast orthosis, thermoplastic type casting material, custom fabricated KAFO, fracture orthosis, femoral fracture cast orthosis, soft, prefabricated, includes fitting and adjustment KAFO, fracture orthosis, femoral fracture cast orthosis, semi-rigid custom fitted KAFO, fracture orthosis, femoral fracture cast orthosis, rigid, prefabricated, includes fitting and adjustment Addition to lower extremity fracture orthosis, plastic shoe insert with ankle joints Addition to lower extremity fracture orthosis, drop lock knee joint Addition to lower extremity fracture orthosis, limited motion knee joint Addition to lower extremity fracture orthosis, adjustable motion knee joint (Lerman type) All 21 PA All All All All All All All All All All All All All All
Orthotic Appliances, All Ages (section 242.180) ational Code M1 M2 TOS Description L2188 L2190 L2192 L2200 L2210 L2220 L2230 L2240 L2250 L220 L225 L2270 Addition to lower extremity fracture orthosis, quadrilateral brim Addition to lower extremity fracture orthosis, waist belt Addition to lower extremity fracture orthosis, hip joint, pelvic band, thigh flange, and pelvic belt Additions to lower extremity, dorsiflexion and plantar flexion Addition to lower extremity, dorsiflexion assist (plantar flexion resist), each joint Addition to lower extremity, dorsiflexion and plantar flexion assist/resist, each joint Addition to lower extremity, split flat caliper stirrups and plate attachment Addition to lower extremity, round caliper and plate attachment Addition to lower extremity, foot plate, molded to patient model, stirrup attachment Addition to lower extremity, reinforced solid stirrup (Scott-Craig type) Addition to lower extremity, long tongue stirrup Addition to lower extremity, varus/valgus correction ( T ) strap, padded/lined or malleolus pad L2275 Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined L2280 L2300 L2310 Addition to lower extremity, molded inner boot Addition to lower extremity, abduction bar (bilateral hip involvement), jointed, adjustable Addition to lower extremity, abduction bar straight All 21 PA All All All All All All All All All All All All All All All
Orthotic Appliances, All Ages (section 242.180) ational Code M1 M2 TOS Description L2320 L2330 L2335 L2340 L2350 L230 L2370 L2375 L2380 L2385 L2390 L2395 Addition to lower extremity, nonmolded lacer Addition to lower extremity, lacer molded to patient model Addition to lower extremity, anterior swing band Addition to lower extremity, pretidial shell, molded to patient model Addition to lower extremity, prosthetic type, (BK) socket, molded to patient model, (used for PTB AFO orthoses) Addition to lower extremity, extended steel shank Addition to lower extremity, Patten bottom Addition to lower extremity, torsion control, ankle joint and half solid stirrup Addition to lower extremity, torsion control, straight knee joint, each joint Addition to lower extremity, straight knee joint, heavy duty, each joint Addition to lower extremity, offset knee joint, each joint Addition to lower extremity, offset knee joint, heavy duty, each joint L2397 Addition to lower extremity orthosis, suspension sleeve L2405 L2415 L2425 Addition to knee joint, lock; drop, stance or swing phase, each joint Addition to knee lock with integrated release mechanism, (bail, cable or equal, any material, each joint Addition to knee joint, disc or dial lock for adjustable knee flexion, each joint L2430 Addition to knee joint, ratchet lock for active and progressive knee extension, each joint All 21 PA All All All All All All All All All All All All All All All
Orthotic Appliances, All Ages (section 242.180) ational Code M1 M2 TOS Description L2435 L2492 L2500 L2510 L2520 L2525 L252 L2530 L2540 L2550 L2570 L2580 L200 L210 L220 Addition to knee joint, polycentric joint, each joint Addition to knee joint, lift loop for drop lock ring Addition to lower extremity, thigh/weight bearing, gulteal/ischial weight bearing, ring Addition to lower extremity, thigh/weight bearing, quadrilateral brim, molded to patient model Addition to lower extremity, thigh/weight bearing, quadrilateral brim, custom fitted Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim molded to patient model Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim, custom fitted Addition to lower extremity, thigh/weight bearing, lacer, nonmolded Addition to lower extremity, thigh/weight bearing, lacer, molded to patient model Addition to lower extremity, thigh/weight bearing, high roll cuff Addition to lower extremity, pelvic control, hip joint, clevis type two position joint, each Addition to lower extremity, pelvic control, pelvic sling Addition to lower extremity, pelvic control, hip joint, Clevis type, or thrust bearing free, each Addition to lower extremity, pelvic control, hip joint, Clevis or thrust bearing, lock, each Addition to lower extremity, pelvic control, hip joint, heavy duty, each All 21 PA All All All All All All All All All All All All All All All
Orthotic Appliances, All Ages (section 242.180) ational Code M1 M2 TOS Description L222 L224 L227 L228 L230 L240 L250 L20 L270 L280 L2750 Addition to lower extremity, pelvic control, hip joint, adjustable flexion, each Addition to lower extremity, pelvic control, hip joint, adjustable flexion, extension, abduction control, each Addition to lower extremity, pelvic control, plastic, molded to patient model, reciprocating hip joint and cables Addition to lower extremity, pelvic control, metal frame, reciprocating hip joint and cables Addition to lower extremity, pelvic control, band and belt unilateral Addition to lower extremity, pelvic control, band and belt bilateral Addition to lower extremity, pelvic and thoracic control, gluteal pad, each Addition to lower extremity, thoracic control, thoracic band Addition to lower extremity, thoracic control, paraspinal uprights Addition to lower extremity, thoracic control, lateral support uprights Addition to lower extremity orthosis, plating chrome or nickel, per bar L2755 Addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepreg composite, per segment L270 L2770 L2780 L2785 Addition to lower extremity orthosis, extension, per extension, per bar (for linear adjustment for growth) Addition to lower extremity orthosis, any material, per bar or joint Addition to lower extremity orthosis, non-corrosive finish, per bar Addition to lower extremity orthosis, drop lock retainer, each All 21 PA All All All All All All All All All All All All All All All
Orthotic Appliances, All Ages (section 242.180) ational Code M1 M2 TOS Description L2795 L2800 L2810 L2820 L2830 L2840 L2850 L2999 L3000 L3002 L3010 L3020 L3030 L3040 L3050 Addition to lower extremity orthosis, knee control, full kneecap Addition to lower extremity orthosis, knee control, kneecap, medial or lateral pull Addition to lower extremity orthosis, knee control, condylar pad Addition to lower extremity orthosis, soft interface for molded plastic, below knee section Addition to lower extremity orthosis, soft interface for molded plastic, above knee section Addition to lower extremity orthosis, tibial length sock, fracture or equal, each Addition to lower extremity orthosis, femoral length sock, fracture or equal, each All 21 PA All All All All All All All Lower extremity orthoses, OS All Foot insert, removable, molded to patient model, CB type, Berkeley shell, each Foot insert, removable, molded to patient model, Plastazote or equal, each Foot insert, removable, molded to patient model, longitudinal arch support, each Foot insert, removable, molded to patient model, longitudinal/metatarsal support, each Foot insert, removable, formed to patient foot, each Foot, arch support, removable, premolded, longitudinal, each Foot, arch support, removable, premolded, metatarsal, each All All All All All All All
Orthotic Appliances, All Ages (section 242.180) ational Code M1 M2 TOS Description L300 L3070 L3080 L3090 L3100 L3150 L3170 Foot, arch support, removable, premolded, longitudinal/metatarsal, each Foot, arch support, non removable attached to shoe, longitudinal, each Foot, arch support, non removable attached to shoe, metatarsal, each Foot, arch support, non removable attached to shoe, longitudinal/metatarsal, each All 21 PA All All All All allus - valgus night dynamic splint All Foot, abduction rotation bar, without shoes L3202 Orthopedic shoe, oxford with supinator or pronator, child L3204 Orthopedic shoe, hightop with supinator or pronator, infant All Foot, plastic heel stabilizer All 21 /A 21 /A L3208 Surgical boot, each, infant 21 /A L3209 Surgical boot, each, child 21 /A L3215 L321 L3219 L3221 Orthopedic footwear, woman s shoes, oxford Orthopedic footwear, woman s shoes, depth inlay Orthopedic footwear, man s shoes, oxford Orthopedic footwear, man s shoes, depth inlay L3224 Orthopedic footwear, woman s shoe, Oxford, used as an integral part of a brace (orthosis) L3225 Orthopedic footwear, man s shoe, oxford, used as an integral part of a brace (orthosis) L3230 L3250 Orthopedic footwear, custom shoes, depth inlay Orthopedic footwear, custom molded shoe, removable inner molded, prosthetic shoe, each All All All All +21 +21 All All
Orthotic Appliances, All Ages (section 242.180) ational Code M1 M2 TOS Description L3253 L3257 L320 L325 L3310 L3332 L3334 L3350 L330 L3370 L3400 L3420 L3450 L3455 L345 L3540 L3580 L3590 L300 Foot, molded shoe Plastazate (or similar), custom fitted, each Orthopedic footwear, additional charge for split size All 21 PA All All Surgical boot/shoe, each All Plastazote sandal, each All Lift, elevation, heel and sole, neoprene, per inch Lift, elevation, inside shoe, tapered, up to one-half inch All All Lift, elevation, heel, per inch All eel wedge All Sole wedge, outside sole All Sole wedge, between sole All Metatarsal bar wedge, rocker All Full sole and heel wedge, between sole All eel, SAC cushion type All eel, new leather, standard All eel, Thomas with wedge All Orthopedic shoe addition, sole full All Orthopedic shoe addition, convert instep to velcro closure Orthopedic shoe addition, convert firm shoe counter to soft counter Transfer for an orthosis from one shoe to another, caliper plate, existing All All All
Orthotic Appliances, All Ages (section 242.180) ational Code M1 M2 TOS Description L320 L330 Transfer of an orthosis from one shoe to another, solid stirrup, existing Transfer of an orthosis from one shoe to another, solid stirrup, new L349 Orthopedic shoe, modification, addition or transfer, OS L350 L30 L370 SO, figure of eight design abduction re-strainer prefabricated, includes fitting and adjustment SO, figure of eight design, abduction restrainer, canvas and webbing, prefabricated, includes fitting and adjustment SO, acromio/clavicular (canvas and webbing type) prefabricated, includes fitting and adjustment L375 SO, vest type abduction restrainer, canvas webbing type, or equal, prefabricated, includes fitting and adjustment L3700 L3710 L3720 L3730 L3740 L3800 L3805 Elbow orthoses (EO), elastic with stays, prefabricated, includes fitting and adjustment EO, elastic with metal joints, prefabricated, includes fitting and adjustment EO, double upright with forearm/arm cuffs, free motion, custom fabricated EO, double upright with forearm/arm cuffs, extension/flexion assist, custom fabricated EO, double upright with forearm/arm cuffs, adjustable position lock with active control, custom fabricated WFO, short opponens, no attachments, custom fabricated WFO, long opponens, no attachment, custom fabricated All 21 PA All All 21 /A All All All All All All All All All All
Orthotic Appliances, All Ages (section 242.180) ational Code M1 M2 TOS Description L3810 L3815 L3820 L3825 L3830 L3835 L3840 L3845 L3850 L3855 L380 L3900 L3901 L3902 L3904 WFO, addition to short and long opponens, thumb abduction ( C ) bar WFO, addition to short and long opponens, second M.P. abduction assist WFO, addition to short and long opponens, I.P. extension assist, with M.P. extension stop WFO, addition to short and long opponens, M.P. extension stop WFO, addition to short and long opponens, M.P. extension assist WFO, addition to short and long opponens, M.P. spring extension assist WFO, addition to short and long opponens, spring swivel thumb WFO, addition to short and long opponens, thumb I.P. extension assist, with M.P. stop WO, addition to short and long opponens, action wrist with dorsiflexion assist WFO, addition to short and long opponens, adjustable M.P. flexion control WFO, addition to short and long opponens, adjustable M.P. flexion control and I.P. WFO, dynamic flexor hinge, reciprocal wrist extension/flexion, finger flexion/extension, wrist or finger driven, custom fabricated WFO, dynamic flexor hinge, reciprocal wrist extension/flexion, finger flexion/extension, cable driven, custom fabricated WFO, external powered, compressed gas, custom fabricated WFO, external powered, electric, custom fabricated All 21 PA All All All All All All All All All All All All All All All
Orthotic Appliances, All Ages (section 242.180) ational Code M1 M2 TOS Description L390** L3907** L3908 L3910 L3912 L3914 L391 L3918 L3920 L3922 L3924 L392 L3928 L3930 L3932 WFO, wrist guantlet, molded to patient model, custom fabricated WFO, wrist guantlet with thumb spica, molded to patient model, custom fabricated WFO, wrist extension control cock-up, nonmolded, prefabricated, includes fitting and adjustment WFO, Swanson design, prefabricated, includes fitting and adjustment FO, flexion glove with elastic finger control, prefabricated, includes fitting and adjustment WO, wrist extension (cock-up) prefabricated, includes fitting and adjustment WFO, wrist extension (cock-up), with outrigger, prefabricated, includes fitting and adjustment FO, knuckle bender prefabricated, includes fitting and adjustment FO, knuckle bender, with outrigger prefabricated, includes fitting and adjustment FO, knuckle bender, two segment to flex joints prefabricated, includes fitting and adjustment WFO, Oppenheimer, prefabricated, includes fitting and adjustment WFO, Thomas suspension, prefabricated, includes fitting and adjustment FO, finger extension, with lock spring, prefabricated, includes fitting and adjustment WFO, finger extension, with wrist support, prefabricated, includes fitting and adjustment FO, safety pin, spring wire, prefabricated, includes fitting and adjustment All 21 PA All All All All All All All All All All All All All All All
Orthotic Appliances, All Ages (section 242.180) ational Code M1 M2 TOS Description L3934 L393 L3938 L3940 L3942 L3944 L394 L3948 L3950 L3952 L3954 FO, safety pin, modified, prefabricated, includes fitting and adjustment WFO, Palmer prefabricated, includes fitting and adjustment WFO, Dorsal wrist, prefabricated, includes fitting and adjustment WFO, Dorsal wrist, with outrigger attachment, prefabricated, includes fitting and adjustment FO, reverse knuckle bender, prefabricated, includes fitting and adjustment FO, reverse knuckle bender, with outrigger, prefabricated, includes fitting and adjustment FO, composite elastic, prefabricated, includes fitting and adjustment FO, finger knuckle bender, prefabricated, includes fitting and adjustment WFO, combination Oppenheimer, with knuckle bender and two attachments, prefabricated, includes fitting and adjustment WFO, combination Oppenheimer, with reverse knuckle and two attachments, prefabricated, includes fitting and adjustment FO, spreading hand, prefabricated, includes fitting and adjustment L395 Addition of joint to upper extremity orthosis, any material; per joint L390 L392 SEWO, abduction, positioning, airplane design, prefabricated, includes fitting and adjustment SEWO, abduction positioning, Erb s palsy design, prefabricated, includes fitting and adjustment All 21 PA All All All All All All All All All All All All All
Orthotic Appliances, All Ages (section 242.180) ational Code M1 M2 TOS Description L393 L394 L395 L39 L398 L399 L3970 L3972 L3974 L3980 L3982 L3984 SEWO, molded shoulder, arm, forearm, and wrist, with articulating elbow joint, custom fabricated SEO, mobile arm supports attached to wheelchair, balanced, adjustable, prefabricated, includes fitting and adjustment SEO mobile arm support attached to wheelchair, balanced, adjustable Rancho type, prefabricated, includes fitting and adjustment SEO, mobile arm support attached to wheelchair, balanced, reclining, prefabricated, includes fitting and adjustment SEO, mobile arm support attached to wheelchair, balanced, friction arm support, (friction dampening to proximal and distal joints), prefabricated, includes fitting and adjustment 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 SEO, addition to mobile arm support elevating proximal arm SEO, addition to mobile arm support, offset or lateral rocker arm with elastic balance control SEO, addition to mobile arm support, supinator pper extremity fracture orthosis, humeral, prefabricated, includes fitting and adjustment pper extremity fracture orthosis, radius/ulnar prefabricated, includes fitting and adjustment pper extremity fracture orthosis, wrist, prefabricated, includes fitting and adjustment All 21 PA All All All All All All All All All All All All
Orthotic Appliances, All Ages (section 242.180) ational Code M1 M2 TOS Description L3985 L398 L3995 pper extremity fracture orthosis, forearm, hand with wrist hinge, custom fabricated pper extremity fracture orthosis, combination of humeral, radius/ulnar, wrist, (example Colles fracture), custom fabricated Addition to upper extremity orthosis sock, fracture or equal, each All 21 PA All All All L3999 pper limb othosis, OS 21 /A L4000 L4010 L4020 L4030 L4040 L4045 L4050 L4055 L400 Replace girdle for spinal orthosis (CTLSO or SO) All Replace trilateral socket brim All Replace quadrilateral socket brim, molded to patient model Replace quadrilateral socket brim, custom fitted All All Replace molded thigh lacer All Replace nonmolded thigh lacer All Replace molded calf lacer All Replace nonmolded calf lacer All Replace high roll cuff All L4070 Replace proximal and distal upright for KAFO All L4080 Replace metal bands KAFO, proximal thigh All L4090 Replace metal bands KAFO-AFO, calf or distal thigh All L4100 Replace leather cuff KAFO, proximal thigh All L4110 Replace leather cuff KAFO-AFO, calf or distal thigh All
Orthotic Appliances, All Ages (section 242.180) ational Code M1 M2 TOS Description L4130 L4350 L430 L4370 L4380 L4392 All 21 PA Replace pretibial shell All Ankle control orthosis, stirrup style, rigid, includes any type interface (e.g., pneumatic, gel), prefabricated, includes fitting and adjustment Walking boot, pneumatic with or without joints, with or without interface material, prefabricated, includes fitting and adjustment Pneumatic full leg splint, prefabricated, includes fitting and adjustment Pneumatic knee splint, prefabricated, includes fitting and adjustment Replacement soft interface material, static AFO L4394 Replace soft interface material, foot drop splint L439 Static AFO, including soft interface material, adjustable for fit, for positioning, pressure reduction, may be used for minimal ambulation, prefabricated, includes fitting and adjustment L4398 Foot drop splint, recumbent positioning device, prefabricated, includes fitting and adjustment All All All All All Orthotic Appliances, All Ages (section 242.180) ational Code M1 M2 TOS L1499 Local Code Z145 Description Spinal orthosis, not otherwise specified (nlisted Prosthetic Devices or Orthotic Appliances (The Manufacturer s invoice must be attached to all claims.) PA /A
Orthotic Appliances, All Ages (section 242.180) ational Code M1 M2 TOS L2999 L349 L3999 L5999 L7499 L8499 L4205 L4210 L7510 L7520 52 Local Code Z145 Z145 Z145 Z145 Z145 Z145 Z183 Z183 Z183 Z183 Description Lower extremity orthoses, OS (nlisted Prosthetic Devices or Orthotic Appliances (The Manufacturer s invoice must be attached to all claims.) Orthopedic shoe, modification, addition or transfer, OS (nlisted Prosthetic Devices or Orthotic Appliances) (The Manufacturer s invoice must be attached to all claims.) pper limb orthosis, OS (nlisted Prosthetic Devices or Orthotic Appliances) (The Manufacturer s invoice must be attached to all claims.) Lower extremity prothesis, not otherwise specified (nlisted Prosthetic Devices or Orthotic Appliances (The Manufacturer s invoice must be attached to all claims.) pper extremity porsthesis, OS (nlisted Prosthetic Devices or Orthotic Appliances) (The Manufacturer s invoice must be attached to all claims.) nlisted procedure for miscellaneous prosthetic services (nlisted Prosthetic Devices or Orthotic Appliances) (The Manufacturer s invoice must be attached to all claims.) Repair of orthotic device, labor component, per 15 minutes Repair of orthotic device, repair or replace minor parts Repair of prosthetic device, hourly rate Repair prosthetic device, labor component, per 15 minutes PA /A /A /A /A /A /A /A /A /A /A
Orthotic Appliances, All Ages (section 242.180) ational Code M1 M2 TOS L2040 Local Code Z1732 Description KAFO, torsion control, bilateral rotation straps, pelvic band/belt, custom fabricated (ight A frame- KAFO, torsion control, bilateral night A frame) L1920 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) L2810 Z1733 Addition to lower extremity orthosis, knee control, condylar pad (Custom night A frame-kafo, torsion control, bilateral night A frame) L3150 Z1733 Foot, abduction rotation bar, without shoes (Custom night A frame-kafo, torsion control, bilateral night A frame) L4090 Z1733 Replace metal bands KAFO-AFO, calf or distal thigh (Custom night A frame-kafo, torsion control, bilateral night A frame) L3140 52 Z1735 Foot, abduction rotation bar, including shoes (Bebox foot orthosis clubfoot abduction orthosis) L3140 Z173 Foot, abduction rotation bar, including shoes (Don Joy Knee orthosis) L349 L3204 Z1738 Z1739 Orthopedic shoe, modification, addition or transfer, OS (Orthopedic footwear, wooden sole shoe, each) Orthopedic shoe, hightop with supinator or pronator, infant (Straight last high top shoe, each, size 2-8) PA /A /A /A /A /A /A /A /A L320 Z1739 Orthopedic shoe, hightop with supinator or pronator, child (Straight last high top shoe, each, size 2-8) /A L3207 Z1739 Orthopedic shoe, hightop with supinator or pronator junior (Straight last high top shoe, each, size 2-8) /A L3217 Z1739 Orthopedic footwear, woman s shoes, hightop, depth inlay (Straight last high top shoe, each, size 2-8) /A
Orthotic Appliances, All Ages (section 242.180) ational Code M1 M2 TOS L3222 L3204 L320 L3207 L3217 L3222 L3204 L320 L3207 L3217 L3222 L3204 L320 Local Code Z1739 Z1740 Z1740 Z1740 Z1740 Z1740 Z1741 Z1741 Z1741 Z1741 Z1741 Z1743 Z1743 Description Orthopedic footwear, man s shoes, hightop, depth inlay (Straight last high top shoe, each, size 2-8) Orthopedic shoe, hightop with supinator or pronator, infant (Straight last high top shoe, each, size 8 1/2-12) Orthopedic shoe, hightop with supinator or pronator, child (Straight last high top shoe, each, size 8 1/2-12) Orthopedic shoe, hightop with supinator or pronator, junior (Straight last high top shoe, each, size 8 1/2-12) Orthopedic footwear, woman s shoes, hightop, depth inlay (Straight last high top shoe, each, size 8 1/2-12) Orthopedic footwear, man s shoes, hightop, depth inlay (Straight last high top shoe, each, size 8 1/2-12) Orthopedic shoe, hightop with supinator or pronator, infant (Regular last high top shoe, each, size 3-) Orthopedic shoe, hightop with supinator or pronator, child (Regular last high top shoe, each, size 3-) Orthopedic shoe, hightop with supinator or pronator, junior (Regular last high top shoe, each, size 3-) Orthopedic footwear, woman s shoes, hightop, depth inlay (Regular last high top shoe, each, size 3-) Orthopedic footwear, man s shoes, hightop, depth inlay (Regular last high top shoe, each, size 3-) Orthopedic shoe, hightop with supinator or pronator, infant (Regular last high top shoe, each, 8 ½ -12) Orthopedic shoe, hightop with supinator or pronator, child (Regular last high top shoe, each, 8 ½ -12) PA /A /A /A /A /A /A /A /A /A /A /A /A /A
Orthotic Appliances, All Ages (section 242.180) ational Code M1 M2 TOS L3207 L3217 L3222 L3204 L320 L3207 L3217 L3222 Local Code Z1743 Z1743 Z1743 Z1744 Z1744 Z1744 Z1744 Z1744 Description Orthopedic shoe, hightop with supinator or pronator, junior (Regular last high top shoe, each, 8 ½ -12) Orthopedic footwear, woman s shoes, hightop, depth inlay (Regular last high top shoe, each, 8 ½ -12) Orthopedic footwear, man s shoes, hightop, depth inlay (Regular last high top shoe, each, 8 ½ -12) Orthopedic shoe, hightop with supinator or pronator, infant (Reverse last closed toe Orthopedic shoe, hightop with supinator or pronator, child (Reverse last closed toe) Orthopedic shoe, hightop with supinator or pronator, junior (Reverse last closed toe) Orthopedic footwear, woman s shoes, hightop, depth inlay (Reverse last closed toe) Orthopedic footwear, man s shoes, hightop, depth inlay (Reverse last closed toe) L3204 Z1745 Orthopedic shoe, hightop with supinator or pronator, infant (Orthopedic shoe, high top, normal last, each, size 3-8) L320 Z1745 Orthopedic shoe, hightop with supinator or pronator, child (Orthopedic shoe, high top, normal last, each, size 3-8) L3207 Z1745 Orthopedic shoe, hightop with supinator or pronator, junior (Orthopedic shoe, high top, normal last, each, size 3-8) L3204 L320 Z174 Z174 Orthopedic shoe, hightop with supinator or pronator, infant (Orthopedic shoe, high top, normal last, each 8 ½-12) Orthopedic shoe, hightop with supinator or pronator, child (Orthopedic shoe, high top, normal last, each 8 ½-12) PA /A /A /A /A /A /A /A /A /A /A
Orthotic Appliances, All Ages (section 242.180) ational Code M1 M2 TOS L3207 L2755 Local Code Z174 Z1747 Description Orthopedic shoe, hightop with supinator or pronator, junior (Orthopedic shoe, high top, normal last, each 8 ½-12) Addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepreg composite, per segment (Carbon composite ankles (addition to AFO) PA /A /A OTE: 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 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 claim. Where only a national code is available, it can be used indefinitely for both electronic and claims. 242.190 Prosthetic Devices, All Ages 9-1-04 Effective for dates of service on and after October 13, 2003, when billing either electronically or on, procedure codes found in this section must be billed with modifier for recipients under 21 years of age or modifier for individual age 21 and over. When a second modifier is listed, that modifier must be used in conjunction with either or. Additionally, when billing on, procedure codes must be billed with type of service (TOS) code for individuals under age 21 or TOS code 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 in the column, if not, an is shownwhen codes are payable for all ages, All is indicated in the column, 21 is shown when the code is payable only for individuals under age 21 and is shown when the code is payable only for those individuals age 21 and over. Prosthetic Devices, All Ages (section 242.190) ational Code M1 M2 TOS Description L5000 L5010 Partial foot, shoe insert with longitudinal arch, toe filler Partial foot, molded socket, ankle height, with toe filler All 21 PA All All
Prosthetic Devices, All Ages (section 242.190) ational Code M1 M2 TOS Description L5020 L5050 L500 L5100 L5105 L5150 L510 L5200 L5210 L5220 L5230 L5250 L5270 L5280 Partial foot, molded socket, tibial tubercle height, with toe filler Ankle, Symes, molded socket, SAC foot Ankle, Symes, metal frame, molded leather socket, articulated ankle/foot Below knee, molded socket, shin, SAC foot Below knee, plastic socket, joints and thigh lacer, SAC foot Knee disarticulation (or through knee), molded socket, external knee joints, shin, SAC foot Knee disarticulation (or through knee), molded socket, bent knee configuration, external knee joints, shin, SAC foot Above knee, molded socket, single axis constant friction knee, shin, SAC foot Above knee, short prosthesis, no knee joint ( stubbies ), with foot blocks, no ankle joints, each Above knee, short prosthesis, no knee joint (stubbies), with articulated ankle/foot, dynamically aligned, each Above knee, for proximal femoral focal deficiency, constant friction knee, shin, SAC foot ip disarticulation, Canadian type, molded socket, hip joint, single axis constant friction knee, shin, SAC foot ip disarticulation, tilt table type, molded socket, locking hip joint, single axis constant friction knee, shin, SAC foot emipelvectomy, Canadian type, molded socket, hip joint, single axis constant friction knee, shin, SAC foot All 21 PA All All All All All All All All All All All All All All
Prosthetic Devices, All Ages (section 242.190) ational Code M1 M2 TOS Description L5301 L5311 L5321 L5331 L5341 L5400 L5410 L5420 L5430 L5450 L540 Below knee, molded socket, shin, SAC foot, endoskeletal system Knee disarticulation (or through knee), molded socket, external knee joints, shin, SAC foot, endoskeletal system Above knee, molded socket, open end, SAC foot, endoskeletal system, single axis knee ip disarticulation, Canadian type, molded socket, endoskeletal system, hip joint, single axis knee, SAC foot emipelvectomy, Canadian type, molded socket, endoskeletal system, hip joint, single axis knee, SAC foot Immediate post surgical or early fitting, application of initial rigid dressing, including fitting, alignment, suspension, and one cast change, below knee Immediate post surgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension, below knee, each additional cast change and realignment Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension, and one cast change AK or knee disarticulation 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 Immediate postsurgical or early fitting, application of nonweight bearing rigid dressing, below knee Immediate post surgical or early fitting, application of nonweight bearing rigid dressing, above knee All 21 PA All All All All All All All All All All All
Prosthetic Devices, All Ages (section 242.190) ational Code M1 M2 TOS Description L5500 L5505 L5510 L5520 L5530 L5535 L5540 L550 L5570 Initial, below knee ( PTB type socket, non-alignable system, pylon, no cover, SAC foot, plaster socket, direct formed Initial, above knee-knee disarticulation (ischial level socket, non-alignable system, pylon, no cover, SAC foot plaster socket, direct formed Preparatory, below knee PTB type socket, non-alignable system, pylon, no cover, SAC foot, plaster socket, molded to model Preparatory, below knee PTB type socket, non-alignable pylon, no cover, SAC foot, thermoplastic or equal, direct formed Preparatory, below knee PTB type socket, non-alignable system, pylon, no cover, SAC foot, thermoplastic or equal, molded to model Preparatory, below knee PTB type socket, non-alignable system, pylon, no cover, SAC foot, prefabricated, adjustable open end socket Preparatory, below knee PTB type socket, non alignable, pylon, no cover, SAC foot, laminated socket, molded to model Preparatory, above knee-knee disarticulation ischial level socket, non-alignable system, pylon, no cover, SAC foot, plaster socket, molded to model Preparatory, above knee-knee disarticulation ischial level socket, non-alignable system, pylon, no cover, SAC foot thermoplastic or equal, direct formed All 21 PA All All All All All All All All All
Prosthetic Devices, All Ages (section 242.190) ational Code M1 M2 TOS Description L5580 L5585 L5590 L5595 L500 L510 L511 L513 Preparatory, above knee-knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, SAC foot, thermoplastic or equal, molded to model Preparatory, above knee-knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, SAC foot, prefabricated adjustable open end socket Preparatory, above knee-knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, SAC foot, laminated socket, molded to model Preparatory, hip disarticulationhemipelvectomy, pylon, no cover, SAC foot, thermoplastic or equal, molded to patient model Preparatory, hip disarticulationhemipelvectomy, pylon, no cover, SAC foot, laminated socket, molded to patient model Addition to lower extremity, endoskeletal system, above knee, hydracadence system Addition to lower extremity, endoskeletal system, above kneeknee disarticulation, 4-bar linkage, with friction swing phase control Addition to lower extremity, endoskeletal system, above kneeknee disarticulation, 4-bar linkage, with hydraulic swing phase control L514 Addition to lower extremity, endoskeletal system, above knee knee disarticulation, 4-bar linkage, with pneumatic swing phase control L51 Addition to lower extremity, endoskeletal system above knee, universal multiplex system, friction swing phase control L517 Addition to lower extremity, quick change self-aligning unit, above or below knee, each All 21 PA All All All All All All All All All
Prosthetic Devices, All Ages (section 242.190) ational Code M1 M2 TOS Description L518 L520 L522 L524 L52 L528 L529 L530 L531 L532 L534 L53 L537 L538 L539 L540 L542 L543 L544 Addition to lower extremity, test socket, Symes Addition to lower extremity, test socket, below knee Addition to lower extremity, test socket, knee disarticulation Addition to lower extremity, test socket, above knee Addition to lower extremity, test socket, hip disarticulation Addition to lower extremity, test socket, hemipelvectomy Addition to lower extremity, below knee, acrylic socket Addition to lower extremity, Symes type, expandable wall socket Addition to lower extremity, above knee or knee disarticulation, acrylic socket Addition to lower extremity, Symes type, PTB brim design socket Addition to lower extremity, Symes type posterior opening (Canadian) socket Additions to lower extremity, Symes type, medial opening socket Addition to lower extremity, below knee, total contact Addition to lower extremity, below knee, leather socket Addition to lower extremity, below knee, wood socket Addition to lower extremity, knee disarticulation, leather socket Addition to lower extremity, above knee, leather socket Addition to lower extremity, hip disarticulation, flexible inner socket, external frame Addition to lower extremity, above knee, wood socket All 21 PA All All All All All All All All All All All All All All All All All All All
Prosthetic Devices, All Ages (section 242.190) ational Code M1 M2 TOS Description L545 L54 L547 L548 L549 L550 L551 L552 L553 L554 L555 L55 L558 L51 Addition to lower extremity, below knee, flexible inner socket, external frame Addition to lower extremity, below knee, air, fluid, gel or equal, cushion socket Addition to lower extremity, below knee suction socket Addition to lower extremity, above knee, air, fluid, gel or equal, cushion socket Addition to lower extremity, ischial containment/narrow M-L socket Addition to lower extremity, total contact, above knee or knee disarticulation socket Addition to lower extremity, above knee, flexible inner socket, external frame Addition to lower extremity, suction suspension, above knee or knee disarticulation, socket Addition to lower extremity, knee disarticulation, expandable wall socket Addition to lower extremity, socket insert, Symes, (Kemblo, Pelite, Aliplast, Plastazote or equal) Addition to lower extremity, socket insert, below knee (Kemblo, Pelite, Aliplast, Plastazote or equal) Addition to lower extremity, socket insert, knee disarticulation (Kemblo, Pelite, Aliplast, Plastazote or equal) Addition to lower extremity, socket insert, above knee (Kemblo, Pelite, Aliplast, Plastazote or equal) Addition to lower extremity, socket insert, multi durometer Symes L55 Addition to lower extremity, socket insert, multo-durometer, below knee All 21 PA All All All All All All All All All All All All All All 21 /A
Prosthetic Devices, All Ages (section 242.190) ational Code M1 M2 TOS Description L5 L58 L570 L572 L574 L575 L57 L577 L578 L580 L582 L584 L58 L588 L590 L592 L594 Additions to lower extremity, below knee, cuff suspension Addition to lower extremity, below knee, molded distal cushion Addition to lower extremity, below knee, molded supracondyular suspension ( PTS or similar) Addition to lower extremity, below knee, removable medial brim suspension Addition to lower extremity, below knee, suspension sleeve, any material, each Addition to lower extremity, below knee, suspension sleeve, heavy duty, any material, each Addition to lower extremity, below knee, knee joints, single axis, pair Addition to lower extremity, below knee, knee joints, polycentric, pair Addition to lower extremity, below knee, joint covers, pair Addition to lower extremity, below knee, thigh lacer, nonmolded Addition to lower extremity, below knee, thigh lacer, gluteal/ischial, molded Addition to lower extremity, below knee, fork strap Addition to lower extremity, below knee, back check (extension control) Addition to lower extremity, below knee, waist belt, webbing Addition to lower extremity, below knee, waist belt, padded and lined Addition to lower extremity, above knee, pelvic control belt, light Addition to lower extremity, above knee, pelvic control belt, padded and lined All 21 PA All All All All All All All All All All All All All All All All All
Prosthetic Devices, All Ages (section 242.190) ational Code M1 M2 TOS Description L595 L59 L597 L598 L599 Addition to lower extremity, above knee, pelvic control, sleeve suspension, neoprene or equal, each Addition to lower extremity, above knee or knee disarticulation, pelvic joint Addition to lower extremity, above knee or knee disarticulation, pelvic band Addition to lower extremity, above knee or knee disarticulation, silesian bandage All lower extremity prosthesis, shoulder harness L5700 Replacement, socket, below knee, molded to patient model L5701 Replacement, socket, above knee/knee disarticulation, including attachment plate, molded to patient model L5702 Replacement, socket, hip disarticulation, including hip joint, molded to patient model L5704 Custom shaped protective cover, below knee L5705 Custom shaped protective cover, above knee L570 Custom shaped protective cover, knee disarticulation L5707 Custom shaped protective cover, hip disarticulation L5710 L5711 L5712 Addition, exoskeletal knee-shin system, single axis, manual lock Addition exoskeletal knee-shin system, single axis, manual lock, ultra-light material Addition exoskeletal knee-shin system, single axis, friction swing and stance phase control (safety knee) All 21 PA All All All All All All All All
Prosthetic Devices, All Ages (section 242.190) ational Code M1 M2 TOS Description L5714 L571 L5718 L5722 L5724 L572 L5728 L5780 L5785 L5790 L5795 L5810 L5811 L5812 Addition, exoskeletal knee-shin system, single axis, variable friction swing phase control Addition, exoskeletal knee-shin system, polycentric, mechanical stance phase lock Addition, exoskeletal knee-shin system, polycentric, friction swing and stance phase control Addition, exoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase control Addition, exoskeletal knee-shin system, single axis, fluid swing phase control Addition, exoskeletal knee-shin system, single axis, external joints, fluid swing phase control Addition, exoskeletal knee-shin system, single axis, fluid swing and stance phase control Addition, exoskeletal knee-shin system, single axis, pneumatic/hydra pneumatic swing phase control Addition, exoskeletal system, below knee, ultra-light material (titanium, carbon fiber or equal) Addition, exoskeletal system, above knee, ultra-light material (titanium, carbon fiber or equal) Addition, exoskeletal system, hip disarticulation, ultra-light material (titanium, carbon fiber or equal) Addition, endoskeletal knee-shin system, single axis, manual lock Addition, endoskeletal knee-shin system, single axis, manual lock, ultra-light material Addition, endoskeletal knee-shin system, single axis, friction swing and stance phase control (safety knee) All 21 PA All All All All All All All All All All All All All All
Prosthetic Devices, All Ages (section 242.190) ational Code M1 M2 TOS Description L581 L5818 L5822 L5824 Addition, endoskeletal knee-shin system, polycentric, mechanical stance phase lock 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 Addition, endoskeletal knee-shin system, single axis, fluid swing phase control L582 Addition, endoskeletal knee-shin system, single axis, hydraulic swing phase control with miniature high activity frame L5828 L5830 Addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control Addition, endoskeletal knee-shin system, single axis, pneumatic/swing phase control L5840 Addition, endoskeletal knee-shin system, 4-bar linkage or multiaxial, pneumatic swing phase control L5845 Addition, endoskeletal knee-shin system, stance flexion feature, adjustable L584 Addition, endoskeletal knee-shin system, microprocessor control feature, swing phase only L5850 L5855 L5910 L5920 Addition, endoskeletal system, above knee or hip disarticulation, knee extension assist Addition, endoskeletal system, hip disarticulation, mechanical hip extension assist Addition, endoskeletal system, below knee, alignable system Addition, endoskeletal system, above knee or hip disarticulation, alignable system All 21 PA All All All All All All All All All All
Prosthetic Devices, All Ages (section 242.190) ational Code M1 M2 TOS Description L5925 Addition, endoskeletal system, above knee, knee disarticulation, manual lock L5930 Addition, endoskeletal system, high activity knee control frame L5940 L5950 L590 Addition, endoskeletal system, below knee, ultra-light material (titanium, carbon fiber or equal) Addition, endoskeletal system, above knee, ultra-light material (titanium, carbon fiber or equal) Addition, endoskeletal system, hip disarticulation, ultra-light material (titanium, carbon fiber or equal) L592 Addition, endoskeletal system, below knee, flexible protective outer surface covering system L594 Addition, endoskeletal system, above knee, flexible protective outer surface covering system L59 Addition, endoskeletal system, hip disarticulation, flexible protective outer surface covering system L598 Addition to lower limb prostheses, multiaxial ankle with swing phase active dorsiflexion feature L5970 L5972 L5974 All lower extremity prostheses, foot, external keel, SAC foot All lower extremity prostheses, flexible keel foot (Safe, Sten, Bock Dynamic or equal) All lower extremity prostheses, foot, single axis ankle/foot L5975 All lower extremity prosthesis, combination single axis ankle and flexible keel foot L597 L5978 All lower extremity prostheses, energy storing foot (Seattle Carbon Copy II or equal) All lower extremity prostheses, foot, multiaxial ankle/foot All 21 PA All All All All All All All All
Prosthetic Devices, All Ages (section 242.190) ational Code M1 M2 TOS Description L5979 All lower extremity prostheses, multi-axial ankle, dynamic response foot, one piece system L5980 All lower extremity prostheses, flexfoot system L5981 All lower extremity prostheses, flex - walk system or equal L5982 L5984 All exoskeletal lower extremity prostheses, axial rotation unit All endoskeletal lower extremity prosthesis, axial rotation unit, with or without adjustability L5985 All endoskeletal lower extremity prostheses, dynamic prosthetic pylon L598 All lower extremity prostheses, multi-axial rotation unit ( MCP or equal) L5987 All lower extremity prostheses, shank foot system with vertical loading pylon L5988 Addition to lower limb prosthesis, vertical shock reducing pylon feature L000 L010 L020 L050 L055 L100 L110 Partial hand, Robin-Aids, thumb remaining (or equal) Partial hand, Robin-Aids, little and/or ring finger remaining (or equal) Partial hand, Robin-Aids, no finger remaining (or equal) Wrist disarticulation, molded socket, flexible elbow hinges, triceps pad Wrist disarticulation, molded socket with expandable interface, flexible elbow hinges, triceps pad Below elbow, molded socket, flexible elbow hinge, triceps pad Below elbow, molded socket (Muenster or orthwestern suspension types) All 21 PA All All All All All All All All All All All
Prosthetic Devices, All Ages (section 242.190) ational Code M1 M2 TOS Description L120 L130 L200 L205 L250 L300 L310 L320 Below elbow, molded double wall split socket, step-up hinges, half cuff Below elbow, molded double wall split socket, stump activated locking hinge, half cuff Elbow disarticulation, molded socket, outside locking hinge, forearm Elbow disarticulation, molded socket with expandable interface, outside locking hinges, forearm Above elbow, molded double wall socket, internal locking elbow, forearm Shoulder disarticulation, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearm Shoulder disarticulation, passive restoration (complete prosthesis) Shoulder disarticulation, passive restoration (shoulder cap only) L350 Interscapular thoracic, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearm L30 L370 L380 L382 Interscapular thoracic, passive restoration (complete prosthesis) Interscapular thoracic, passive restoration (shoulder cap only) 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 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 21 PA All All All All All All All All All All All All
Prosthetic Devices, All Ages (section 242.190) ational Code M1 M2 TOS Description L384 L38 L388 L400 L450 L500 L550 L570 L580 L582 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 Immediate postsurgical or early fitting, each additional cast change and realignment Immediate postsurgical or early fitting, application of rigid dressing only Below elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping Elbow disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue shaping Above elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping Shoulder disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue shaping Interscapular thoracic, molded socket, endoskeletal system including soft prosthetic tissue shaping Preparatory, wrist disarticulation or below elbow, single wall plastic socket, friction wrist, flexible elbow hinges, figure of eight harness, humeral cuff, Bowden cable control, SMC or equal pylon, no cover, molded to patient model Preparatory, wrist disarticulation or below elbow, single wall socket, friction wrist, flexible elbow hinges, figure of eight harness, humeral cuff, Bowden cable control, SMC or equal pylon, no cover, direct formed All 21 PA All All All All All All All All All All
Prosthetic Devices, All Ages (section 242.190) ational Code M1 M2 TOS Description L584 L58 L588 L590 L00 L05 L10 L15 L1 L20 L23 Preparatory, elbow disarticulation or above elbow, single wall plastic socket, friction wrist, locking elbow, figure of eight harness, fair lead cable control, SMC or equal pylon, no cover, molded to patient model Preparatory, elbow disarticulation or above elbow, single wall socket, friction wrist, locking elbow, figure of eight harness, fair lead cable control, SMC or equal pylon, no cover, direct formed Preparatory, shoulder disarticulation or interscapular thoracic, single wall plastic socket, shoulder joint, locking elbow, friction wrist, chest strap, fair lead cable control, SMC or equal pylon, no cover, molded to patient model Preparatory, shoulder disarticulation or interscapular thoracic, single wall socket, shoulder joint, locking elbow, friction wrist, chest strap, fair lead cable control, SMC or equal pylon, no cover, direct formed pper extremity additions, polycentric hinge, pair pper extremity additions, single pivot hinge, pair pper extremity additions, flexible metal hinge, pair pper extremity addition, disconnect locking wrist unit pper extremity addition, additional disconnect insert for locking wrist unit, each pper extremity addition, flexion/extension wrist unit, with or without friction pper extremity addition, spring assisted rotational wrist unit with latch release All 21 PA All All All All All All All All All All All
Prosthetic Devices, All Ages (section 242.190) ational Code M1 M2 TOS Description L25 L28 L29 L30 L32 L35 L37 L40 L41 L42 L45 L50 L55 L0 L5 L70 L72 L75 pper extremity addition, rotation wrist unit with cable lock pper extremity addition, quick disconnect hook adapter, Otto Bock or equal pper extremity addition, quick disconnect lamination collar with coupling piece, Otto Bock or equal pper extremity addition, stainless steel, any wrist pper extremity addition, latex suspension sleeve, each pper extremity additions, lift assist for elbow pper extremity addition, nudge control elbow lock pper extremity additions, shoulder abduction joint, pair pper extremity addition, excursion amplifier, pulley type pper extremity addition, excursion amplifier, lever type pper extremity addition, shoulder flexion-abduction joint, each pper extremity addition, shoulder universal joint, each pper extremity addition, standard control cable, extra pper extremity addition, heavy duty control cable pper extremity addition, teflon, or equal, cable lining pper extremity addition, hook to hand cable adapter pper extremity addition, harness, chest or shoulder, saddle type pper extremity addition, harness, (e.g., figure of eight type), single cable design All 21 PA All All All All All All All All All All All All All All All All All All
Prosthetic Devices, All Ages (section 242.190) ational Code M1 M2 TOS Description L7 L80 L82 L84 L8 L87 L88 L89 L90 L91 L92 pper extremity additions, harness, (e.g., figure of eight type), dual cable design pper extremity addition, test socket, wrist disarticulation or below elbow pper extremity addition, test socket, elbow disarticulation or above elbow pper extremity addition, test socket, shoulder disarticulation or interscapular thoracic pper extremity addition, suction socket pper extremity addition, frame type socket, below elbow or wrist disarticulation pper extremity addition, frame type socket, above elbow or elbow disarticulation pper extremity addition, frame type socket, shoulder disarticulation pper extremity addition, frame type socket, interscapular-thoracic pper extremity addition, removable insert, each pper extremity addition, silicone gel insert or equal, each L93 pper extremity addition, locking elbow, forearm counterbalance L700 L705 L710 L715 L720 Terminal device, hook, Dorrance or equal, model # 3 Terminal device, hook, Dorrance or equal, model # 3 Terminal device, hook, Dorrance or equal, model # 5x Terminal device, hook, Dorrance or equal, Model # 5xa Terminal device, hook, Dorrance or equal, model # All 21 PA All All All All All All All All All All All All All All All All
Prosthetic Devices, All Ages (section 242.190) ational Code M1 M2 TOS Description L725 L730 L735 L740 L745 L750 L755 L75 L770 L775 L780 L790 L795 L800 L805 L80 L807 L808 L809 L810 Terminal device, hook, Dorrance or equal, model # 7 Terminal device, hook, Dorrance or equal, model # 7LO Terminal device, hook, Dorrance or equal, model # 8 Terminal device, hook, Dorrance or equal, model # 8x Terminal device, hook, Dorrance or equal, model # 88x Terminal device, hook, Dorrance or equal, model # 10P Terminal device, hook, Dorrance or equal, model # 10x Terminal device, hook, Dorrance or equal, model # 12P Terminal device, hook, Dorrance or equal, model # 99x Terminal device, hook, Dorrance or equal, model # 555 Terminal device, hook, Dorrance or equal, model # SS555 Terminal device, hook-accu hook or equal Terminal device, hook 2 load or equal Terminal device, hook-aprl VC or equal Terminal device, modifier wrist flexion unit Terminal device, hook, TRS grip, Grip III, VC, or equal Terminal device, hook, Grip I, Grip II, VC, or equal Terminal device, hook, TRS Adept, infant or child, VC, or equal Terminal device, hook, TRS Super Sport, passive Terminal device, pincher tool, Otto Bock or equal All 21 PA All All All All All All All All All All All All All All All All All All All All
Prosthetic Devices, All Ages (section 242.190) ational Code M1 M2 TOS Description L825 L830 L835 L840 L845 L850 L855 L80 L85 L87 L88 L870 L872 L873 L875 L880 L890 L895 L900 Terminal device, hand, Dorrance, VO All 21 PA All Terminal device, hand, APRL, VC All Terminal device, hand, Sierra, VO All Terminal device, hand, Becker Imperial Terminal device, hand, Becker Lock Grip Terminal device, hand, Becker Plylite Terminal device, hand, Robin-Aids, VO Terminal device, hand, Robin-Aids, VO soft Terminal device, hand, passive hand Terminal device, hand, Detroit Infant and (mechanical) Terminal device, hand, passive infant hand, Steeper, osmer or equal All All All All All All All All Terminal device, hand, child mitt All Terminal device, hand, child hand Terminal device, hand, mechanical infant hand, Steeper or equal All All Terminal device, hand, Bock, VC All Terminal device, hand, Bock, VO All Terminal device, gloves for above hands, production glove Terminal device, glove for above hands, custom glove and restoration (casts, shading and measurements included), partial hand, with glove, thumb or one finger remaining All All All
Prosthetic Devices, All Ages (section 242.190) ational Code M1 M2 TOS Description L905 L910 L915 L920* L925* L930* L935* L940* and restoration (casts, shading and measurements included), partial hand, with glove, multiple fingers remaining and restoration (casts, shading and measurements included), partial hand, with glove, no fingers remaining and restoration (shading and measurements included), replacement glove for above 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 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 Below elbow, external power, selfsuspended inner socket, removable forearm shell, Otto Bock or equal switch, cables, two batteries and one charger, switch control of terminal device Below elbow, external power, selfsuspended inner socket, removable forearm shell, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device 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 21 PA All All All All All All All All
Prosthetic Devices, All Ages (section 242.190) ational Code M1 M2 TOS Description L945* L950* L955* L90* L95* L970* 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 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 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 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 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 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 21 PA All All All All All All
Prosthetic Devices, All Ages (section 242.190) ational Code M1 M2 TOS Description L975* L7010* L7015* L7020* L7025* L7030* L7035* L7040* L7045* L7170* L7180* 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 Electronic hand, Otto Bock, Steeper or equal, switch controlled Electronic hand, System Teknik, Variety Village or equal, switch controlled Electronic greifer, Otto Bock or equal, switch controlled Electronic hand, Otto Bock or equal, myoelectronically controlled Electronic hand, System Teknik, Variety Village or equal, myoelectronically controlled Electronic greifer, Otto Bock or equal, myoelectronically controlled Prehensile actuator, osmer or equal, switch controlled Electronic hook, child, Michigan or equal, switch controlled Electronic elbow, osmer or equal, switch controlled Electronic elbow, tah or equal, myoelectronically controlled L7185 Electronic elbow, adolescent, Variety Village or equal, switch controlled L718 Electronic elbow, child, Variety Village or equal, switch controlled L7190 Electronic elbow, adolescent, Variety Village or equal, myoelectronically controlled L7191 Electronic elbow, child, Variety Village or equal, myoelectronically controlled All 21 PA All All All All All All All All All All All 21 /A 21 /A 21 /A 21 /A
Prosthetic Devices, All Ages (section 242.190) ational Code M1 M2 TOS Description L720* L721* L72* L7272* L7274* L730* L732* L734* L73* L8000 L8010 Electronic wrist rotator, Otto Bock or equal All 21 PA All Electronic wrist rotator, for tah arm All Servo control, Steeper or equal All Analogue control, B or equal All Proportional control, -12 volt, Liberty, tah or equal Six volt battery, Otto Bock or equal, each Battery charger, six volt, Otto Bock or equal Twelve volt battery, tah or equal, each Battery charger, twelve volt, tah or equal All All All All All Breast prosthesis, mastectomy bra All Breast prosthesis, mastectomy sleeve L8015 External breast prosthesis garment, with mastectomy form, postmastectomy L8020 L8030 L8100 L8300 L8310 L8320 L8330 All Breast prosthesis, mastectomy form All Breast prosthesis, silicone or equal All Gradient support compression stocking, below knee, 18-30 mmhg, each All Truss, single with standard pad All Truss, double with standard pads All Truss, addition to standard pad, water pad Truss, addition to standard pad, scrotal pad All All
Prosthetic Devices, All Ages (section 242.190) ational Code M1 M2 TOS Description All 21 PA L8400 Prosthetic sheath, below knee, each All L8410 Prosthetic sheath, above knee, each All L8415 Prosthetic sheath, upper limb, each All L8417 Prosthetic sheath/sock, including a gel cushion layer, below knee or above knee, each L8420 Prosthetic sock, multiple ply, below knee, each All L8430 Prosthetic sock, multiple ply, above knee, each All L8435 Prosthetic sock, multiple ply upper limb, each All L8440 Prosthetic shrinker, below knee, each All L840 Prosthetic shrinker, above knee, each All L845 Prosthetic shrinker, upper limb, each All L8470 Prosthetic sock, single ply, fitting below knee, each All L8480 Prosthetic sock, single ply fitting, above knee, each All L8485 Prosthetic sock, single ply, fitting, upper limb, each L8490 Addition to prosthetic sheath/sock, air seal suction retention system L8500 Artificial larynx, any type All L8501 Tracheostomy speaking valve All L800 Implantable breast prosthesis, silicone or equal All *Replacement only
Prosthetic Devices, All Ages (section 242.190) ational Code M1 M2 TOS L1499 L2999 L349 L3999 L5999 L7499 Local Code Z145 Z145 Z145 Z145 Z145 Z145 Description Spinal orthosis, not otherwise specified (nlisted Prosthetic Devices or Orthotic Appliances (The manufacturer s invoice must be attached to all claims.) Lower extremity orthoses, OS (nlisted Prosthetic Devices or Orthotic Appliances (The manufacturer s invoice must be attached to all claims.) Orthopedic shoe, modification, adition or transfer, OS (nlisted Prosthetic Devices or Orthotic Appliances (The manufacturer s invoice must be attached to all claims.) pper limb orthosis, OS (nlisted Prosthetic Devices or Orthotic Appliances (The manufacturer s invoice must be attached to all claims.) Lower extremity prosthesis, not otherwise specified (nlisted Prosthetic Devices or Orthotic Appliances (The manufacturer s invoice must be attached to all claims.) pper extremity prothesis, OS (nlisted Prosthetic Devices or Orthotic Appliances (The manufacturer s invoice must be attached to all claims.) PA /A /A /A /A /A /A or Rental
Prosthetic Devices, All Ages (section 242.190) ational Code M1 M2 TOS L8499 L4205 L4210 L7510 L7520 L7510 52 Local Code Z145 Z183 Z183 Z183 Z183 Z1748 Description nlisted procedure for miscellaneous prosthetic services (nlisted Prosthetic Devices or Orthotic Appliances (The manufacturer s invoice must be attached to all claims.) Repair of orthotic device, labor component, per 15 minutes (Orthotics and Prosthetics Repairs) Repair of orthotic device, repair or replace minor parts (Orthotics and Prosthetics Repairs) Repair of prosthetic device, repair or replace minor parts (Orthotics and Prosthetics Repairs) Repair prosthetic device, labor component, per 15 minutes (Orthotics and Prosthetics Repairs) Repair of prosthetic device, repair or replace minor parts (Twister cables - repair/replace) PA /A /A /A /A /A /A or Rental OTE: 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 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 claim. Where only a national code is available, it can be used indefinitely for both electronic and claims. 242.191 Specialized Wheelchairs and Wheelchair Seating Systems for Individuals Age Two Through Adult 9-1-04 Effective for dates of service on and after October 13, 2003, when billing either electronically or on, procedure codes found in this section must be billed with modifier for recipients under 21 years of age or modifier for recipients age 21 and over. When a second modifier is listed, that modifier must be used in conjunction with either or. Additionally, when billing on, procedure codes found in this section must be billed with a type of service (TOS) code for individuals under age 21 or TOS code 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 in the column, if not, an 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. ** ly for TOS code. # This procedure code is payable for individuals ages 2 through 20, using TOS code. Prior authorization is required through tilization 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. ote: W/C or w/c indicates wheelchair Specialized Wheelchairs and Wheelchair Seating Systems for Individuals Age Two Through Adult (section 242.191) ational Code M1 M2 TOS PA Description E0950 7 E0951 E0952 E0954 E0955 7 E0957 7 E0958 E0959 7 7 7 or Rental Wheelchair accessory, tray, each **** eel loop/holder, with or without ankle strap, each **** Toe loop/holder, each **** Semi-pneumatic caster, each **** W/C accessory, headrest, cushioned, prefabricated, w/fixed mounting hardware, each W/C accessory, medial thigh support, prefabricated, w/fixed mounting hardware, each Manual W/C accessory, one-arm drive attachment, each Manual W/C accessory, adapter for amputee, each
Specialized Wheelchairs and Wheelchair Seating Systems for Individuals Age Two Through Adult (section 242.191) ational Code M1 M2 TOS PA Description E090 7 E091 E097 7 E097 7 E097 7 E097 7 E097 7 E0970 E0971 E0974 E0978 7 E0981 7 E0992 E0994 E1002 7 E1004 7 E100 7 E1010 7 2 2 3 3 4 4 2 **** **** W/C accessory, shoulder harness/straps or chest strap including any type mounting hardware Manual W/C accessory, wheel lock brake extension (handle), each Manual W/C accessory, hand rim w/projections, each Manual W/C accessory, hand rim w/projections, each Manual W/C accessory, hand rim w/projections, each Manual W/C accessory, hand rim w/projections, each Manual W/C accessory, hand rim w/projections, each o. 2. footplates, except for elevating legrest or Rental **** Anti-tipping device W/C **** **** Manual W/C accessory, anti-rollback device, each W/C accessory, safety belt/pelvic strap, each W/C accessory, seat upholstery, replacement only, each **** Manual w/c accessory, solid seat insert **** Armrest, each W/C accessory, power seating system, tilt only W/C accessory, power seat system, recline only, w/mechanical shear reduction W/C accessory, power seating system, combination tilt and recline, w/o shear reduction W/C accessory, addition to power seating system, power leg elevation system, including leg rest, each
Specialized Wheelchairs and Wheelchair Seating Systems for Individuals Age Two Through Adult (section 242.191) ational Code M1 M2 TOS PA Description E1019 7 E1030 7 E105* E1084* E108* E1088* E1090 E1092* E1093* E1110* E1170* E1172* E1180* E1200* E1211* **** **** **** **** **** W/C accessory, power seating, heavy duty feature, patient weight capacity greater than 250 lbs, and less than or equal to 400 lbs Wheelchair accessory, ventilator tray, gimbaled Power attachment (to convert any W/C to motorized W/C, e.g., Solo) emi-w/c; detachable arms, desk or full-length, swing-away, detachable, elevating legrests emi W/C; detachable arms, desk or full-length, swing-away, detachable footrests igh strength lightweight W/C; detachable arms, desk or full-length, swing-away, detachable, elevating legrests igh-strength lightweight W/C; detachable arms, desk or full-length, swing-away, detachable footrests Wide, heavy-duty W/C; detachable arms, desk or full-length, swing-away, detachable, elevating legrests Wide, heavy-duty W/C; detachable arms, desk or full-length arms, swingaway, detachable footrests Semi-reclining W/C; detachable arms, desk or full-length, elevating legrest Amputee W/C; fixed full-length arms, swing-away, detachable, elevating legrests Amputee W/C; detachable arms, desk or full-length, without footrests or legrests Amputee W/C; detachable arms, desk or full-length, swing-away, detachable footrests Amputee W/C; fixed full-length arms, swing-away, detachable footrests Motorized W/C; detachable arms, desk or full-length, swing-away, detachable, elevating legrests or Rental
Specialized Wheelchairs and Wheelchair Seating Systems for Individuals Age Two Through Adult (section 242.191) ational Code M1 M2 TOS PA Description E1213* E1220* E1230* E1240* E120* E1280* E1290* E2203 7 E2310 7 E2311 7 E2320 7 4 4 **** Motorized W/C; detachable arms, desk or full-length, swing-away, detachable footrests W/C, specially sized or constructed (indicate brand name, model number, if any, and justification) Power operated vehicle (three- or fourwheel nonhighway), specify brand name and model number Lightweight W/C; detachable arms, desk or full-length, swing-away, detachable, elevating legrest Lightweight W/C; detachable arms, desk or full-length, swing-away, detachable footrests eavy-duty W/C; detachable arms, desk or full-length, elevating legrests eavy-duty W/C; detachable arms, swing-away, detachable footrests Manual w/c accessory, nonstandard seat frame depth, 20 to less than 22 inches 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 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 Power w/c accessory, hand or chin control interface, remote joystick or touchpad, proportional, including all related electronics and fixed mounting hardware or Rental
Specialized Wheelchairs and Wheelchair Seating Systems for Individuals Age Two Through Adult (section 242.191) ational Code M1 M2 TOS PA Description E2322 7 E2323 7 E2324 7 E2325 7 E232 7 E2327 7 E233 7 E233 7 E235 7 E235 7 Power w/c accessory, hand control interface, multiple mechanical switches, nonproportional, including all related electronics, mechanical stop switch, and fixed mounting hardware Power w/c accessory, specialty joystick handle for hand control interface, prefabricated Power w/c accessory, chin cup for chin control interface Power w/c accessory, sip & puff interface nonproportional, including all related electronics, mechanical stop switch, and manual swingaway mounting hardware Power w/c accessory, breath tube kit for sip & puff interface Power w/c accessory, head control interface, mechanical, proportional, including all related electronics, mechanical direction change switch, and fixed mounting hardware Power w/c accessory, group 24 sealed lead acid battery, each Power w/c accessory, group 24 sealed lead acid battery, each (e.g., gel cell, absorbed glassmat) Power w/c accessory, -1 sealed lead acid battery, each, gel cell Power w/c accessory, -1 sealed lead acid battery, each, gel cell or Rental Specialized Wheelchairs and Wheelchair Seating Systems for Individuals Age Two Through Adult (section 242.191) ational Code M1 M2 TOS E1050 Local Code Description PA Z1590* Full reclining W/C, fixed fulllength arms, swing-away, detachable elevating legrests ****
Specialized Wheelchairs and Wheelchair Seating Systems for Individuals Age Two Through Adult (section 242.191) ational Code M1 M2 TOS E100 E120 E108 E0973 7 K0023 K011 K0038 K0039 K0040 K0047 K0059 K0108 2 Local Code Description PA Z1592* Full reclining W/C, detachable arms, desk or full-length, swingaway detachable, elevating legrests Z1597* Lightweight W/C, detachable arms, desk or full-length, swingaway, detachable footrests Z1599* emi- W/C, detachable arms, desk or full-length, swing-away detachable footrests Z105 Z10 Z108 W/C accessory, adjustable height, detachable armrest, complete assembly, each Solid back insert, planar back, single density foam, attached with straps Seating system, combined back and seat module, custom fabricated for attachment to W/C base **** **** **** **** Z109 Leg strap, each **** Z110 Leg strap, style, each **** Z111 Adjustable angle footplate, each **** Z114 Elevating legrest, upper hanger bracket, each **** Z115 Plastic coated handrim, each **** Z11 Other accessories (Applicable pages from the manufacturer s catalog must be attached to the claim form.) ****
Specialized Wheelchairs and Wheelchair Seating Systems for Individuals Age Two Through Adult (section 242.191) ational Code M1 M2 TOS E1340 K0071 K004 K005 K0074 K0074 K0071 K0072 K0073 K0102 E0972 E0972 K0104 3 3 Local Code Description PA Z119 Z125 Z128 Repair or nonroutine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes (nlisted Repairs/Parts Wheelchairs) (Applicable pages from the manufacturer s catalog must be attached to the claim form.) Front caster assembly, complete, with pneumatic tire, each 22, rear wheels Zero pressure tube (flat free insert), any size, each **** **** **** Z129 Spoke protectors, each **** Z130 Z131 Z132 Z132 Pneumatic caster tire, any size each (8 x 1 1/4 ) front casters) Pneumatic caster tire, any size each (Pneumatic casters 8 x 1 3/4 (each), front casters) Front caster assembly, complete, with pneumatic tire, each (Polyurethane caster 5 ) Front caster assembly, complete, with semipneumatic tire, each (Polyurethane caster 5 ) **** **** **** **** Z133 Caster pin lock, each **** Z153 Crutch and cane holder, each **** Z154 Z155 W/C accessory, transfer board or device, each (Wood transfer board) W/C accessory, transfer board or device, each (Plastic transfer board) Z15 Cylinder tank carrier, each
Specialized Wheelchairs and Wheelchair Seating Systems for Individuals Age Two Through Adult (section 242.191) ational Code M1 M2 TOS E230 7 E232 E234 E235 E231 7 Local Code Description PA Z158 Z159 Power w/c accessory, 22 F non-sealed lead acid battery, each Power wheelchair accessory, group 24 non-sealed lead acid battery, each Z10 Power wheelchair accessory, - 1 non-sealed lead acid battery, each Z11 Power wheelchair accessory, - 1 sealed lead acid battery, each, (e.g., gel cell, absorbed glassmat) Z12 Power w/c accessory, 22 F sealed lead acid battery, each, (e.g., gel cell, absorbed glassmat) E1091 52 Z17** outh stroller **** E0700 E092 E093 E094 E095 E095 7 E2201 7 2 2 3 3 Z19 Safety equipment (e.g., belt, harness or vest) Travel restraint auto safe harness (E-Z on vest) **** Z172 One-inch cushion, for W/C **** Z172 Two-inch cushion, for W/C **** Z172 Three-inch cushion, for W/C **** Z172 Four-inch cushion, for W/C **** Z177 Z178 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) Manual w/c accessory, nonstandard seat frame width > than or equal to 20 inches and <24 inches **** ****
Specialized Wheelchairs and Wheelchair Seating Systems for Individuals Age Two Through Adult (section 242.191) ational Code M1 M2 TOS K005 Local Code Description PA Z178 Seat height less than 17 inches or equal to or greater than 21 inches for a high strength, lightweight, or ultralightweight W/C E1232 Z179* W/C, pediatric size, tilt-in-space, folding, adjustable, with seating system E1233 Z179* W/C, pediatric size, tilt-inspace, rigid, adjustable, without seating system E1234 Z179* W/C, pediatric size, tilt-in-space, folding, adjustable, without seating system E1235 E1237 E1238 K0005 K0005 K011 E1340 2 Z179* W/C, pediatric size, rigid, adjustable, with seating system Z179* W/C, pediatric size, rigid, adjustable, without seating system Z179* W/C, pediatric size, folding, adjustable, without seating system Z180* ltralightweight W/C igh performance manual W/C-adult Z181* ltralightweight W/C (igh performance manual W/C with growth adjustability-child) Z182 Z1758 Seating system, combined back and seat module, custom fabricated for attachment to W/C base Repair or nonroutine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes (Labor (a maximum of twenty [20] units [20 units = 5 hours of labor] per date of service is allowable.) **** ****
Specialized Wheelchairs and Wheelchair Seating Systems for Individuals Age Two Through Adult (section 242.191) ational Code M1 M2 TOS K011 K011 E0992 E0992 K0023 K0023 E09 7 K0038 E0980 E0978 3 3 3 3 2 2 2 2 Local Code Description PA Z175 Z17 Z178 Z179 Z1771 Z1772 Z1783 Z1790 Z1797 Z1799 Seating system, combined back and seat module, custom fabricated for attachment to W/C base (Foam-In-Place Back Pindot, Contour System, Quick Foam) Seating system, combined back and seat module, custom fabricated for attachment to W/C base (Foam-In-Place Seat (Pindot Quick Foam Contour System) Manual w/c access, solid seat insert (Foam & Plywood Seat, MPI Like) Manual w/c access, solid seat insert (Foam and Plywood Flat Side) Solid back insert, planar back, single density foam, attached with straps (Foam & Plywood Back, MPI Like) Solid back insert, planar back, single density foam, attached with straps (Foam & Plywood Flat Back) Manual W/C accessory, headrest extension, each (eadrest/fixture, O.B. (4-LG 45-SM) Leg strap, each (Foot Straps (Pair) Safety vest, W/C (Chest panel 21-SM 22-LG) W/C accessory, safety belt/ pelvic strap, each (Belt, safety or chest, w/pad) **** **** **** **** **** **** **** **** **** **** K0038 Z1802** Leg strap, each (Knee strap) E0980 E0950 2 2 Z1803 Z1804 Safety vest, W/C (Shoulder retractors) W/C accessory, tray, each (ABS tray (4-SM 5-LG) **** ****
Specialized Wheelchairs and Wheelchair Seating Systems for Individuals Age Two Through Adult (section 242.191) ational Code M1 M2 TOS E0950 E0950 E0950 K0019 K00 K0012 K0012 K0010 K0010 K0011 K0011 E1004 5 5 4 4 Local Code Description PA Z1805 Z1807 W/C accessory, tray, each (Clear upper Ex support system) W/C accessory, tray, each (Tray, customized) **** Z1810 W/C accessory, tray, each Z1813 Arm pad, each Z1992 Solid tire, any size, each (20-2 Tires for manual W/C (ea.) (Replacement) Z2108 Z2109 Z2110 Z2111 Z2112 Z2113 Z2114 Lightweight portable motorized/power W/C (Motorized folding frame, DA, swing away foot rests) Lightweight portable motorized/power W/C (Motorized folding frame, DA, swing away ELR) Standard weight frame motorized/power W/C (Motorized, standard frame, DA, swing away foot rests) Standard weight frame motorized/power W/C (Motorized, standard frame, DA, swing away ELR) Standard-weight frame motorized/power, W/C with programmable control parameters for speed adjustment, tremor dampening, acceleration control and braking Standard-weight frame motorized/power, W/C with programmable control parameters for speed adjustment, tremor dampening, acceleration control and braking W/C accessory, power seating system, recline only, with mechanical shear reduction
Specialized Wheelchairs and Wheelchair Seating Systems for Individuals Age Two Through Adult (section 242.191) ational Code M1 M2 TOS E1002 E100 K0017 E0950 E0982 7 K0024 K0045 E097 7 E0959 E0959 K0070 K0097 K0093 7 7 Local Code Description PA Z2115 Z211 Z2117 Z2119 Z2120 Z2121 Z2122 Z2123 Z2124 Z2125 Z212 Z2127 Z2128 W/C accessory power seating system, tilt only W/C accessory, power seating system, combination tilt and recline, without mechanical shear reduction (Power tilt and recline system with zero sheer) Detachable, adjustable height armrest, base, each (Dual post and adjustable height DA) W/C accessory, tray, each (Removable inged Overlay for Tray) W/C accessory, back upholstery, replacement only, each (Standard back upholstery replacement) Solid back insert, planar back, single density foam, with adjustable hook on hardware Footrest, complete assembly (padded custom foot box) Manual W/C accessory, hand rim w/projections, each (Vertical/oblique projection hand rims 8-10-12) Manual W/C accessory, adapter for amputee, each Manual W/C accessory, adapter for amputee, each (Amputee axle plate for high performance manual W/C (ea) Rear wheel assembly, complete with pneumatic tire, spokes or molded, each (20 /22 /24 /2 /ea. replacement) Wheel, zero pressure tire tube (flat free insert) for power base, any size, each Rear wheel zero pressure tire tube (flat free insert) for power W/C any size, each **** **** **** **** **** **** **** **** **** **** ****
Specialized Wheelchairs and Wheelchair Seating Systems for Individuals Age Two Through Adult (section 242.191) ational Code M1 M2 TOS K0074 K0099 K004 E237 7 E23 7 E1091 E095 7 E111 E0178 E0178 E0178 E017 2 2 2 2 Local Code Description PA Z2129 Z2130 Z2131 Z2132 Z2133 Pneumatic caster tire, any size each (9 x 2 3/4 for power base W/C) Front caster for power W/C (9 x 2 3/4 foam filled) Zero pressure tube (flat free insert), any size, each (12 or 14 ) Power w/c accessory, battery charger, dual mode, sealed or non-sealed, each (24-Volt Battery Charger - Dual Mode (Replacement) 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) **** **** **** Z2134 outh positioning stroller Z213 Z214 Z2147 Z2148 Z2149 Z2150 W/C accessory, lateral trunk or hip support, prefabricated w/fixed mounting hardware, each (Lateral trunk supports (swing away) (ea) Manual adult size W/C, includes tilt in space Gel or gel-like pressure pad or cushion, nonpositioning (Sm., 10-14 Gel) Gel or gel-like pressure pad or cushion, nonpositioning (Med., 14-18 Gel, low pressure) Gel or gel-like pressure pad or cushion, nonpositioning (Lg., over 18 Gel, width or depth) Air pressure pad or cushion, nonpositioning (II-LW-no maintenance, low pressure and positioning cushion) ****
Specialized Wheelchairs and Wheelchair Seating Systems for Individuals Age Two Through Adult (section 242.191) ational Code M1 M2 TOS E0178 K0114 E1228 E0992 E0992 E0192 E0192 K008 K0074 K0078 E0953 K0078 K0094 3 3 2 2 4 4 2 Local Code Description PA Z2151 Z2152 Z2153 Z2155 Z215 Z210 Z211 Z212 Z213 Z214 Z215 Z21 Z217 Gel or gel-like pressure pad or cushion, nonpositioning (Gel Growth - Adj., low pressure and positioning cushion) Back support system for use with a W/C, with inner frame, prefabricated (Positioning back standard height) Special back height for W/C (Positioning tall back) Manual w/c accessory, solid seat insert (Adjustable solid standard seat w/hardware) Manual w/c accessory, solid seat insert (Large adjustable solid seat w/hardware) Low pressure and positioning equalization pad, for W/C (air flotation cushion w/cover) Low pressure and positioning equalization pad, for W/C (Low pressure & positioning air and foam flotation cushion w/cover) Pneumatic tire tube, each (20-2 for manual W/C (ea) Replacement) Pneumatic caster tire, any size, each ( -8 for manual W/C (ea) Replacement) Pneumatic caster tire tube, each ( -8 for manual W/C (ea) (Replacement) Pneumatic tire, each (8 x 2 for manual W/C (ea) Replacement) Pneumatic caster tire tube, each (8 x 2 tubes for manual W/C (ea) (Replacement) Wheel tire for power base, any size, each (20 x 2 1/8 Replacement) **** **** **** ****
Specialized Wheelchairs and Wheelchair Seating Systems for Individuals Age Two Through Adult (section 242.191) ational Code M1 M2 TOS K0091 K007 K0091 K007 K0078 K0452 K0452 K0452 K0044 K0081 K0043 K007 E0973 7 2 2 2 2 2 2 Local Code Description PA Z218 Z219 Z2170 Z2171 Z2172 Z2173 Z2174 Z217 Z2177 Z2179 Z2182 Z2193 Z2194 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) Solid caster tire, any size, each 10 x 3 Rear Wheel for Power W/C (ea) Replacement 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) Solid caster tire, any size, each (9 x 3 Caster Tire for Power W/C (ea) (Replacement) Pneumatic caster tire tube, each (9 x 3 for Power W/C (ea) (Replacement) W/C bearings, any type (Rear Wheel Stem (Replacement) W/C bearings, any type (Caster Bearing (Replacement) W/C bearings, any type (Power Base Wheel Bearing (Replacement) Footrest, upper hanger bracket, each (SWFR anger bracket, replacement) Wheel lock assembly, complete, each (igh push or pull wheel lock (replacement) Footrest, lower extension tube, each (SWFR, replacement) Solid caster tire, any size, each (Polyurethane 5 (Replacement) W/C accessory, adjustable height, detachable armrest, complete assembly, each (eight Adj. Arms (Replacement) **** **** **** **** ****
Specialized Wheelchairs and Wheelchair Seating Systems for Individuals Age Two Through Adult (section 242.191) ational Code M1 M2 TOS K0017 E095 7 E1235 2 2 Local Code Description PA Z2195 Z2201 Z2204 Detachable, adjustable height armrest, base, each (Receiver for height adj. arms, replacement) W/C accessory, lateral trunk or hip support, prefabricated w/fixed mounting hardware, each (Med. Chest Panel Support) W/C, pediatric size, rigid, adjustable, with seating system (Snug Seat I Mobility System) E1070 Z2520 # Fully reclining W/C, detachable arms, desk or full-length, swingaway, detachable footrests K0093 E2201 7 E2201 7 E2203 7 K005 E1225 2 2 2 2 Z2553 Z2555 Z2557 Z2558 Z2559 Z250 Rear wheel zero pressure tire tube (flat free insert) for power W/C, any size, each (Mag. Airless Insert Drive Wheel) Manual w/c accessory, nonstandard seat frame width>than or equal to 20 inches and <24 inches (Frame Width - 14"-15") Manual w/c accessory, nonstandard seat frame width>than or equal to 20 inches and <24 inches (Frame Width-19"-20") Manual w/c accessory, nonstandard seat frame depth, 20 to less than 22 inches (Frame Long - 1", 17"3, 18", 19"3, 20" Depth) 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) Manual W/C accessory, semireclining back, (recline greater than 15 degrees, but less than 80 degrees), each (Folding Backrest 8 Degree Bend Low 15" 1") **** **** **** **** **** **** **** **** Rental only () () ()
Specialized Wheelchairs and Wheelchair Seating Systems for Individuals Age Two Through Adult (section 242.191) ational Code M1 M2 TOS E1228 E1228 E1228 Local Code Description PA Z251 Z252 Z253 Special back height for W/C (Folding Backrest Tall 19" 20") Special back height for W/C (Folding Straight Backrest Low (15" - 1") Special back height for W/C (Folding Straight Backrest Tall (19" - 20") E0990 Z254 W/C accessory, elevating leg rest, complete assembly, each E0990 7 E2203 7 E2201 7 E2203 7 E2203 7 E1029 7 K010 K0020 K0074 3 3 3 3 Z255 Z25 Z257 Z258 Z259 Z2570 W/C accessory, elevating leg rest, complete assembly, each (Elevating Leg Rest 90 Degree (12" - 1" Width) Manual w/c accessory, nonstandard seat frame depth, 20 to less than 22 inches (Seat Depth 19" - 20") Manual w/c accessory, nonstandard seat frame width > than or equal to 20 inches and < 24 inches (Seat Width 20") Manual w/c accessory, nonstandard seat frame depth, 20 to less than 22 inches (Seat Depth 15") Manual w/c accessory, nonstandard seat frame depth, 20 to less than 22 inches (Seat Depth 17" - 18") Wheelchair accessory, ventilator tray, fixed (Ventilator Tray With Battery Tray) **** **** **** **** **** **** **** **** **** Z2572 Arm trough, each **** Z2575 Z2578 Fixed, adjustable height armrest, pair Pneumatic caster tire, any size, each (Pneumatic Caster 8 X 2 With Airless Insert) **** ****
Specialized Wheelchairs and Wheelchair Seating Systems for Individuals Age Two Through Adult (section 242.191) ational Code M1 M2 TOS K007 E097 7 E095 7 E1013 E1020 3 3 2 Local Code Description PA Z2579 Z2583 Z2584 Z2587 Z2590 Pneumatic tire, any size,(pneumatic Caster 8 X 2 With Airless Insert) Manual W/C accessory, hand rim w/projections, each (Projection Vertical or Obilque) W/C accessory, lateral trunk or hip support, prefabricated w/fixed mounting hardware, each (Chest/Thoracic Supports) Integrated seating system, contoured, for pediatric W/C (Deep Contour Back 14" 19" Width) Residual limb support system for W/C (Adjustable Contour Lateral Thigh Support) **** **** **** **** E233 Z2593 Group 24 Gel Batteries **** E1013 Z2594 Integrated seating system, contoured, for pediatric W/C (Adjustable Contour Seat 10" - 12" Frame ) E1013 Z2595 Integrated seating system, contoured, for pediatric W/C (Adjustable Contour Seat 14" - 1" Frame) E102 Z2597 Lateral thoracic support, contoured, for pediatric W/C, each (includes hardware) (Adjustable Contour Back 10" - 12" Frame) E102 Z2598 Lateral thoracic support, contoured, for pediatric W/C, each (includes hardware (Adjustable Contour Back 14" - 1" Frame)) E1228 E1235 E0950 7 8 8 Z210 Special back height for W/C (igh back contour seat) Z211 1,2 W/C, pediatric size, rigid, adjustable with seating system (Rigid W/C Frame) Z212 Wheelchair accessory, tray, each (Lap Tray for Switch Array) **** **** **** **** ****
Specialized Wheelchairs and Wheelchair Seating Systems for Individuals Age Two Through Adult (section 242.191) ational Code M1 M2 TOS E0950 7 K0014 E0950 3 3 Local Code Description PA Z213 Z214 1,2 Z217 Wheelchair accessory, tray, each (Lap Tray Switch Array) Other motorized/ power W/C base (Center Drive power base) W/C accessory, tray, each (Custom) **** **** The following procedure codes may only be billed on. Specialized Wheelchairs and Wheelchair Seating Systems for Individuals Age Two Through Adult (section 242.191) o ational Code M1 M2 TOS Local Code Description PA Z113 Z13 One piece footboard (Each) Group 27 deep cycle battery (each) **** or Rental Z1785 W/C Mounting Kit, O.B. **** Z1789 Custom eadrest **** Z1793 Custom foot platform **** Z1824** PC Car Seat/Snug Seat Z2137 Z2138 Z2139 Adjustable Rem. Abductor w/hardware (ea) Adjustable Flip Down Abductor w/hardware (ea) Lateral ip/thigh support w/hardware (ea) **** **** **** Z2140 Adductor - no hardware **** Z2141 Abductor - no hardware **** Z2142 ip guides - no hardware Z2143 Fluid supplement
The following procedure codes may only be billed on. Specialized Wheelchairs and Wheelchair Seating Systems for Individuals Age Two Through Adult (section 242.191) o ational Code M1 M2 TOS Local Code Description PA or Rental Z2145 Laterals - no hardware **** Z2157 Z2158 Z2159 Z2175 Z2178 Z2180 Z2181 Standard Seat Cover for Cushion (Replacement) Air Exchange Seat Cover for Cushions (Replacement) Fluid Flo-lite pad (Replacement) Power W/C Sleeve Top or Bottom Stem Bearing (Replacement) SWFR Pivot Saddle (Replacement) SWFR Latch Block (Replacement) SWFR Composite Foot Plate (Replacement) **** **** Z2183 Shoe olders S/M/L/XL **** Z2184 Z2185 X-Tube Assembly Folding W/C (Replacement) Rigid Wheelchair Growth Kit **** Z218 Rigid Side Guard **** Z2187 Fabric Side Guard **** Z2188 Sub Occipital Three Piece ead Set W/REM ardware **** Z2189 Forehead Strap System **** Z2190 Regular Links **** Z2192 Z219 Pneumatic or Semi Casters (Replacement) 8 x 1 1/4 (ea) or 8 x 1 3/4 (ea) Swing Away Adj. Stroller andles **** ****
The following procedure codes may only be billed on. Specialized Wheelchairs and Wheelchair Seating Systems for Individuals Age Two Through Adult (section 242.191) o ational Code M1 M2 TOS Local Code Description PA Z2200 Support Fixture for ead Rest **** or Rental Z2202 Lg. Chest Panel Support **** Z2203 Elbow Block w/bracket **** Z2554 Z2571 Swing Away Retractable Joystick Mount Power Elevating Leg Rest With Calf Pads **** **** Z2582 Quick Release Axle **** Z2585 Growing Seat Pan **** Z258 Growing Back pholstery **** Z2588 Deep Contour Back 20" Width Z2589 Z2591 1 Adjustable Contour Lateral Pelvic Support eavy Duty Motor Pack 350 Pounds **** **** Z2592 Remote Joystick Module **** Z259 Adjustable Contour Seat Attaching ardware **** Z2599 Transit Option **** Z204 Z207 Z208 Adjustable Back pholstery Lateral/Posterior Pelvic Support Shoulder arness Guide Kit **** **** **** Z209 niversal ead Rest Kit **** Z215 Remote Joystick With 1/8" Jacks Z21 Swing Away Mount (Joystick) **** ****
OTE: 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 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 claim. Where only a national code is available, it can be used indefinitely for both electronic and claims. 242.192 Specialized Rehabilitative Equipment, All Ages 9-1-04 Effective for dates of service on and after October 13, 2003, when billing either electronically or on, procedure codes found in this section must be billed with modifier for recipients under 21 years of age or modifier for recipients age 21 and over. When a second modifier is listed, that modifier must be used in conjunction with either or. Additionally, when billing on, procedure codes must be billed with a type of service (TOS) code for individuals under 21 years of age or type of service code 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 in the column, if not, an 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) ational Code M1 M2 TOS Description PA E038 7 E038 7 2 Standing frame system, any size, with or without wheels Standing frame system, any size, with or without wheels Specialized Rehabilitative Equipment, All Ages (section 242.192) ational Code M1 M2 TOS Local Code Description PA E1031 5 Z2037** Rollabout chair, any and all types with casters five inches or greater (Low Back Activity Chair)
Specialized Rehabilitative Equipment, All Ages (section 242.192) ational Code M1 M2 TOS Local Code Description PA E1031 Z2041** Rollabout chair, any and all types with casters five inches or greater (Transition Toddler Chair - Sm.) E1031 Z2042** Rollabout chair, any and all types with casters five inches or greater (Transition Toddler Chair - Lg.) E0701 E0701 Z2053 Z2054 elmet with face guard and soft interface material, prefabricated (Soft Shell elmets) elmet with face guard and soft interface material, prefabricated (ard Shell elmets) E1035 Z2055** Multi-positional patient transfer system, with integrated seat, operated by care giver (Carrie Seat - Pre School) E1035 Z205** Multi-positional patient transfer system, with integrated seat, operated by care giver (Carrie Seat Elementary) E1035 2 Z2057** Multi-positional patient transfer system, with integrated seat, operated by care giver (Carrie Seat - Jr.)
Specialized Rehabilitative Equipment, All Ages (section 242.192) ational Code M1 M2 TOS E1035 3 3 Local Code Description PA Z2058 Multi-positional patient transfer system, with integrated seat, operated by care giver (Carrie Seat - Sm. Adult) E1031 Z2059** Rollabout chair, any and all types with casters five inches or greater (Corner Chair w/tray & Casters - Sm.) E1031 3 Z200** Rollabout chair, any and all types with casters five inches or greater (Corner Chair w/tray & Casters - Lg.) E1031 4 Z201** Rollabout chair, any and all types with casters five inches or greater (Bolster Chair w/tray, Chest Support & Casters - Sm.) E0245 E0245 E0245 E0245 3 3 4 4 5 5 Z203 Z204 Z205 Z20 Tub stool or bench (30 Bath Chair) Tub stool or bench (38 Bath Chair) Tub stool or bench (47 Bath Chair) Tub stool or bench (5 Bath Chair) E013 Z207 Commode chair, stationary, with fixed arms (Potty Chair Sm). E01 Z208 Commode chair, mobile, with detachable arms (Potty Chair Lg)
Specialized Rehabilitative Equipment, All Ages (section 242.192) ational Code M1 M2 TOS E0245 E0245 E0245 E0241 E0241 E0241 E024 2 2 52 52 2 2 Local Code Description PA Z2078 Z2079 Z2080 Z2081 Z2082 Z2083 Z2084 Tub stool or bench (Padded Tub Transfer Bench) Tub stool or bench (on-padded tub transfer bench) Tub stool or bench (Adj. Bath Chair w/back) Bathroom wall rail, each (Bolt-on Sm. Grab Bar) Bathroom wall rail, each (Bolt-on Lg. Grab Bar) Bathroom wall rail, each (Bolt-on Med. Grab Bar) Transfer tub rail attachment (Clamp-on Tub Grab Bar) E018 Z2085 Commode chair, extra wide and/or heavy duty, stationary or mobile, with or without arms, any type, each (Rehab Shower/Commode Chair) E018 Z2085 Commode chair, extra wide and/or heavy duty, stationary or mobile, with or without arms, any type, each (Rehab Shower/Commode Chair)
Specialized Rehabilitative Equipment, All Ages (section 242.192) ational Code M1 M2 TOS Local Code Description PA E018 Z2088 Commode chair, extra wide and/or heavy duty, stationary or mobile, with or without arms, any type, each (Adaptive Commode Chair) E018 52 Z2088 Commode chair, extra wide and/or heavy duty, stationary or mobile, with or without arms, any type, each (Adaptive Commode Chair) E0149 E0950 E0700 E0701 2 2 Z2098 Z200 Z201 Z203 Walker, heavy duty, wheeled, rigid or folding, any type (4 Wheel Reverse Walker) Wheelchair accessory, tray, each (Tray for gait trainer) Safety equipment (e.g., belt, harness or vest (Chin Guard for Safety elmet sm) elmet with face guard and soft interface material, prefabricated (face guard for safety helmet)
The following list of codes may only be billed on. Specialized Rehabilitative Equipment, All Ages (section 242.192) o ational Code M1 M2 TOS Local Code Local Code Description PA or Rental Z199 Sm. 51 Supine Stander Z1997 Lg. 71 Supine Stander Z1998** 27 Prone Stander Z2000** 42 Prone Stander Z2001 50 Prone Stander Z2002 Adj. Abduction Wedge w/hip stabilizer Z2003 Tray for Stander-Prone Z2004 Tray for Stander-Supine Z2005 Foot Sandals for Standers Z200** p Rite Stander - Sm. Z2007** p Rite Stander - Med. Z2008 p Rite Stander - Lg. Z2009 Z2010 Z2011 Caster Base for p Rite Stander - Sm. Caster Base for p Rite Stander - Med. Caster Base for p Rite Stander - Lg. Z2012** Tumble Form Tri Stander w/tray - Sm. Z2013** Tumble Form Tri Stander w/tray - Lg. Z2015** 48 Side Lyer Z201** 72 Side Lyer Z2017** Tumble Form Feeder Seat - Sm.
The following list of codes may only be billed on. Specialized Rehabilitative Equipment, All Ages (section 242.192) o ational Code M1 M2 TOS Local Code Local Code Description PA Z2018** Tumble Form Feeder Seat - Med. Z2019** Tumble Form Feeder Seat - Lg. or Rental Z2020** Floor Sitter Wedge Z2021** Mobile Floor Sitter Med/Lg. Z2022** Tumble Form Therapy Wedge 4 - Sm. Z2023** Tumble Form Therapy Wedge - Sm. Z202** Tumble Form Therapy Wedge 8 - Med. Z2029** Tumble Form Therapy Wedge 10 - Lg. Z2030** Tumble Form Therapy Rolls 4 Z2031** Tumble Form Therapy Rolls Z2032** Tumble Form Therapy Rolls 8 Z2034** Tumble Form Therapy Rolls 12 Z2035** Tumble Form Therapy Rolls 14 Z203** Tumble Form Therapy Rolls 1 Z2038** Therapy Ball - Sm. Z2039** Therapy Ball - Med. Z2040** Therapy Ball - Lg. Z2043** Seat & Back Pad for Toddler Chairs Z2044** Tray for Toddler Chair Z2045** 14 T&S igh Back w/support Activity Chair
The following list of codes may only be billed on. Specialized Rehabilitative Equipment, All Ages (section 242.192) o ational Code M1 M2 TOS Local Code Local Code Description PA Z204** 1 T&S igh Back w/support Activity Chair or Rental Z2047 Orthopedic Car Seat Z2048 4 Deluxe Wedge w/strap Z2072 Z2073 Z2074 Z2075 Lg. Wrap Around Bath Support Sm. Wrap Around Back Support Lg. Toilet Support w/i Back Sm. Toilet Support w/i Back Z2077 Flexible Shower ose Z2089 Toilet Seat Reducer Ring (Padded) Z2090** 14 Gait Trainer Z2091** 19 Gait Trainer Z2092** Intermediate Gait Trainer Z2093 Adult Gait Trainer Z2094** Tyke Strider Walker w/2 Wheels Z2095** Tweener Strider Walker w/2 Wheels Z209** Middle Strider Walker w/2 Wheels Z2097 Adult Strider Walker w/2 Wheels Z2099 4 Wheel Reverse Walker Z2100 4 Wheel Reverse Walker Z2101 4 Wheel Reverse Walker
The following list of codes may only be billed on. Specialized Rehabilitative Equipment, All Ages (section 242.192) o ational Code M1 M2 TOS Local Code Local Code Description PA or Rental Z2102 4 Wheel Reverse Walker Z2104 Z2105 Z210 4 Wheel Front Swivel Reverse Walker 4 Wheel Front Swivel Reverse Walker 4 Wheel Front Swivel Reverse Walker Z2107 4 Wheel Front Swivel Reverse Walker Z2239 Bath Chair eadrest Z205 Diverter Valve for andheld Shower OTE: 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 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 claim. Where only a national code is available, it can be used indefinitely for both electronic and claims. 242.193 Augmentative Communication Device, All Ages 9-1-04 The augmentative communication device is covered for recipients under 21 years of age when prescribed as a result of an SDT 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 for recipients under 21 and type of service 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. Effective for dates of service on and after October 13, 2003, when billing either electronically or on, procedure codes found in this section must be billed with modifier for recipients
under 21 years of age or modifier for recipients age 21 and over. When a second modifier is listed, that modifier must be used in conjunction with either or. Additionally, when billing on, procedure codes must be billed with a type of service (TOS) "" for individuals under age 21 or TOS "" 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 in the column, if not, an 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) ational Code M1 M2 TOS PA Description E2512 7 Accessory for speech generating device, mounting system or Rental Augmentative Communication Device, All Ages (section 242.193) ational Code M1 M2 TOS E2599 7 E2500 7 Local Code Description PA Z1972 Z1974 Accessory for speech generating device, not otherwise classified (Switches - used with training aids and augmentative communication devices as a means of access.) 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.) or Rental
Augmentative Communication Device, All Ages (section 242.193) ational Code M1 M2 TOS E2502 7 E2504 7 E250 7 E2508 7 Local Code Description PA Z1975 Z1975 Z1975 Z197 Speech generating device, digitized speech, using pre-recorded messages, greater than 8 minutes but less than or equal to 20 minutes recording time (Simple Voice Output Device - simple devices with limited storage capacity and voice output only.) 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.) Speech generating device, digitized speech, using pre-recorded messages, greater than 40 minutes recording time. (Simple Voice Output Device - simple devices with limited storage capacity and voice output only.) 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) or Rental
Augmentative Communication Device, All Ages (section 242.193) ational Code M1 M2 TOS E2510 7 E2510 7 E2511 7 V533 Local Code Description PA Z1977 Speech generating device synthesized speech, permitting multiple methods of message formulation and multiple methods of device access (igher Technology Voice Output Communication Aids - offer greater memory capabilities, various types of output, computer interface options, etc.) Z1978 Z1979 Z220 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-ofthe-art communication aid technology. as 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.) 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.) Repair/modification of augmentative communicative system or device (excludes adaptive hearing aid)(augmentative Communication Device Repair - parts only) or Rental
Augmentative Communication Device, All Ages (section 242.193) ational Code M1 M2 TOS V533 Local Code Description PA Z221 Repair/modification of augmentative communicative system or device (excludes adaptive hearing aid)(augmentative Communication Device Repair - labor only) or Rental OTE: 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 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 claim. Where only a national code is available, it can be used indefinitely for both electronic and claims. OTE: 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 9-1-04 Place of Service Paper Claims Electronic Claims Inpatient ospital 1 21 Outpatient ospital 2 22 Doctor s Office 3 11 Patient s ome 4 12 Day Care Facility 5 52 ight Care Facility 52 ursing ome 7 33 Skilled ursing Facility 8 31 Ambulance 9 41 Other Locations 0 99 Independent Laboratory A 81 Ambulatory Surgical Center B 24 Residential Treatment Center C 5 Specialized Treatment Facility D 5 Comprehensive Outpatient Rehabilitative Facility E 2 Independent Kidney Disease F 5
Place of Service Paper Claims Electronic Claims Treatment Center Inpatient Psychiatric Facility G 51 Type of Service ( only) Over 21 sed Equipment I Initial Rental nder 21 Modifiers - Service provided as part of SDT Program K-Durable Medical Equipment (DME) item, initial claim, first month's rental -ew Equipment RR-Durable Medical Equipment (DME) Rental -Medicaid Level of Care 1 (defined by state) 2-Medicaid level of Care 2 (defined by state) 3-Medicaid level of care 3 (defined by state) 4-Medicaid level of care 4 (defined by state) 5-Medicaid level of care 5 (defined by state) -sed durable medical equipment (DME) 52-Reduced Services