New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 55 - PROSTHETIC AND ORTHOTIC SERVICES
Subchapter 2 - CENTERS FOR MEDICARE AND MEDICAID SERVICES HEALTHCARE COMMON PROCEDURE CODING SYSTEM HCPCS
Section 10:55-2.3 - HCPCS Procedure Codes and Maximum Fee Allowance Schedule for Orthotic Services
Universal Citation: NJ Admin Code 10:55-2.3
Current through Register Vol. 56, No. 18, September 16, 2024
| HCPCS | Description | Maximum |
|---|---|---|
| Code | Fee | |
| Allowance $ | ||
| (a) ORTHOTIC DEVICES (L0100-L0999) | ||
| 1. SPINAL: CERVICAL | ||
| L0112 | Cranial cervical orthosis, congenital torticollis | 879.82 |
| type, with or without soft interface material, | ||
| adjustable range of motion joint, custom fabricated | ||
| L0113 | Cranial cervical orthosis, tortcollis type, with or | B.R. |
| without joint, with or without soft interface | ||
| material, prefabricated, includes fitting and | ||
| adjustment | ||
| L0120 | Cervical, flexible, nonadjustable (foam collar) | 13.04 |
| L0130 | Cervical, flexible, thermoplastic collar, molded to | 54.40 |
| patient | ||
| L0140 | Cervical, semi-rigid, adjustable (plastic collar) | 24.40 |
| L0150 | Cervical, semi-rigid, adjustable molded chin up | 75.20 |
| (plastic collar with mandibular/occipital piece) | ||
| L0160 | Cervical, semi-rigid, wire frame | 100.00 |
| occipital/mandibular support | ||
| L0170 | Cervical collar, molded to patient model | 300.00 |
| L0172 | Cervical collar, semi-rigid, thermoplastic foam, | 68.34 |
| two piece | ||
| L0174 | Cervical collar, semi-rigid, thermoplastic foam, | 113.90 |
| two piece with thoracic extension | ||
| 2. MULTIPLE POST COLLAR | ||
| L0180 | Cervical, multiple post collar occipital/mandibular | 163.80 |
| supports, adjustable | ||
| L0190 | Cervical, multiple post collar, | 240.00 |
| occipital/mandibular supports, adjustable cervical | ||
| bars (Somi, Guilford, Taylor types) | ||
| L0200 | Cervical, multiple post collar, | 175.00 |
| occipital/mandibular supports, adjustable cervical | ||
| bars, and thoracic extension | ||
| 3. SPINAL: THORACIC | ||
| L0210 | Thoracic rib belt, custom fitted | 13.20 |
| L0220 | Thoracic rib belt, custom fabricated | 24.40 |
| 4. SPINAL: THORACIC-LUMBAR-SACRAL ORTHOSIS (TLSO) | ||
| L0430 | Spinal orthosis, anterior-posterior-lateral | 880.92 |
| control, with interface material, custom fitted | ||
| (Dewall posture protector only) | ||
| L0450 | TLSO, flexible, provides trunk support, upper | 122.58 |
| 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 | ||
| L0452 | TLSO, flexible, provides trunk support, upper | 264.68 |
| 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 | ||
| L0454 | TLSO, flexible, provides trunk support, extends | 220.09 |
| 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 | ||
| L0456 | TLSO, flexible, provides trunk support, thoracic | |
| region, rigid posterior panel and soft anterior apron, | ||
| extends from the sacrococcygeal junction and | 220.96 | |
| terminates just inferior to the scapular spine, | ||
| restricts gross trunk motion in the sagittal plane, | ||
| produces intracavitary pressure to reduce load on the | ||
| intervertebral disks, includes straps and closures, | ||
| prefabricated, includes fitting and adjustment | ||
| L0458 | TLSO, triplanar control, modular segmented spinal | 440.57 |
| 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 xiphoid, soft liner, | ||
| restricts gross trunk motion in the sagittal, coronal, | ||
| and transverse planes, lateral strength is provided by | ||
| overlapping plastic and stabilizing closures, includes | ||
| straps and closures, prefabricated, includes fitting | ||
| and adjustment | ||
| L0460 | TLSO, triplanar control, modular segmented spinal | 440.57 |
| 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, includes | ||
| straps and closures, prefabricated, includes fitting | ||
| and adjustment | ||
| L0462 | TLSO, triplanar control, modular segmented spinal | 440.57 |
| system, three 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, includes | ||
| straps and closures, prefabricated, includes fitting | ||
| and adjustment | ||
| L0464 | TLSO, triplanar control, modular segmented spinal | 437.70 |
| system, four rigid plastic shells, posterior extends | ||
| from sacrococcygeal junction and terminates just | ||
| inferior to scapular spine, anterior extends from | ||
| 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, includes | ||
| straps and closures, prefabricated, includes fitting | ||
| and adjustment | ||
| L0466 | TLSO, sagittal control, rigid posterior frame and | 224.99 |
| flexible soft anterior apron with straps, closures and | ||
| padding, restricts gross trunk motion in sagittal | ||
| plane, produces intracavity pressure to reduce load on | ||
| intervertebral disks, includes fitting and shaping the | ||
| frame, prefabricated, includes fitting and adjustment | ||
| L0468 | TLSO, sagittal-coronal control, rigid posterior | |
| frame and flexible soft anterior apron with straps, | ||
| closures and padding, extends from sacrococcygeal | 276.04 | |
| junction over scapulae, lateral strength provided by | ||
| pelvic, thoracic, and lateral frame pieces, restricts | ||
| gross trunk motion in sagittal, and coronal planes, | ||
| produces intracavitary pressure to reduce load on | ||
| intervertebral disks, includes fitting and shaping the | ||
| frame, prefabricated, includes fitting and adjustment | ||
| L0470 | TLSO, triplanar control, rigid posterior frame and | 447.64 |
| flexible soft anterior apron with straps, closures and | ||
| padding, extends from sacrococcygeal junction to | ||
| scapular, 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 | ||
| L0472 | TLSO, triplanar control, hyperextension, rigid | 291.60 |
| anterior and lateral frame extends from symphysis | ||
| pubis to sternal notch with two anterior components | ||
| (one public 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. | ||
| L0474 | TLSO, triplanar control, rigid posterior frame with | 499.65 |
| flexible soft apron anterior 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 the 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 | ||
| L0480 | TLSO, triplanar control, one piece rigid plastic | 1,035.33 |
| 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 | ||
| L0482 | TLSO, triplanar control, one piece rigid plastic | |
| shell with interface liner, multiple straps and | ||
| closures, posterior extends from sacrococcygeal | 1,153.79 | |
| junction and terminates just inferior to scapular | ||
| spine, anterior extends from symphysis pubis to | ||
| sternal notch, anterior or posterior opening, | ||
| restricts gross trunk motion in sagittal, coronal, and | ||
| transverse planes, includes a carved plaster or | ||
| cad-cam model, custom fabricated | ||
| L0484 | TLSO, triplanar control, two piece rigid plastic | 1,146.26 |
| 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 | ||
| L0486 | TLSO, triplanar control, two piece rigid plastic | 1,218.72 |
| 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 | ||
| L0488 | TLSO, triplanar control, one piece rigid plastic | 895.12 |
| 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 | ||
| L0490 | TLSO, sagittal-coronal control, one piece rigid | 677.26 |
| plastic shell, with overlapping reinforced anterior, | ||
| with multiple straps and closures, posterior extends | ||
| from sacrococcygeal junction and terminates at or | ||
| before the T-9 vertebra, anterior extends from | ||
| symphysis pubis to xiphoid, anterior opening, | ||
| restricts gross trunk motion in sagittal and coronal | ||
| planes, prefabricated, includes fitting and adjustment | ||
| 5. SPINAL: LUMBAR--SACRAL--ORTHOSIS (LSO)--FLEXIBLE | ||
| L0491 | TLSO, sagittal-coronal control, modular segmented | 475.12 |
| spinal system, two rigid plastic shells, posterior | ||
| extends from the sacroccygeal 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 and | ||
| coronal planes, lateral strength is provided by | ||
| overlapping plastic and stabilizing closures, includes | ||
| straps and closures, prefabricated, includes fitting | ||
| and adjustment | ||
| L0492 | TLSO, sagittal-coronal control, modular segmented | |
| spinal system, three rigid plastic shells, posterior | ||
| extends from the sacroccygeal junction and terminates | 312.11 | |
| just inferior to the scapular spine, anterior extends | ||
| from the symphysis pubis to the xiphoid, soft liner, | ||
| restricts gross trunk motion in the sagittal and | ||
| coronal planes, lateral strength is provided by | ||
| overlapping plastic and stabilizing closures, | ||
| prefabricated, includes fitting and adjustment | ||
| 6. SPINAL: SACROILIAC/FLEXIBLE | ||
| L0600 | Sacroiliac, flexible (sacroiliac surgical support), | 40.72 |
| custom fitted | ||
| L0610 | Sacroiliac, flexible (sacroiliac surgical support), | 89.28 |
| custom fabricated | ||
| 7. SEMI-RIGID | ||
| L0620 | Sacroiliac, semi-rigid (Goldthwaite, Osgood types), | 192.00 |
| with apron front | ||
| 8. SPINAL: CERVICAL-THORACIC-LUMBAR-SACRAL-HALO PROCEDURE | ||
| ANTERIOR-POSTERIOR-LATERAL CONTROL | ||
| L0621 | Sacroiliac orthosis, flexible, provides | 57.33 |
| pelvic-sacral support, reduces motion about the | ||
| sacroiliac joint, includes straps, closures, may | ||
| include pendulous abdomen design, may be | ||
| prefabricated, includes fitting and adjustment | ||
| L0622 | Sacroiliac orthosis, flexible, provides | 153.10 |
| pelvic-sacral support, reduces motion about the | ||
| sacroiliac joint, includes straps, closures, may | ||
| include pendulous abdomen design, custom fabricated | ||
| L0623 | Sacroiliac orthosis, provides pelvic-sacral | B.R. |
| support, with rigid or semi-rigid panels over the | ||
| sacrum and abdomen, reduces motion about the | ||
| sacroiliac joint, includes straps, closures, may | ||
| include pendulous abdomen design, prefabricated, | ||
| includes fitting and adjustment | ||
| L0624 | Sacroiliac orthosis, provides pelvic-sacral | B.R. |
| support, with rigid or semi-rigid panels placed over | ||
| the sacrum and abdomen, reduces motion about the | ||
| sacroiliac joint, includes straps, closures, may | ||
| include pendulous abdomen design, custom fabricated | ||
| L0625 | Lumbar orthosis, flexible provides lumbar support, | 34.07 |
| posterior extends from L-1 to below L-5 vertebra, | ||
| produces intracavitary pressure to reduce load on the | ||
| intervertebral discs, includes straps, closures, may | ||
| include pendulous abdomen design, shoulder straps, | ||
| stays prefabricated, includes fitting and adjustments | ||
| L0626 | Lumbar orthosis, sagittal control, with rigid | 48.22 |
| posterior panel(s), posterior extends from L-1 below | ||
| L-5 vertebra, produces intracavitary pressure to | ||
| reduce load on the invertebral discs, includes straps, | ||
| closures, may include padding, stays, shoulder straps, | ||
| pendulous abdomen design, prefabricated, includes | ||
| fitting and adjustment | ||
| L0627 | Lumbar orthosis, sagittal control, with rigid | |
| anterior and posterior panels, posterior extends from | 254.29 | |
| L-1 to below L-5 vertebra, produces intracavitary | ||
| pressure to reduce load on the invertebral discs, | ||
| includes straps, closures, may include padding, | ||
| shoulder straps, pendulous abdomen design, | ||
| prefabricated, includes fitting and adjustment | ||
| L0628 | Lumbar-sacral, flexible provides lumbo-sacral | 51.90 |
| support, posterior extends from sacrococcygeal | ||
| junction to T-9 vertebra, produces intracavitary | ||
| pressure to reduce load on the invertebral discs, | ||
| includes straps, closures, may include stays, shoulder | ||
| straps, pendulous abdomen design, prefabricated, | ||
| includes fitting and adjustment | ||
| L0629 | Lumbar-sacral orthosis, flexible, provides | B.R. |
| lumbo-sacral support, posterior extends from | ||
| sacrococcygeal junction to T-9 vertebra, produces | ||
| intracavitary pressure to reduce load on the | ||
| intervertebral discs, includes straps, closures, may | ||
| include stays, shoulder straps, pendulous abdomen | ||
| design, prefabricated, includes fitting and adjustment | ||
| L0630 | Lumbar-sacral orthosis, sagittal control, with | 100.19 |
| rigid posterior panel(s), posterior extends from | ||
| sacrococcygeal junction to T-9 vertebra, produces | ||
| intracavitary pressure to reduce load on the | ||
| intervertebral discs, includes straps, closures, may | ||
| include padding, stays, shoulder straps, pendulous | ||
| abdomen design, prefabricated, includes fitting and | ||
| adjustment | ||
| L0631 | Lumbar-sacral orthosis sagittal control, with rigid | 635.08 |
| anterior and posterior panels, posterior extends from | ||
| sacroccygeal junction T-9 vertebra, produces | ||
| intracavitary pressure to reduce load on the | ||
| intervertebral discs, includes straps, closures, may | ||
| include padding, shoulder straps, pendulous abdomen | ||
| design, prefabricated includes fitting and adjustment | ||
| L0632 | Lumbar-sacral orthosis sagittal control, with rigid | B.R. |
| anterior and posterior panels, posterior extends from | ||
| sacroccygeal junction T-9 vertebra, produces | ||
| intracavitary pressure to reduce load on the | ||
| intervertebral discs, includes straps, closures, may | ||
| include padding, shoulder straps, pendulous abdomen | ||
| design, prefabricated includes fitting and adjustment | ||
| custom fabricated | ||
| L0633 | Lumbar-sacral orthosis, sagittal-coronal control, | 177.39 |
| with rigid posterior frame/panel(s), posterior extends | ||
| from sacrococcygeal junction to T-9 vertebra, lateral | ||
| strength provided by rigid lateral frame/panels, | ||
| produces intracavitary pressure to reduce load on | ||
| intervertebral discs, includes straps, closures, may | ||
| include padding, stays, shoulder straps, penduloud | ||
| abdomen design, prefabricated, includes fitting and | ||
| adjustment | ||
| L0634 | Lumbar-sacral orthosis, sagittal-coronal, with | |
| rigid posterior frame/panel(s), posterior extends from | B.R. | |
| sacroccygeal junction to T-9 vertebra, lateral | ||
| strength provided by rigid lateral frame/panel(s), | ||
| produces intracavitary pressure to reduce load on | ||
| intervertebral discs, includes straps, closures, may | ||
| include padding, stays, shoulder straps, pendulous | ||
| abdomen design, custom fabricated | ||
| L0635 | Lumbar-sacral orthosis, sagittal-coronal control, | 603.06 |
| lumbar flexion rigid posterior frame/panels, lateral | ||
| articulating design to flex the lumbar spine, | ||
| posterior extends from sacrococcygeal junction T-9 | ||
| vertebra, lateral strength provided by rigid lateral | ||
| frames/panel(s), produces intracavitary pressure to | ||
| reduce load on intervertebral discs, include padding, | ||
| anterior panel, pendulous abdomen design, | ||
| prefabricated, includes fitting and adjustment | ||
| L0636 | Lumbar-sacral orthosis, sagittal-coronal control, | 894.38 |
| lumbar flexion, rigid posterior frames/panels, lateral | ||
| articulating design to flex the lumbar spine, | ||
| posterior extends from sacrococcygeal junction to T-9 | ||
| vertebra, lateral strength provided by rigid lateral | ||
| frame/panels, produces intracavitary pressure to | ||
| reduce load on intervertebral discs, includes straps, | ||
| closures, may include padding, anterior panel, | ||
| pendulous abdomen design, custom fabricated | ||
| L0637 | Lumbar-sacral orthosis, sagittal-coronal, control, | 664.58 |
| lumbarflexion, rigid posterior frame/panels, posterior | ||
| extends from sacrococcygeal junction to T-9 vertebra, | ||
| lateral sacrococcygeal junction to T-9 vertebra, | ||
| lateral, shoulder straps, pendulous abdomen design, | ||
| prefabricated includes fitting and adjustment | ||
| L0638 | Lumbar-sacral orthosis, sagittal-coronal control, | 815.91 |
| with rigid anterior and posterior frames/panels, | ||
| posterior extends from sacrococcygeal junction to T-9 | ||
| vertebra, lateral strength provided by rigid lateral | ||
| frames/panels, produces intracavitary pressure to | ||
| reduce load on intervertebral discs, includes straps, | ||
| closures, may include padding shoulder straps, | ||
| pendulous abdomen design, prefabricated includes | ||
| fitting and adjustment | ||
| L0639 | Lumbar-sacral orthosis, sagittal-coronal control, | 664.58 |
| rigid shell(s)/panel(s), posterior extends from | ||
| sacrococcygeal junction to T-9 vertebra, anterior | ||
| extends from symphysis pubis to xyphoid, produces | ||
| intracavitary pressure to reduce load on the | ||
| intervertebral discs, overall strength is provided by | ||
| overlapping rigid material and stabilizing closures, | ||
| includes straps, closures, may include soft interface, | ||
| pendulous abdomen design, custom prefabricated | ||
| includes fitting and adjustment | ||
| L0640 | Lumbar-sacral orthosis, sagittal-coronal control, | |
| rigid shell(s)/panel(s), posterior extends from | ||
| sacrococcygeal junction to T-9 vertebra, anterior | 647.33 | |
| extends from symphysis pubis to xyphoid, produces | ||
| intracavitary pressure to reduce load on the | ||
| intervertebral discs, overall strength is provided by | ||
| overlapping rigid material and stabilizing closures, | ||
| includes straps, closures, may include soft interface, | ||
| pendulous abdomen design, custom fabricated | ||
| L0700 | Cervical-thoracic-lumbarsacral-orthoses (CTLSO), | 1,160.00 |
| anterior-posterior-lateral-control, molded to patient | ||
| model (Minerva type) | ||
| L0710 | CTLSO, anterior-posterior-lateral-control, molded | 1,280.00 |
| to patient model, with interface material (Minerva | ||
| type) | ||
| 9. HALO PROCEDURE | ||
| L0810 | Halo procedure, cervical halo incorporated into | 1,677.11 |
| jacket vest | ||
| L0820 | Halo procedure, cervical halo incorporated into | 1,200.00 |
| plaster body jacket | ||
| L0830 | Halo procedure, cervical halo incorporated into | 2,053.61 |
| Milwaukee type orthosis | ||
| L0859 | Addition to halo procedure, magnetic resonance | 721.98 |
| image compatible systems, rings and pins, any material | ||
| L0861 | Addition to halo procedure, replacement liner, | 135.48 |
| interface material | ||
| 10. ADDITIONS TO SPINAL ORTHOSES | ||
| L0970 | TLSO, corset front | 33.60 |
| L0972 | LSO, corset front | 69.20 |
| L0974 | TLSO, full corset | 88.20 |
| L0976 | LSO, full corset | 103.88 |
| L0978 | Axillary crutch extension | 35.00 |
| L0980 | Peroneal straps, pair | 11.33 |
| L0982 | Stocking supporter grips, set of four (4) | 9.60 |
| L0984 | Protective body sock, each | 34.12 |
| L0999 | Addition to spinal orthosis, not otherwise | B.R. |
| specified | ||
| (b) ORTHOTIC DEVICES--SCOLIOSIS PROCEDURES (L1000-L1499) | ||
| The orthotic care of scoliosis differs from other care in that the | ||
| treatment is more dynamic in nature and uses ongoing continual modification of | ||
| the orthosis to the patient's changing condition. This coding structure uses | ||
| the proper names or eponyms of the procedures because they have historic and | ||
| universal acceptance in the profession. It should be recognized that | ||
| variations to the basic procedures described by the founders/developers are | ||
| accepted in various medical and orthotic practices throughout the country. All | ||
| procedures include model of patient when indicated. | ||
| 1. SCOLIOSIS: CERVICAL--THORACIC--LUMBAR--SACRAL ORTHOSIS | ||
| (CTLSO) (MILWAUKEE) | ||
| L1000 | Cervical-thoracic-lumbar-sacral orthosis (CTLSO), | 1,134.00 |
| inclusive of furnishing initial orthoses including | ||
| model | ||
| L1001 | Cervical-thoracic-lumbar-sacral orthosis, | B.R. |
| immobilizer, infant size, prefabricated, includes | ||
| fitting and adjustment | ||
| L1005 | Tension based scoliosis orthosis and accessory | 1,990.05 |
| pads, includes fitting and adjustment | ||
| L1010 | Additions to (CTLSO) or scoliosis orthosis, axilla | 44.88 |
| sling | ||
| L1020 | Addition to CTLSO or scoliosis orthosis, kyphosis | 25.00 |
| pad | ||
| L1025 | Addition to CTLSO or scoliosis orthosis, kyphosis | 77.29 |
| pad, floating | ||
| L1030 | Addition to CTLSO or scoliosis orthosis, lumbar | 40.83 |
| bolster pad | ||
| L1040 | Addition to CTLSO or scoliosis orthosis, lumbar or | 39.00 |
| lumbar rib pad | ||
| L1050 | Addition to CTLSO or scoliosis orthosis, sternal | 39.00 |
| pad | ||
| L1060 | Addition to CTLSO or scoliosis orthosis, thoracic | 39.00 |
| pad | ||
| L1070 | Addition to CTLSO or scoliosis orthosis, trapezius | 51.00 |
| sling | ||
| L1080 | Addition to CTLSO or scoliosis orthosis, outrigger | 35.42 |
| L1085 | Addition to CTLSO or scoliosis orthosis, outrigger | 108.45 |
| bilateral with vertical extensions | ||
| L1090 | Addition to CTLSO or scoliosis orthosis, lumbar | 51.00 |
| sling | ||
| L1100 | Addition to CTLSO or scoliosis orthosis, ring | 66.00 |
| flange, plastic or leather | ||
| L1110 | Addition to CTLSO or scoliosis orthosis, ring | 90.00 |
| flange, plastic or leather, molded to patient model | ||
| L1120 | Addition to CTLSO or scoliosis orthosis, cover for | 26.05 |
| upright, each | ||
| 2. SCOLIOSIS: THORACIC--LUMBAR--SACRAL ORTHOSIS (TLSO) (LOW | ||
| PROFILE) | ||
| L1200 | Thoracic-lumbar-sacral-orthosis (TLSO), inclusive | 1,037.53 |
| of furnishing initial orthosis only | ||
| L1210 | Additions to TLSO, (low profile), lateral thoracic | 175.00 |
| extension | ||
| L1220 | Additions to TLSO, (low profile), anterior thoracic | 175.00 |
| extension | ||
| L1230 | Additions to TLSO, (low profile), Milwaukee type | 340.00 |
| superstructure | ||
| L1240 | Additions to TLSO, (low profile), lumbar derotation | 44.75 |
| pad | ||
| L1250 | Addition to TLSO, (low profile), anterior asis pad | 44.75 |
| L1260 | Addition to TLSO, (low profile), anterior thoracic | 44.75 |
| derotation pad | ||
| L1270 | Addition to TLSO, (low profile), abdominal pad | 44.75 |
| L1280 | Addition to TLSO, (low profile), rib gusset | 61.02 |
| (elastic), each | ||
| L1290 | Addition to TLSO, (low profile), lateral | 40.68 |
| trochanteric pad | ||
| 3. OTHER SCOLIOSIS PROCEDURES | ||
| L1300 | Other scoliosis procedure, body jacket molded to | 1,200.00 |
| patient model | ||
| L1310 | Other scoliosis procedure, post-operative body | 1,200.00 |
| jacket | ||
| L1499 | Unlisted procedure for spinal orthosis | B.R. |
| 4. THORACIC--HIP--KNEE--ANKLE ORTHOSIS (THKAO) | ||
| L1500 | Thoracic-hip-knee-ankle orthoses (THKAO), mobility | 1,243.33 |
| frame (Newington, Parapodium types) | ||
| L1510 | THKAO, standing frame | 877.67 |
| L1520 | THKAO, swivel walker | 1,487.44 |
| (c) ORTHOTIC DEVICES--LOWER LIMB (L1600-L2699) | ||
| The procedures in L1600-L2999 are considered as "base" or "basic | ||
| procedures" and may be modified by listing procedures from the "additions" | ||
| sections and adding them to the base procedures. | ||
| 1. LOWER LIMB: HIP--FLEXIBLE | ||
| L1600 | Hip orthoses (HO), abduction control of hip joints, | 40.32 |
| flexible, Frejka type with cover | ||
| L1610 | HO, abduction control of hip joints, flexible, | 25.00 |
| (Frejka cover only) | ||
| L1620 | HO, abduction control of hip joints, flexible, | 75.00 |
| (Pavlik harness) | ||
| L1630 | HO, abduction control of hip joints, semi-flexible | 111.31 |
| (Von Rosen type) | ||
| L1640 | HO, abduction control of hip joints, static, pelvic | 250.00 |
| band or spreader bar, thigh cuffs | ||
| L1650 | HO, abduction control of hip joints, static, | 150.00 |
| adjustable, custom fitted (Ilfled type) | ||
| L1652 | Hip orthosis, bilateral thigh cuffs with adjustable | 224.08 |
| abductor spreader bar, adult size, prefabricated, | ||
| includes fitting and adjustment, any type | ||
| L1660 | HO, abduction control of hip joints, static, | 109.07 |
| plastic, custom fitted | ||
| L1680 | HO, abduction control of hip joints, dynamic, | 802.72 |
| pelvic control, adjustable hip motion control, thigh | ||
| cuffs (Rancho hip action type) | ||
| L1685 | HO, abduction control of hip joints, postoperative | 610.20 |
| hip adduction type, custom fabricated | ||
| L1686 | HO, abduction control of hip joint, postoperative | 600.00 |
| hip abduction type, custom fitted | ||
| L1690 | Combination, bilateral, lumbo-sacral, hip, femur | 1,040.29 |
| orthosis providing adduction and internal rotation | ||
| control | ||
| 2. LOWER LIMB--LEGG PERTHES | ||
| L1700 | Legg Perthes orthosis, (Toronto type) | 996.07 |
| L1710 | Legg Perthes orthosis, (Newington type) | 1,159.26 |
| L1720 | Legg Perthes orthosis, trilateral, (Tachdijan type) | 852.85 |
| L1730 | Legg Perthes orthosis, (Scottish Rite type) | 739.21 |
| L1750 | Legg Perthes orthosis, Legg Perthes sling (Sam | 80.00 |
| Brown | ||
| L1755 | Legg Perthes orthosis, (Patten Bottom type) | 854.40 |
| 3. LOWER LIMB: KNEE | ||
| L1810 | KO, elastic with joints | 61.04 |
| L1820 | KO, elastic with condyle pads and joints | 72.40 |
| L1830 | KO, immobilizer; canvas longitudinal | 52.88 |
| L1831 | KO, Locking knee joint(s), positional orthosis, | 185.00 |
| prefabricated includes fitting and adjustment | ||
| L1832 | KO, adjustable knee joints, positional orthosis, | 320.00 |
| rigid support, custom fitted | ||
| L1834 | KO, without knee joint, rigid, molded to patient | 388.00 |
| model | ||
| L1836 | Knee orthosis, rigid, without joint(s), includes | 83.87 |
| soft interface material, prefabricated, includes | ||
| fitting and adjustment | ||
| L1840 | KO, derotation, medial-lateral, anterior cruciate | 520.00 |
| ligament, custom fabricated to patient model | ||
| L1843 | Knee orthosis (KO); single upright, thigh and calf, | 392.81 |
| with adjustable flexion and extension joint, | ||
| medial-lateral and rotation control, custom fitted | ||
| L1844 | KO, single upright, thigh and calf, with adjustable | 852.38 |
| flexion and extension joint, medial-lateral and | ||
| rotation control, molded to patient model | ||
| L1845 | KO, double upright, thigh and calf, with adjustable | 468.00 |
| flexion and extension joint, medial-lateral and | ||
| rotation control, custom fitted | ||
| L1846 | KO, double upright, thigh and calf, with adjustable | 528.80 |
| flexion and extension joint, medial-lateral and | ||
| rotation control, molded to patient model | ||
| L1847 | Knee orthosis (KO); double upright with adjustable | 309.42 |
| joint, with inflatable air support chamber(s) | ||
| L1850 | KO, Swedish type | 148.00 |
| L1858 | KO, molded plastic, polycentric knee joints, | 610.20 |
| pneumatic knee pads (CTI) | ||
| L1860 | KO, modification of supracondylar prosthetic | 555.68 |
| socket, molded to patient model (SK) | ||
| 4. LOWER LIMB: ANKLE-FOOT | ||
| L1900 | Ankle-foot orthoses (AFO), spring wire, | 158.64 |
| dorsiflexion assist calf band | ||
| L1901 | Ankle orthosis, elastic, prefabricated, includes | 11.13 |
| fitting and adjustment (for example, neoprene, lycra) | ||
| L1902 | AFO, ankle gauntlet, custom fitted | 48.81 |
| L1904 | AFO, molded ankle gauntlet, molded to patient model | 284.76 |
| L1906 | AFO, multiligamentus ankle support | 75.00 |
| L1907 | AFO, Supramalleolar with straps, with or without | 353.71 |
| interface/pads, custom fabricated | ||
| L1910 | AFO, posterior, single bar, clasp attachment to | 192.99 |
| shoe counter | ||
| L1920 | AFO, single upright with static or adjustable stop | 200.00 |
| (Phelps or Perlstein type) | ||
| L1930 | AFO, custom fitted, plastic | 156.80 |
| L1932 | AFO, rigid anterior tibial section, total carbon | 552.04 |
| fiber equal material, prefabricated, includes fitting | ||
| and adjustment | ||
| L1940 | AFO, molded to patient model, plastic | 387.94 |
| L1945 | AFO, molded to patient model, plastic, rigid | 540.00 |
| anterior tibial section (floor reaction) | ||
| L1950 | AFO, spiral, molded to patient model (Irm type), | 593.22 |
| plastic | ||
| L1951 | AFO, spiral, (Institute of Rehabilitative Medicine | 527.61 |
| type), plastic or other material, prefabricated, | ||
| includes fitting and adjustment | ||
| L1960 | AFO, posterior solid ankle, molded to patient | 421.60 |
| model, plastic | ||
| L1970 | AFO, plastic molded to patient model, with ankle | 513.35 |
| joint | ||
| L1971 | AFO, plastic or other material, with ankle joint, | 294.64 |
| prefabricated, includes fitting and adjustment | ||
| L1980 | AFO, single upright free plantar dorsiflexion, | 229.60 |
| solid stirrup, calf band/cuff (single bar "BK" | ||
| orthosis) | ||
| L1990 | AFO, double upright free plantar dorsiflexion, | 287.20 |
| solid stirrup, calf band/cuff (double bar "BK" | ||
| orthosis) | ||
| X4005 | Tone reducing orthoses knee high, custom molded, | 1,121.00 |
| supply by orthotist, each | ||
| X4006 | Tone reducing orthoses ankle high, custom molded, | 350.00 |
| supply by orthotist, each | ||
| X4007 | Swedo ankle orthoses, each | 90.00 |
| X4450 | AFO, posterior leaf spring molded to patient model | 386.40 |
| (Tirr, Rancho) includes casting | ||
| 5. LOWER LIMB: HIP-KNEE-ANKLE-FOOT ORTHOSIS (KAFO)--OR ANY | ||
| COMBINATION | ||
| L2000, L2020, and L2036 are base procedures which may be used with any | ||
| knee joint; L2010 and L2030 shall only be used with no knee joint. | ||
| L2000 | Knee-ankle-foot-orthoses (KAFO), single upright, | 760.00 |
| free knee, free ankle, solid stirrup, thigh and calf | ||
| bands/cuffs (single bar "AK" orthosis) | ||
| L2005 | Knee-ankle-foot-orthosis (KAFO); single or double | 2,534.97 |
| upright, stance control, automatic lock and swing | ||
| phase release, mechanical activation, includes ankle | ||
| joint, any type, custom fabricated | ||
| L2010 | KAFO, single upright, free ankle, solid stirrup, | 568.68 |
| thigh and calf bands/cuffs (single bar "AK" orthosis), | ||
| without knee joint | ||
| L2020 | KAFO, double upright, free knee, free ankle, solid | 786.13 |
| stirrup, thigh and calf bands/cuffs (double bar "AK" | ||
| orthosis) | ||
| L2030 | KAFO, double upright, free ankle, solid stirrup, | 571.20 |
| thigh and calf bands/cuffs (double bar "AK" orthosis), | ||
| without knee joint | ||
| L2034 | Full plastic single upright, with or without free | 1,289.57 |
| motion knee, medial lateral, rotation control, with or | ||
| without free motion ankle, custom fabricated | ||
| L2035 | Knee-ankle-foot-orthosis (KAFO); full plastic, | B.R. |
| static, prefabricated (pediatric size) | ||
| L2036 | KAFO, full plastic, double upright, free knee, | 1,000.00 |
| molded to patient model | ||
| L2037 | KAFO, full plastic, single upright, free knee, | 900.00 |
| molded to patient model | ||
| L2038 | KAFO, full plastic, without knee joint, multiaxis | 900.00 |
| molded to patient model (lively orthosis or equal) | ||
| 6. TORSION CONTROL | ||
| L2040 | Hip-knee-ankle-foot orthosis (HKAFO), torsion | 131.05 |
| control, bilateral rotation straps, pelvic band/belt | ||
| L2050 | HKAFO, torsion control, bilateral torsion cables, | 223.44 |
| hip joint, pelvic band/belt | ||
| L2060 | HKAFO, torsion control, bilateral torsion cables, | 250.00 |
| ball bearing hip joint, pelvic band/belt | ||
| L2070 | HKAFO, torsion control, unilateral rotation straps, | 90.76 |
| pelvic band/belt | ||
| L2080 | HKAFO, torsion control, unilateral torsion cable, | 200.00 |
| hip joint, pelvic band/belt | ||
| L2090 | HKAFO, torsion control, unilateral torsion cable, | 200.00 |
| ball bearing hip joint, pelvic band/belt | ||
| 7. FRACTURE ORTHOSES | ||
| L2106 | AFO, fracture orthosis, tibial fracture cast | 284.76 |
| orthosis, thermoplastic type casting material, molded | ||
| to patient | ||
| L2108 | AFO, fracture orthosis, tibial fracture cast | 569.60 |
| orthosis, molded to patient model | ||
| L2112 | AFO, fracture orthosis, tibial fracture orthosis, | 244.08 |
| soft custom fitted | ||
| L2114 | AFO, fracture orthosis, tibial fracture orthosis, | 321.37 |
| semi-rigid custom fitted | ||
| L2116 | AFO, fracture orthosis, tibial fracture orthosis, | 366.40 |
| rigid custom fitted | ||
| L2126 | KAFO, fracture orthosis, femoral fracture cast | 651.20 |
| orthosis, thermoplastic type casting material, molded | ||
| to patient | ||
| L2128 | KAFO, fracture orthosis, femoral fracture cast, | 895.20 |
| molded to patient model | ||
| L2132 | KAFO, fracture orthosis, femoral fracture cast | 488.16 |
| orthosis, soft custom fitted | ||
| L2134 | KAFO, fracture orthosis, femoral fracture cast | 528.81 |
| orthosis, semi-rigid custom fitted | ||
| L2136 | KAFO, fracture orthosis, femoral fracture cast | 630.40 |
| orthosis, rigid custom fitted | ||
| 8. ADDITIONS TO FRACTURE ORTHOSIS | ||
| L2180 | Addition to lower extremity fracture orthosis, | 53.69 |
| plastic shoe insert with ankle joints | ||
| L2182 | Addition to lower extremity fracture orthosis, drop | 48.80 |
| lock knee joint | ||
| L2184 | Addition to lower extremity fracture orthosis, | 69.16 |
| limited motion knee joint | ||
| L2186 | Addition to lower extremity fracture orthosis, | 101.70 |
| adjustable motion knee joint, Lerman type | ||
| L2188 | Addition to lower extremity fracture orthosis, | 203.40 |
| quadrilateral brim | ||
| L2190 | Addition to lower extremity fracture orthosis, | 48.81 |
| waist belt | ||
| L2192 | Addition to lower extremity fracture orthosis, hip | 203.40 |
| joint pelvic band, thigh flange, and pelvic belt | ||
| 9. ADDITIONS TO LOWER EXTREMITY ORTHOSIS; | ||
| SHOE--ANKLE--SHIN--KNEE | ||
| L2200 | Addition to lower extremity, limited ankle motion, | 30.80 |
| each joint | ||
| L2210 | Addition to lower extremity, dorsiflexion assist | 48.00 |
| (plantar flexion resist), each joint | ||
| L2220 | Addition to lower extremity, dorsiflexion and | 59.65 |
| plantar flexion assist/resist, each joint | ||
| L2230 | Addition to lower extremity, split flat caliper | 49.95 |
| stirrups and plate attachment | ||
| L2232 | Addition to lower extremity orthosis, rocker bottom | 61.57 |
| for total contact ankle foot orthosis, for custom | ||
| fabricated orthosis only | ||
| L2240 | Addition to lower extremity, round caliper and | 54.10 |
| plate attachment | ||
| L2250 | Addition to lower extremity, foot plate, molded to | 234.08 |
| patient model, stirrup attachment | ||
| L2260 | Addition to lower extremity, reinforced solid | 169.83 |
| stirrup (Scott-Craig type) | ||
| L2265 | Addition to lower extremity, long tongue stirrup | 32.00 |
| L2270 | Addition to lower extremity, varus/valgus | 35.03 |
| correction ("T") strap, padded/lined or malleolus pad | ||
| L2275 | Addition to lower extremity, varus/vulgus | 65.71 |
| corrections, plastic modification, padded/lined | ||
| L2280 | Addition to lower extremity, molded inner boot | 105.76 |
| L2300 | Addition to lower extremity, abduction bar | 175.00 |
| (bilateral hip involvement), jointed, adjustable | ||
| L2310 | Addition to lower extremity, abduction bar, | 80.01 |
| straight | ||
| L2320 | Addition to lower extremity, nonmolded lacer | 96.00 |
| L2330 | Addition to lower extremity, lacer molded to | 190.00 |
| patient model | ||
| L2335 | Addition to lower extremity, anterior swing band | 122.04 |
| L2340 | Addition to lower extremity, pretibial shell, | 284.80 |
| molded to patient model | ||
| L2350 | Addition to lower extremity, prosthetic type, (BK) | 447.52 |
| socket, molded to patient model (used for "PTB" "AFO" | ||
| orthoses) | ||
| L2360 | Addition to lower extremity, extended steel shank | 41.16 |
| L2370 | Addition to lower extremity, patten bottom | 164.00 |
| L2375 | Addition to lower extremity, torsion control, ankle | 75.80 |
| joint and half solid stirrup | ||
| L2380 | Addition to lower extremity, torsion control, | 32.00 |
| straight knee joint, each joint | ||
| L2385 | Addition to lower extremity, straight knee joint, | 52.88 |
| heavy duty, each joint | ||
| L2387 | Addition to lower extremity, polycentric knee | 98.08 |
| joint, for custom fabricated knee ankle foot orthosis, | ||
| each joint | ||
| L2390 | Addition to lower extremity, offset knee joint, | 52.88 |
| each joint | ||
| L2395 | Addition to lower extremity, offset knee joint, | 73.60 |
| heavy duty, each joint | ||
| L2397 | Addition to lower extremity orthosis, suspension | 61.53 |
| sleeve | ||
| 10. ADDITIONS TO STRAIGHT KNEE OR OFFSET KNEE JOINTS | ||
| L2405 | Addition to knee joint, drop lock, each joint | 24.80 |
| L2415 | Addition to knee joint, cam lock (Swiss, French | 101.60 |
| Bail types), each joint | ||
| L2425 | Addition to knee joint, disc or dial lock for | 142.00 |
| adjustable knee flexion, each joint | ||
| L2435 | Addition to knee joint, polycentric joint, each | 97.63 |
| joint | ||
| L2492 | Addition to knee joint, lift loop for drop lock | 68.80 |
| ring | ||
| 11. ADDITIONS--THIGH/WEIGHT BEARING--GLUTEAL/ISCHIAL WEIGHT | ||
| BEARING | ||
| L2500 | Addition to lower extremity, thigh/weight bearing, | 117.60 |
| gluteal/ischial weight bearing, ring | ||
| L2510 | Addition to lower extremity, thigh/weight bearing, | 508.81 |
| quadrilateral brim, molded to patient model | ||
| L2520 | Addition to lower extremity, thigh/weight bearing, | 336.00 |
| quadrilateral brim, custom fitted | ||
| L2525 | Addition to lower extremity, thigh/weight bearing, | 660.00 |
| ischial containment/narrow M-L brim molded to patient | ||
| model | ||
| L2526 | Addition to lower extremity, thigh/weight bearing, | 380.00 |
| ischial containment/narrow M-L brim, custom fitted | ||
| L2530 | Addition to lower extremity, thigh/weight bearing, | 146.48 |
| lacer, nonmolded | ||
| L2540 | Addition to lower extremity, thigh/weight bearing, | 196.00 |
| lacer, molded to patient model | ||
| L2550 | Addition to lower extremity, thigh/weight bearing, | 61.04 |
| high roll cuff | ||
| 12. ADDITIONS: PELVIC AND THORACIC CONTROL | ||
| L2570 | Addition to lower extremity, pelvic control, hip | 280.00 |
| joint, clevis type two position joint, each | ||
| L2580 | Addition to lower extremity, pelvic control, pelvic | 240.00 |
| sling | ||
| L2600 | Addition to lower extremity, pelvic control, hip | 108.00 |
| joint, clevis type, or thrust bearing, free, each | ||
| L2610 | Addition to lower extremity, pelvic control, hip | 132.00 |
| joint, clevis or thrust bearing, lock, each | ||
| L2620 | Addition to lower extremity, pelvic control, hip | 160.00 |
| joint, heavy-duty, each | ||
| L2622 | Addition to lower extremity, pelvic control, hip | 170.85 |
| joint, adjustable flexion, each | ||
| L2624 | Addition to lower extremity, pelvic control, hip | 102.40 |
| joint, adjustable flexion, extension, abduction | ||
| control, each | ||
| L2627 | Addition to lower extremity, pelvic control, | 840.00 |
| plastic, molded to patient model, reciprocating hip | ||
| joint and cables | ||
| L2628 | Addition to lower extremity, pelvic control, metal | 840.00 |
| frame, reciprocating hip joint and cables | ||
| L2630 | Addition to lower extremity, pelvic control, band | 166.88 |
| and belt, unilateral | ||
| L2640 | Addition to lower extremity, pelvic control, band | 201.60 |
| and belt, bilateral | ||
| L2650 | Addition to lower extremity, pelvic and thoracic | 86.80 |
| control, gluteal pad, each | ||
| L2660 | Addition to lower extremity, thoracic control, | 18.00 |
| thoracic band | ||
| L2670 | Addition to lower extremity, thoracic control, | 32.00 |
| paraspinal uprights | ||
| L2680 | Addition to lower extremity, thoracic control, | 32.00 |
| lateral support uprights | ||
| (d) ADDITIONS--GENERAL (L2750-L2999) | ||
| L2750 | Addition to lower extremity orthosis, plating | 52.00 |
| chrome or nickel, per bar | ||
| L2755 | High strength, lightweight material, all hybrid | 82.12 |
| lamination/prepeg composite, per segment, for custom | ||
| fabricated orthosis only | ||
| L2760 | Addition to lower extremity orthosis, extension, | 32.00 |
| per extension, per bar (for lineal adjustment for | ||
| growth) | ||
| L2768 | Orthotic side bar disconnect device, per bar | 81.01 |
| L2795 | Addition to lower extremity orthosis, knee control, | 62.21 |
| full kneecap | ||
| L2800 | Addition to lower extremity orthosis, knee control, | 64.80 |
| kneecap, medical or lateral pull | ||
| L2810 | Addition to lower extremity orthosis, knee control, | 54.57 |
| condylar pad | ||
| L2820 | Addition to lower extremity orthosis, soft | 40.68 |
| interface for molded plastic, below knee section | ||
| L2830 | Addition to lower extremity orthosis, soft | 40.68 |
| interface for molded plastic, above knee section | ||
| L2840 | Addition to lower extremity orthosis, tibial length | 28.00 |
| sock, fracture or equal, each | ||
| L2850 | Addition to lower extremity orthosis, femoral | 33.60 |
| length sock, fracture or equal, each | ||
| L2861 | Addition to lower extremity joint, knee or ankle, | B.R. |
| concentric adjustable torsion style mechanism for | ||
| custom fabricated orthotics only, each | ||
| L2999 | Unlisted procedures for lower extremity orthoses | B.R. |
| (e) FOOT, ORTHOPEDIC SHOES MODIFICATIONS, TRANSFERS | ||
| 1. FOOT, INSERTS, REMOVABLE, MOLDED TO PATIENT MODEL | ||
| L3000 | Foot insert, removable, molded to patient model, | 140.00 |
| "UCB" type, Berkeley shell, each | ||
| L3001 | Foot insert, removable, molded to patient model; | 76.00 |
| Spenco, each Qualifier: Custom Spenco device | ||
| L3002 | Foot insert, removable, molded to patient model, | 76.00 |
| Plastazote or equal, each | ||
| L3003 | Foot insert, removable, molded to patient model, | 76.00 |
| silicone gel, each | ||
| L3010 | Foot insert, removable, molded to patient model; | 76.00 |
| longitudinal arch support, each Qualifier: Any custom | ||
| leather/metal device (Example: Schaeffer, Whitman) | ||
| L3020 | Foot insert, removable, molded to patient model; | 88.00 |
| longitudinal/metatarsal support, each Qualifier: Any | ||
| custom leather/plastic device, full foot only | ||
| L3030 | Foot insert, removable, formed to patient foot, | 48.00 |
| each Qualifier: Only off-the-shelf Spenco | ||
| L3031 | Foot, insert/plate, removable, addition to lower | B.R. |
| extremity orthosis, high strength, lightweight | ||
| material, all hybrid lamination/prepreg composite, | ||
| each | ||
| 2. ARCH SUPPORTS, REMOVABLE, PREMOLDED | ||
| L3040 | Foot, arch support, removable, premolded; | 29.60 |
| longitudinal, each Qualifier: Only off-the-shelf | ||
| plastazote | ||
| L3050 | Foot, arch support, removable, premolded | 32.00 |
| metatarsal, each Qualifier: Only off-the-shelf with | ||
| metatarsal or heel pad with no longitudinal control | ||
| L3060 | Foot, arch support, removable, premolded, | 48.00 |
| longitudinal/metatarsal, each Qualifier: Only | ||
| off-the-shelf with longitudinal control | ||
| 3. ARCH SUPPORT, NON-REMOVABLE, ATTACHED TO SHOE | ||
| L3070 | Foot, arch support, nonremovable, attached to shoe, | 16.00 |
| longitudinal, each | ||
| L3080 | Foot, arch support, nonremovable, attached to shoe, | 20.00 |
| metatarsal, each | ||
| L3090 | Foot, arch support, nonremovable, attached to shoe | 24.00 |
| longitudinal/metatarsal, each | ||
| L3100 | Hallus-Valgus night dynamic splint | 20.00 |
| 4. ABDUCTION AND ROTATION BARS | ||
| L3140 | Foot, rotation positioning device, including | 56.00 |
| shoe(s) | ||
| L3150 | Foot, rotation positioning device, without shoe(s) | 60.00 |
| L3160 | Foot, adjustable shoe-style positioning device | B.R. |
| L3170 | Foot, plastic heel stabilizer | 112.00 |
| 5. ORTHOPEDIC FOOTWEAR | ||
| L3201 | Orthopedic shoe, oxford with supinator or pronator, | 48.00 |
| infant | ||
| L3202 | Orthopedic shoe, oxford with supinator or pronator, | 48.00 |
| child | ||
| L3203 | Orthopedic shoe, oxford with supinator or pronator, | 48.00 |
| junior | ||
| L3204 | Orthopedic shoe, hightop with supinator or | 48.00 |
| pronator, infant | ||
| L3206 | Orthopedic shoe, hightop with supinator or | 48.00 |
| pronator, child | ||
| L3207 | Orthopedic shoe, hightop with supinator or | 48.00 |
| pronator, junior | ||
| L3208 | Surgical boot, each infant | 24.00 |
| L3209 | Surgical boot, each child | 24.00 |
| L3211 | Surgical boot, each junior | 24.00 |
| L3212 | Benesch boot, pair, infant | 48.00 |
| L3213 | Benesch boot, pair, child | 48.00 |
| L3214 | Benesch boot, pair, junior | 48.00 |
| L3215 | Orthopedic footwear, ladies shoes, oxford | 76.00 |
| L3216 | Orthopedic footwear, ladies shoes, depth inlay | 100.00 |
| L3217 | Orthopedic footwear, ladies shoes, hightop, depth | 116.00 |
| inlay | ||
| L3219 | Orthopedic footwear, men's shoes, oxford | 76.00 |
| L3221 | Orthopedic footwear, men's shoes, depth inlay | 100.00 |
| L3222 | Orthopedic footwear, men's shoes, hightop, depth | 116.00 |
| inlay | ||
| L3224 | Orthopedic footwear, woman's shoe, oxford, used as | B.R. |
| an integral part of a brace (orthosis) | ||
| L3225 | Orthopedic footwear, man's shoe, oxford, used as an | B.R. |
| integral part of a brace (orthosis) | ||
| L3230 | Orthopedic footwear, custom shoes, depth inlay | 380.00 |
| L3250 | Orthopedic footwear, custom molded shoe, removable | 250.00 |
| inner mold, prosthetic shoe, each | ||
| L3251 | Foot, shoe molded to patient model, silicone shoe, | 280.00 |
| each | ||
| L3252 | Foot, shoe molded to patient model, Plastazote (or | 256.00 |
| similar), custom fabricated, each | ||
| L3253 | Foot, molded shoe Plastazote (or similar), custom | 112.00 |
| fitted, each | ||
| L3254 | Nonstandard size or width | 20.00 |
| L3255 | Nonstandard size or length | 20.00 |
| L3257 | Orthopedic footwear, additional charge for split | 50.00 |
| size | ||
| L3260 | Ambulatory surgical boot, each | 88.00 |
| L3265 | Plastazote sandal, each | 56.00 |
| 6. SHOE MODIFICATION--LIFTS | ||
| L3300 | Lift, elevation, heel, tapered to metatarsals, per | 64.00 |
| inch | ||
| L3310 | Lift, elevation, heel and sole, neoprene, per inch | 64.00 |
| L3320 | Lift, elevation, heel and sole, cork, per inch | 100.00 |
| L3330 | Lift, elevation, metal extension (skate) | 316.00 |
| L3332 | Lift, elevation, inside shoe, tapered, up to | 44.00 |
| one-half inch | ||
| L3334 | Lift, elevation, heel, per inch | 36.00 |
| 7. WEDGES | ||
| L3340 | Heel wedge, Sach | 10.40 |
| L3350 | Heel wedge | 12.00 |
| L3360 | Sole wedge, outside sole | 12.00 |
| L3370 | Sole wedge, between sole | 14.40 |
| L3380 | Clubfoot wedge | 12.00 |
| L3390 | Outflare wedge | 16.00 |
| L3400 | Metatarsal bar wedge, rocker | 16.00 |
| L3410 | Metatarsal bar wedge, between sole | 16.00 |
| L3420 | Full sole and heel wedge, between sole | 24.00 |
| L3430 | Heel, counter, plastic reinforced | 24.00 |
| L3440 | Heel, counter, leather reinforced | 24.00 |
| L3450 | Heel, Sach cushion type | 64.00 |
| L3455 | Heel, new leather, standard | 8.00 |
| L3460 | Heel, new rubber, standard | 8.00 |
| L3465 | Heel, Thomas with wedge | 20.00 |
| L3470 | Heel, Thomas extended to ball | 24.00 |
| L3480 | Heel, pad and depression for spur | 16.00 |
| L3485 | Heel, pad, removable for spur | 32.00 |
| 8. MISCELLANEOUS SHOE ADDITIONS | ||
| L3500 | Miscellaneous shoe addition, insole, leather | 4.00 |
| L3510 | Miscellaneous shoe addition, insole, rubber | 8.00 |
| L3520 | Miscellaneous shoe additions, insole, felt covered | 8.00 |
| with leather | ||
| L3530 | Miscellaneous shoe addition, sole, half | 12.00 |
| L3540 | Miscellaneous shoe addition, sole, full | 36.00 |
| L3550 | Miscellaneous shoe addition, toe tap, standard | 4.00 |
| L3560 | Miscellaneous shoe addition, toe tap, horseshoe | 6.40 |
| L3570 | Miscellaneous shoe addition, special extension to | 152.00 |
| instep (leather with eyelets) | ||
| L3580 | Miscellaneous shoe addition, convert instep to | 13.60 |
| Velcro closure | ||
| L3590 | Miscellaneous shoe addition, convert firm shoe | 28.00 |
| counter to soft counter | ||
| L3595 | Miscellaneous shoe addition, March bar | 12.00 |
| 9. TRANSFER OR REPLACEMENT | ||
| L3600 | Transfer of an orthosis from one shoe to another, | 48.00 |
| caliper plate, existing | ||
| L3610 | Transfer of an orthosis from one shoe to another, | 76.00 |
| caliper plate, new | ||
| L3620 | Transfer of an orthosis from one shoe to another, | 39.04 |
| solid stirrup, existing | ||
| L3630 | Transfer of an orthosis from one shoe to another, | 76.00 |
| solid stirrup, new | ||
| L3640 | Transfer of an orthosis from one shoe to another, | 28.00 |
| Dennis Browne splint (Riveton), both shoes | ||
| L3649 | Unlisted procedures for foot orthopedic shoes, shoe | B.R. |
| modifications and transfers | ||
| (f) ORTHOTIC DEVICES--UPPER LIMB (L3650-L3999) | ||
| Note: The procedures in this section are considered as "base" or "basic | ||
| procedures" and may be modified by listing procedures from the "additions" | ||
| sections and adding them to the base procedure. | ||
| 1. UPPER LIMB: SHOULDER | ||
| L3650 | Shoulder orthosis, (SO), figure of "8" design | 32.00 |
| abduction restrainer | ||
| L3660 | SO, figure of "8" design abduction restrainer, | 60.00 |
| canvas and webbing | ||
| L3670 | SO, acromion/clavicular (canvas and webbing type) | 88.62 |
| L3671 | Shoulder orthosis, shoulder cap design, without | 507.32 |
| joints, may include soft interface, straps, custom | ||
| fabricated, includes fitting and adjustment | ||
| L3672 | Shoulder orthosis, abduction positioning (airplane | 630.88 |
| design), thoracic component and support bar, without | ||
| joints, may include soft interface, straps, custom | ||
| fabricated, includes fitting and adjustment | ||
| L3673 | Shoulder orthosis, abduction positioning (airplane | 687.58 |
| design), thoracic component and support bar, includes | ||
| non torsion joint/turnbuckle, may include soft | ||
| interface, straps, custom fabricated, includes fitting | ||
| and adjustment | ||
| L3675 | Shoulder orthosis, (SO); vest type abduction | 85.92 |
| restrainer, canvas webbing type, or equal | ||
| L3677 | Hard plastic, shoulder stabilizer, prefabricated, | B.R. |
| includes fitting and adjustment | ||
| 2. UPPER LIMB: ELBOW | ||
| L3702 | Elbow orthosis (EO), without joints, may include | 162.57 |
| soft interface, straps, custom fabricated, includes | ||
| fitting and adjustment | ||
| L3710 | EO, elastic with metal joints | 60.00 |
| L3720 | EO, double upright with forearm/arm cuffs, free | 520.00 |
| motion | ||
| L3730 | EO, double upright with forearm/arm cuffs, | 617.71 |
| extension/flexion assist | ||
| L3740 | EO, double upright with forearm/arm cuffs, | 692.08 |
| adjustable position with lock with active control | ||
| L3760 | Elbow orthosis (EO), with adjustable position | 272.89 |
| locking joint(s), prefabricated, includes fitting and | ||
| adjustment | ||
| L3762 | Elbow orthosis, rigid, without joints, includes | 61.51 |
| soft interface material prefabricated, includes | ||
| fitting and adjustment | ||
| 3. UPPER LIMB: WRIST-HAND-FINGER | ||
| L3763 | Elbow wrist hand orthosis; rigid, without joints, | 433.83 |
| may include soft interface, straps, custom fabricated, | ||
| includes fitting and adjustment | ||
| L3764 | Elbow wrist hand orthosis; includes one or more | 545.99 |
| nontorsion joints, elastic bands, turnbuckles, may | ||
| include soft interface, straps, custom fabricated, | ||
| includes fitting and adjustment | ||
| L3765 | Elbow wrist hand finger orthosis, rigid without | 721.91 |
| joints, may include soft interface, straps, custom | ||
| fabricated, includes fitting and adjustment | ||
| L3766 | Elbow wrist hand finger orthosis, includes one or | 764.45 |
| more nontorsion joints, elastic bands, turnbuckles, | ||
| may include soft interface, straps, custom fabricated, | ||
| includes fitting and adjustment | ||
| L3806 | Wrist-hand-finger-orthoses (WHFO); includes one or | 255.75 |
| more nontorsion joint(s), turnbuckles, elastic | ||
| bands/springs, may include soft interface material, | ||
| straps, custom fabricated, includes fitting and | ||
| adjustment | ||
| L3807 | WHFO, extension assist, with inflatable Palmer Air | 135.08 |
| support, with or without thumb extension | ||
| L3808 | Wrist-hand-finger-orthoses (WHFO); rigid without | 228.44 |
| joints, may include soft interface material; straps, | ||
| custom fabricated, includes fitting and adjustment | ||
| 4. ADDITIONS | ||
| L3891 | Addition to upper extremity joint, wrist or elbow, | B.R. |
| concentric adjustable torsion style mechanism for | ||
| custom fabricated orthotics only, each | ||
| 5. DYNAMIC FLEXOR HINGE, RECIPROCAL WRIST EXTENSION/FLEXION, | ||
| FINGER FLEXION/EXTENSION | ||
| L3900 | WHFO, dynamic flexor hinge; reciprocal wrist | 800.00 |
| extension/flexion, finger flexion/extension, wrist or | ||
| finger driven | ||
| L3901 | WHFO, dynamic flexor hinge; reciprocal wrist | 884.00 |
| extension/flexion, finger flexion/extension, cable | ||
| driven | ||
| 6. EXTERNAL POWER | ||
| L3904 | WHFO, external powered, electric | 369.00 |
| L3905 | Wrist hand orthosis, includes one or more | 558.35 |
| nontorsion joints, elastic bands, turnbuckles, may | ||
| include soft interface, straps, custom fabricated, | ||
| includes fitting and adjustment | ||
| 7. OTHER WRIST-HAND-FINGER ORTHOSES--CUSTOM FITTED | ||
| L3906 | WHFO, wrist gauntlet, molded to patient model | 267.41 |
| L3908 | WHFO, wrist extension control cock-up, non-molded | 50.13 |
| L3911 | Wrist hand finger orthosis, elastic, prefabricated, | B.R. |
| includes fitting and adjustment (for example, | ||
| neoprene, lycra) | ||
| L3912 | WHFO, flexion glove with elastic finger control | 67.25 |
| L3913 | Hand finger orthosis, without joints, may include | 152.49 |
| soft interface, straps, custom fabricated, includes | ||
| fitting and adjustment | ||
| L3915 | Wrist-hand orthosis, includes one or more | 299.27 |
| nontorsion joint(s), elastic bands, turnbuckles, may | ||
| include soft interface straps, prefabricated, includes | ||
| fitting and adjustment | ||
| L3917 | Hand orthosis, metacarpal fracture orthosis, | 22.26 |
| prefabricated, includes fitting and adjustment | ||
| 8. UPPER LIMB: SHOULDER-ELBOW-WRIST-HAND ABDUCTION | ||
| POSITIONING--CUSTOM FITTED | ||
| L3960 | Shoulder-elbow-wrist-hand orthosis (SEWHO), | 460.00 |
| abduction positioning, airplane design | ||
| L3961 | SEWHO, shoulder cap design, without joints, may | 945.92 |
| include soft interface, straps, custom fabricated, | ||
| includes fitting and adjustment | ||
| L3962 | SEWHO, abduction positioning, Erbs Palsey design | 420.00 |
| L3963 | SEWHO, molded shoulder, arm, forearm, and wrist, | 847.70 |
| with articulating elbow joint | ||
| L3964 | SEWHO, mobile arm support attached to wheelchair, | 520.00 |
| balanced and fitted to patient, adjustable | ||
| L3965 | SEWHO, radial arm support attached to wheelchair, | 759.66 |
| balanced and fitted to patient, adjustable rancho type | ||
| L3966 | SEWHO, mobile arm support attached to wheelchair, | 488.00 |
| balanced and fitted to patient, reclining | ||
| L3967 | SEWHO, abduction positioning (airplane design), | 1,116.82 |
| thoracic component and support bar, without joints, | ||
| may include soft interface, straps, custom fabricated, | ||
| includes fitting and adjustment | ||
| L3968 | SEWHO, mobile arm support attached to wheelchair, | 680.00 |
| balanced and fitted to patient, friction arm support | ||
| (friction dampening to proximal and distal joints) | ||
| L3969 | SEWHO, mobile arm support, monosuspension arm and | 417.06 |
| hand support, overhead elbow forearm hand sling | ||
| support, yoke type arm suspension support | ||
| 9. ADDITIONS TO MOBILE ARM SUPPORTS | ||
| L3970 | SEWHO, addition to mobile arm support, elevating | 200.00 |
| proximal arm | ||
| L3971 | SEWHO, shoulder cap design, includes one or more | 1,060.12 |
| nontorsion joints, elastic bands, turnbuckles, may | ||
| include soft interface, straps, custom fabricated, | ||
| includes fitting and adjustment | ||
| L3972 | SEWHO, addition to mobile arm support, offset or | 112.00 |
| lateral rocker arm with elastic balance control | ||
| L3973 | SEWHO, abduction positioning (airplane design), | 1,116.82 |
| thoracic component and support bar, includes one or | ||
| more nontorsion joints, elastic bands, turnbuckles, | ||
| may include soft interface, straps, custom fabricated, | ||
| includes fitting and adjustment | ||
| L3974 | SEWHO, addition to mobile arm support, supinator | 112.00 |
| L3975 | SEWHO, without joints, may include soft interface, | 945.92 |
| straps, custom fabricated, includes fitting and | ||
| adjustment | ||
| L3976 | SEWHO, abduction positioning (airplane design), | 945.92 |
| thoracic component and support bar, without joints, | ||
| may include soft interface, straps, custom fabricated, | ||
| includes fitting and adjustment | ||
| L3977 | SEWHO, shoulder cap design, includes one or more | 1,060.12 |
| nontorsion joints, elastic bands, turnbuckles, may | ||
| include soft interface, straps, custom fabricated, | ||
| includes fitting and adjustment | ||
| L3978 | SEWHO, abduction positioning (airplane design), | 1,116.82 |
| thoracic component and support bar, includes one or | ||
| more nontorsion joints, elastic bands, turnbuckles, | ||
| may include soft interface, straps, custom fabricated, | ||
| includes fitting and adjustment | ||
| 10. UPPER LIMB--FRACTURE ORTHOSIS | ||
| L3980 | Upper extremity fracture orthosis, humeral | 163.17 |
| L3982 | Upper extremity fracture orthosis, radius/ulnar | 172.00 |
| L3984 | Upper extremity fracture orthosis, wrist | 122.40 |
| L3995 | Addition to upper extremity orthosis, sock, | 14.80 |
| fracture or equal, each | ||
| L3999 | Unlisted procedures for upper limb orthosis | B.R. |
| (g) SPECIFIC REPAIR (L4000-L4199) | ||
| L4000 | Replace girdle for Milwaukee orthosis | 696.00 |
| L4002 | Replacement strap, any orthosis, includes all | 18.00 |
| components, any length, any type | ||
| L4010 | Replace trilateral socket brim | 444.59 |
| L4020 | Replace quadrilateral socket brim, molded to | 532.00 |
| patient model | ||
| L4030 | Replace quadrilateral socket brim, custom fitted | 373.06 |
| L4040 | Replace molded thigh lacer | 272.53 |
| L4045 | Replace nonmolded thigh lacer | 140.00 |
| L4050 | Replace molded calf lacer | 331.80 |
| L4055 | Replace nonmolded calf lacer | 61.02 |
| L4060 | Replace high roll cuff | 136.00 |
| L4070 | Replace proximal and distal upright for KAFO | 168.00 |
| L4080 | Replace metal bands KAFO, proximal thigh | 72.00 |
| L4090 | Replace metal bands KAFO-AFO, calf or distal thigh | 60.00 |
| L4100 | Replace leather cuff KAFO, proximal thigh | 80.00 |
| L4110 | Replace leather cuff KAFO-AFO, calf or distal thigh | 52.00 |
| L4130 | Replace pretibial shell | 331.45 |
| (h) REPAIRS (L4200-L4299) | ||
| L4205 | Repair of orthotic device, quarter-hour rate | 10.60 |
| L4210 | Repair of orthotic device, repair or replace minor | 69.00 |
| parts | ||
| (i) ANCILLARY ORTHOTIC SERVICES (L4300-L4399 AND X3680) | ||
| L4350 | Pneumatic ankle control splint (for example, | 52.00 |
| aircast) | ||
| L4360 | Pneumatic walking splint (for example, aircast) | 160.00 |
| L4370 | Pneumatic full leg splint (for example, aircast) | 88.00 |
| L4380 | Pneumatic knee splint (for example, aircast) | 56.00 |
| L4386 | Non-pneumatic walking splint, with or without | 99.66 |
| joints, prefabricated, includes fitting and adjustment | ||
| L4392 | Replace soft interface material, ankle contracture | 13.56 |
| splint | ||
| L4394 | Replace soft interface material, foot drop splint | 9.90 |
| L4396 | Ankle contracture splint | 96.67 |
| L4398 | Foot drop splint, recumbent positioning device | 44.52 |
| X3680 | Travel time per round trip, per day | 40.72 |
Disclaimer: These regulations may not be the most recent version. New Jersey may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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