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 10:55-2.4 - HCPCS Procedure Codes and Maximum Fee Allowance Schedule for Prosthetic Services
Universal Citation: NJ Admin Code 10:55-2.4
Current through Register Vol. 56, No. 18, September 16, 2024
| HCPCS | Description | Maximum |
|---|---|---|
| Code | Fee | |
| Allowance $ | ||
| (a) PROSTHETIC PROCEDURES--LOWER LIMB (L5000-L5999) | ||
| The procedures in this section are considered as "base" or "basic | ||
| procedures" and may be modified by listing items/procedures or special | ||
| material from the "additions" section and adding them to the base procedure. | ||
| 1. PARTIAL FOOT | ||
| L5000 | Partial foot, shoe insert with longitudinal arch, | 339.53 |
| toe filler | ||
| L5010 | Partial foot, molded socket, ankle height, with | 680.00 |
| toe filler | ||
| L5020 | Partial foot, molded socket, tibial tubercle | 1,040.00 |
| height, with toe filler | ||
| 2. ANKLE | ||
| L5050 | Ankle, Syme, molded socket, Sach foot | 1,360.00 |
| L5060 | Ankle, Syme, metal frame, molded leather socket, | 2,000.00 |
| articulated ankle/foot | ||
| 3. BELOW KNEE | ||
| L5100 | Below knee, molded socket, shin, Sach foot | 1,036.56 |
| L5105 | Below knee, plastic socket, joints and thigh | 2,000.00 |
| lacer, Sach foot | ||
| 4. KNEE DISARTICULATION | ||
| L5150 | Knee disarticulation (or through knee), molded | 2,500.00 |
| socket, external knee joints, shin, Sach foot | ||
| L5160 | Knee disarticulation (or through knee), molded | 2,683.30 |
| socket, bent knee configuration, external knee | ||
| joints, shin, Sach foot | ||
| 5. ABOVE KNEE | ||
| L5200 | Above knee, molded socket, single axis constant | 1,301.76 |
| friction knee, shin, Sach foot | ||
| L5210 | Above knee, short prosthesis, no knee joint | 1,360.00 |
| ("stubbies"), with foot blocks, no ankle joints, each | ||
| L5220 | Above knee, short prosthesis, no knee joint | 1,680.00 |
| ("stubbies"), with articulated ankle/foot, | ||
| dynamically aligned, each | ||
| L5230 | Above knee, for proximal femoral focal deficiency, | 1,607.20 |
| constant friction knee, shin, Sach foot | ||
| 6. HIP DISARTICULATION | ||
| L5250 | Hip disarticulation, Canadian type; molded socket, | 3,040.00 |
| hip joint, single axis constant friction knee, shin | ||
| Sach foot | ||
| L5270 | Hip disarticulation, tilt table type, molded | 3,040.00 |
| socket, locking hip joint, single axis constant | ||
| friction knee, shin, Sach foot | ||
| 7. HEMIPELVECTOMY | ||
| L5280 | Hemipelvectomy, Canadian type; molded socket, hip | 3,440.00 |
| joint, single axis constant friction knee, shin, Sach | ||
| foot | ||
| 8. ENDOSKELETAL: BELOW KNEE | ||
| L5301 | Below knee, molded socket, shin, each foot | 1,379.04 |
| endoskeletal system | ||
| 9. ENDOSKELETAL: KNEE DISARTICULATION | ||
| L5311 | Knee disarticulation (or through knee), molded | 2,129.46 |
| socket, external knee joints, shin, Sach foot, | ||
| endoskeletal system | ||
| 10. ENDOSKELETAL: ABOVE KNEE | ||
| L5321 | Above knee, molded socket, open end, Sach foot, | 2,085.72 |
| endoskeletal system, single axis knee | ||
| 11. ENDOSKELETAL: HIP DISARTICULATION | ||
| L5331 | Hip disarticulation, Canadian type, molded socket, | 2,951.37 |
| endoskeletal system, hip joint, single axis knee, | ||
| each foot | ||
| 12. ENDOSKELETAL: HEMIPELVECTOMY | ||
| L5341 | Hemipelvectomy, Canadian type, molded socket, | 3,231.24 |
| endoskeletal system, hip joint, single axis knee, | ||
| each foot | ||
| 13. IMMEDIATE POSTSURGICAL OR EARLY FITTING PROCEDURES | ||
| L5400 | Immediate postsurgical or early fitting, | 844.78 |
| application of initial rigid dressing, including | ||
| fitting, alignment, suspension, and one cast change, | ||
| below knee | ||
| L5410 | Immediate postsurgical or early fitting, | 328.42 |
| application of initial rigid dressing, including | ||
| fitting, alignment and suspension, below knee, each | ||
| additional cast change and realignment | ||
| L5420 | Immediate postsurgical or early fitting, | 1,070.47 |
| application of initial rigid dressing, including | ||
| fitting, alignment and suspension and one cast change | ||
| "AK" or knee disarticulation | ||
| L5430 | Immediate postsurgical or early fitting, | 461.40 |
| application of initial rigid dressing, including | ||
| fitting, alignment and suspension, "AK" or knee | ||
| disarticulation, each additional cast change and | ||
| realignment | ||
| L5450 | Immediate postsurgical or early fitting, | 200.00 |
| application of nonweight bearing rigid dressing, | ||
| below knee | ||
| L5460 | Immediate postsurgical or early fitting, | 240.00 |
| application of nonweight bearing rigid dressing, | ||
| above knee | ||
| 14. INITIAL PROSTHESIS | ||
| L5500 | Initial, below knee "PTB" type socket, "USMC" or | 726.60 |
| equal pylon, no cover, Sach foot, plaster socket, | ||
| direct formed | ||
| L5505 | Initial, above knee--knee disarticulation, ischial | 980.00 |
| level socket, "USMC" or equal pylon, no cover, Sach | ||
| foot plaster socket, direct formed | ||
| 15. PREPARATORY PROSTHESIS | ||
| L5510 | Preparatory, below knee "PTB" type socket, "USMC" | 726.60 |
| or equal pylon, no cover, Sach foot, plaster socket, | ||
| molded to model | ||
| L5520 | Preparatory, below knee "PTB" type socket, "USMC" | 960.00 |
| or equal pylon, no cover, Sach foot, thermoplastic or | ||
| equal, direct formed | ||
| L5530 | Preparatory, below knee "PTB" type socket, "USMC" | 1,120.00 |
| or equal pylon, no cover, Sach foot, thermoplastic or | ||
| equal, molded to model | ||
| L5535 | Preparatory, below knee "PTB" type socket, "USMC" | 1,000.00 |
| or equal pylon, no cover, Sach foot, prefabricated, | ||
| adjustable open end socket | ||
| L5540 | Preparatory, below knee "PTB" type socket, "USMC" | 1,146.60 |
| or equal pylon, no cover, Sach foot, laminated | ||
| socket, molded to model | ||
| L5560 | Preparatory, above knee--knee disarticulation, | 1,120.00 |
| ischial level socket, "USMC" or equal pylon, no | ||
| cover, Sach foot, plaster socket, molded to model | ||
| L5570 | Preparatory, above knee--knee disarticulation, | 1,200.00 |
| ischial level socket, "USMC" or equal pylon, no | ||
| cover, Sach foot, thermoplastic or equal, direct | ||
| formed | ||
| L5580 | Preparatory, above knee--knee disarticulation, | 1,320.00 |
| ischial level socket, "USMC" or equal pylon, no cover | ||
| Sach foot, thermoplastic or equal, molded to model | ||
| L5585 | Preparatory, above knee--knee disarticulation, | 1,248.88 |
| ischial level socket, "USMC" or equal pylon, no | ||
| cover, Sach foot, prefabricated adjustable open end | ||
| socket | ||
| L5590 | Preparatory, above knee--knee disarticulation, | 1,499.40 |
| ischial level socket, "USMC" or equal pylon, no | ||
| cover, Sach foot, laminated socket, molded to model | ||
| L5595 | Preparatory, hip disarticulation-hemipelvectomy, | 2,120.00 |
| pylon, no cover, Sach foot, thermoplastic or equal, | ||
| molded to patient model | ||
| 16. ADDITIONS TO LOWER EXTREMITY | ||
| L5600 | Preparatory, hip disarticulation-hemipelvectomy, | 2,240.00 |
| pylon, no cover, Sach foot, laminated socket, molded | ||
| to patient model | ||
| L5610 | Addition to lower extremity, above knee, | 1,454.31 |
| hydracadence system | ||
| L5611 | Addition to lower extremity, above knee--knee | 768.00 |
| disarticulation, 4-bar linkage, with friction swing | ||
| phase control | ||
| L5613 | Addition to lower extremity, above knee--knee | 1,240.00 |
| disarticulation, 4-bar linkage, with hydraulic swing | ||
| phase control | ||
| L5614 | Addition to lower extremity, above knee--knee | 2,307.16 |
| disarticulation, 4-bar linkage, with pneumatic swing | ||
| phase control | ||
| L5616 | Additions to lower extremity, above knee, | 720.00 |
| universal multiplex system, friction swing phase | ||
| control | ||
| L5617 | Addition to lower extremity, quick self-aligning | 320.52 |
| unit, above knee or below knee, each | ||
| 17. ADDITIONS: TEST SOCKETS | ||
| L5618 | Addition to lower extremity, test socket, Symes | 160.00 |
| L5620 | Addition to lower extremity, test socket, below | 208.63 |
| knee | ||
| L5622 | Addition to lower extremity, test socket, knee | 264.00 |
| disarticulation | ||
| L5624 | Addition to lower extremity, test socket, above | 240.00 |
| knee | ||
| L5626 | Addition to lower extremity, test socket, hip | 300.00 |
| disarticulation | ||
| L5628 | Addition to lower extremity, test socket, | 340.00 |
| hemipelvectomy | ||
| L5629 | Addition to lower extremity, below knee, acrylic | 289.07 |
| socket | ||
| 18. ADDITIONS: SOCKET VARIATIONS | ||
| L5630 | Addition to lower extremity, Symes type, | 280.00 |
| expandable wall socket | ||
| L5631 | Addition to lower extremity, above knee or knee | 320.00 |
| disarticulation, acrylic socket | ||
| L5632 | Addition to lower extremity, Symes type, "PTB" | 180.02 |
| brim design socket | ||
| L5634 | Addition to lower extremity, Symes type, posterior | 231.74 |
| opening (Canadian) socket | ||
| L5636 | Addition to lower extremity, Symes type, medial | 196.85 |
| opening socket | ||
| L5637 | Addition to lower extremity, below knee, total | 160.00 |
| contact | ||
| L5638 | Addition to lower extremity, below knee, leather | 320.00 |
| socket | ||
| L5639 | Addition to lower extremity, below knee, wood | 600.00 |
| socket | ||
| L5640 | Addition to lower extremity, knee disarticulation, | 400.00 |
| leather socket | ||
| L5642 | Addition to lower extremity, above knee, leather | 400.00 |
| socket | ||
| L5643 | Addition to lower extremity, hip disarticulation, | 691.20 |
| flexible inner socket, external frame | ||
| L5644 | Addition to lower extremity, above knee, wood | 400.00 |
| socket | ||
| L5645 | Addition to lower extremity, below knee, flexible | 325.44 |
| inner socket, external frame | ||
| L5646 | Addition to lower extremity, below knee, air | 260.00 |
| cushion socket | ||
| L5647 | Addition to lower extremity, below knee, suction | 223.74 |
| socket | ||
| L5648 | Addition to lower extremity, above knee, air | 300.00 |
| cushion socket | ||
| L5649 | Addition to lower extremity, ischial | 1,354.99 |
| containment/narrow M-L socket | ||
| L5650 | Addition to lower extremity, total contact, above | 354.91 |
| knee or knee disarticulation socket | ||
| L5651 | Addition to lower extremity, above knee, flexible | 528.84 |
| inner socket, external frame | ||
| L5652 | Addition to lower extremity, suction suspension, | 310.53 |
| above knee or knee disarticulation socket | ||
| L5653 | Addition to lower extremity, knee disarticulation, | 408.96 |
| expandable wall socket | ||
| 19. ADDITIONS SOCKET INSERT AND SUSPENSION | ||
| L5654 | Addition to lower extremity, socket insert, Symes | 231.71 |
| (Kemblo, Pelite, Aliplast, Plastazote or equal) | ||
| L5655 | Addition to lower extremity, socket insert, below | 184.80 |
| knee (Kemblo, Pelite, Aliplast, Plastazote or equal) | ||
| L5656 | Addition to lower extremity, socket insert, knee | 273.00 |
| disarticulation (Kemblo, Pelite, Aliplast, Plastazote | ||
| or equal) | ||
| L5658 | Addition to lower extremity, socket insert, above | 259.38 |
| knee (Kemblo, Pelite, Aliplast, Plastazote or equal) | ||
| L5661 | Addition to lower extremity, socket insert, | 438.84 |
| multi-durometer, Symes | ||
| L5665 | Addition to lower extremity, socket insert, | 223.74 |
| multidurometer, below knee | ||
| L5666 | Addition to lower extremity, below knee, cuff | 40.72 |
| suspension | ||
| L5668 | Addition to lower extremity, below knee, molded | 77.53 |
| distal cushion | ||
| L5670 | Addition to lower extremity, below knee, molded | 199.00 |
| supracondylar suspension ("PTS" or similar) | ||
| L5671 | Addition to lower extremity: below knee, molded | 315.64 |
| supracondylar suspension ("PTS" or similar) | ||
| L5672 | Addition to lower extremity, below knee, removable | 220.00 |
| medial brim suspension | ||
| L5673 | Addition to lower extremity, below knee/above | 506.15 |
| knee, custom fabricated from existing mold or | ||
| prefabricated, socket insert, silicone gel, | ||
| elastomeric or equal, for use with locking mechanisms | ||
| L5676 | Addition to lower extremity, below knee, knee | 178.96 |
| joints, single axis, pair | ||
| L5677 | Addition to lower extremity, below knee, knee | 203.40 |
| joints, polycentric, pair | ||
| L5678 | Addition to lower extremity, below knee joint | 20.00 |
| covers, pair | ||
| L5679 | Addition to lower extremity, below knee/above | 421.77 |
| knee, custom fabricated from existing mold or | ||
| prefabricated, socket insert, silicone gel, | ||
| elastomeric or equal, not for use with locking | ||
| mechanism | ||
| L5680 | Addition to lower extremity, below knee, thigh | 172.88 |
| lacer, nonmolded | ||
| L5681 | Addition to lower extremity, below knee/above | 828.47 |
| knee, custom fabricated socket insert for congenital | ||
| or atypical traumatic amputee, silicone gel | ||
| elastomeric or equal, for use with or without locking | ||
| mechanism, initial only (for other than initial, use | ||
| code L5673 or L5679) | ||
| L5682 | Addition to lower extremity, below knee, thigh | 420.00 |
| lacer, gluteal/ischial, molded | ||
| L5683 | Addition to lower extremity, below knee/above | 828.47 |
| knee, custom fabricated socket insert for other than | ||
| congenital or atypical traumatic amputee, silicone | ||
| gel elastomeric or equal, for use with or without | ||
| locking mechanism, initial only (for other than | ||
| initial, use code L5673 or L5679) | ||
| L5684 | Addition to lower extremity, below knee, fork | 32.56 |
| strap | ||
| L5685 | Addition to lower extremity prosthesis, below | 79.39 |
| knee, suspension/sealing sleeve, with or without | ||
| valve, any material, each | ||
| L5686 | Addition to lower extremity, below knee, back | 32.00 |
| check (extension control) | ||
| L5688 | Addition to lower extremity, below knee, waist | 40.72 |
| belt, webbing | ||
| L5690 | Addition to lower extremity, below knee, waist | 71.62 |
| belt, padded and lined | ||
| L5692 | Addition to lower extremity, above knee, pelvic | 69.20 |
| control belt, light | ||
| L5694 | Addition to lower extremity, above knee, pelvic | 125.53 |
| control belt, padded and lined | ||
| L5695 | Addition to lower extremity, below knee, pelvic | 100.00 |
| control, sleeve suspension, neoprene or equal, Sach | ||
| L5696 | Addition to lower extremity, above knee or knee | 140.00 |
| disarticulation, pelvic joint | ||
| L5697 | Addition to lower extremity, above knee or knee | 32.56 |
| disarticulation, pelvic band | ||
| L5698 | Addition to lower extremity, above knee or knee | 72.40 |
| disarticulation, silesian bandage | ||
| L5699 | All lower extremity prostheses, shoulder harness | 113.40 |
| 20. REPLACEMENTS/ADDITIONS: EXOSKELETAL KNEE-SHIN SYSTEM | ||
| L5700 | Replacement, socket, below knee, molded to patient | 1,549.30 |
| model | ||
| L5701 | Replacement, socket, above knee-knee | 1,922.04 |
| disarticulation, including attachment plate, molded | ||
| to patient model | ||
| L5702 | Replacement, socket, hip disarticulation, | 2,422.44 |
| including hip joint, molded to patient model | ||
| L5703 | Ankle, symes, molded to patient model, socket | 1,468.67 |
| without solid ankle cushion heel (Sach) foot, | ||
| replacement only | ||
| L5704 | Replacement, custom shaped protective cover, below | 315.89 |
| knee | ||
| L5705 | Replacement, custom shaped protective cover, above | 579.14 |
| knee | ||
| L5706 | Replacement, custom shaped protective cover, knee | 564.88 |
| disarticulation | ||
| L5707 | Replacement, custom shaped protective cover, hip | 758.92 |
| disarticulation | ||
| L5710 | Addition, exoskeletal knee-shin system, single | 174.96 |
| axis, manual lock | ||
| L5711 | Addition, exoskeletal knee-shin system, single | 284.80 |
| axis, manual lock, ultra-light material | ||
| L5712 | Addition, exoskeletal knee-shin system, single | 252.00 |
| axis, friction swing and stance phase control (safety | ||
| knee) | ||
| L5714 | Addition, exoskeletal knee-shin system, single | 280.00 |
| axis, variable friction swing phase control (safety | ||
| knee) | ||
| L5716 | Addition, exoskeletal knee-shin system, | 420.00 |
| polycentric, mechanical stance phase lock | ||
| L5718 | Addition, exoskeletal knee-shin system, | 420.00 |
| polycentric, friction swing and stance phase control | ||
| L5722 | Addition, exoskeletal knee-shin system, single | 633.19 |
| axis, pneumatic swing, friction stance phase control | ||
| L5724 | Addition, exoskeletal knee-shin system, single | 880.00 |
| axis, fluid swing phase control | ||
| L5726 | Addition, exoskeletal knee-shin system, single | 1,000.00 |
| axis, external joints fluid swing phase control | ||
| L5728 | Addition, exoskeletal knee-shin system, single | 1,540.00 |
| axis, fluid swing and stance phase control | ||
| L5780 | Addition, exoskeletal knee-shin system, single | 600.00 |
| axis, pneumatic/hydra pneumatic swing phase control | ||
| L5781 | Addition to lower limb prosthesis, vacuum pump, | 2,520.06 |
| residual limb volume management and moisture | ||
| evacuation system | ||
| L5782 | Addition to lower limb prosthesis, vacuum pump, | B.R. |
| residual limb volume management and moisture | ||
| evacuation system, heavy duty | ||
| 21. COMPONENT MODIFICATION | ||
| L5785 | Addition, exoskeletal system, below knee, | 203.40 |
| ultra-light material (titanium, carbon fiber or | ||
| equal) | ||
| L5790 | Addition, exoskeletal system, above knee, | 305.10 |
| ultra-light material (titanium, carbon fiber or | ||
| equal) | ||
| L5795 | Addition, exoskeletal system, hip disarticulation, | 406.80 |
| ultra-light material (titanium, carbon fiber or | ||
| equal) | ||
| 22. ENDOSKELETAL | ||
| L5810 | Addition, endoskeletal knee-shin system, single | 264.62 |
| axis, manual lock | ||
| L5811 | Addition, endoskeletal knee-shin system, single | 325.44 |
| axis, manual lock, ultra-light material | ||
| L5812 | Addition, endoskeletal knee-shin system, single | 284.80 |
| axis, friction swing and stance phase control (safety | ||
| knee) | ||
| L5814 | Addition, endoskeletal knee-shin system, | 400.00 |
| polycentric; hydraulic swing phase control, | ||
| mechanical stance phase lock | ||
| L5816 | Addition, endoskeletal knee-shin system, | 386.46 |
| polycentric, mechanical stance phase lock | ||
| L5818 | Addition, endoskeletal knee-shin system, | 552.00 |
| polycentric, friction swing and stance phase control | ||
| L5822 | Addition, endoskeletal knee-shin system, single | 1,120.00 |
| axis, pneumatic swing, friction stance phase control | ||
| L5824 | Addition, endoskeletal knee-shin system, single | 610.20 |
| axis, fluid swing phase control | ||
| L5826 | Addition, endoskeletal knee-shin system, single | B.R. |
| axis; hydraulic swing phase control, with miniature | ||
| high activity frame. | ||
| L5828 | Addition, endoskeletal knee-shin system, single | 1,440.00 |
| axis, fluid swing and stance phase control | ||
| L5830 | Addition, endoskeletal knee-shin system, single | 1,076.00 |
| axis, pneumatic/swing phase control | ||
| L5840 | Addition, endoskeletal knee-shin system, | 1,262.80 |
| multi-axial, pneumatic/swing phase control | ||
| L5845 | Addition, endoskeletal, knee-shin system, stance | 2,211.66 |
| flexion feature, adjustable | ||
| L5848 | Addition to endoskeletal, knee-shin system, | 677.28 |
| hydraulic stance extension, dampening feature, | ||
| adjustable | ||
| L5850 | Addition, endoskeletal system, above knee or hip | 64.80 |
| disarticulation, knee extension assist | ||
| L5855 | Addition, endoskeletal system, hip | 171.52 |
| disarticulation, mechanical hip extension assist | ||
| L5856 | Addition to lower extremity prosthesis, | 15,188.22 |
| endoskeletal knee-shin system, microprocessor control | ||
| feature, swing and stance phase includes electronic | ||
| sensor(s), any type | ||
| L5857 | Addition to lower extremity prosthesis, | 5,347.34 |
| endoskeletal knee-shin system, microprocessor control | ||
| feature, swing phase only, includes electronic | ||
| sensor(s), any type | ||
| L5858 | Addition to lower extremity prosthesis, | 11,519.80 |
| endoskeletal knee shin system, microprocessor control | ||
| feature, stance phase only, includes electronic | ||
| sensor(s), any type | ||
| L5910 | Addition, endoskeletal system, below knee, | 280.25 |
| alignable system | ||
| L5920 | Addition, endoskeletal system, above knee or hip | 252.00 |
| disarticulation, alignable system | ||
| L5925 | Addition, endoskeletal system, above knee, knee | 186.61 |
| disarticulation or hip disarticulation, manual lock | ||
| L5930 | Addition, endoskeletal system, high activity knee | 1,928.18 |
| control frame | ||
| L5940 | Addition, endoskeletal system, below knee, | 224.00 |
| ultra-light material (titanium, carbon fiber or | ||
| equal) | ||
| L5950 | Addition, endoskeletal system, above knee, | 500.00 |
| ultra-light material (titanium, carbon fiber or | ||
| equal) | ||
| L5960 | Addition, endoskeletal system, hip | 467.82 |
| disarticulation, ultra-light material (titanium, | ||
| carbon fiber or equal) | ||
| L5962 | Addition, endoskeletal system, below knee, | 326.45 |
| flexible protective outer surface covering system | ||
| L5964 | Addition, endoskeletal system, above knee, | 566.20 |
| flexible protective outer surface covering system | ||
| L5966 | Addition, endoskeletal system, hip | 729.36 |
| disarticulation, flexible protective outer surface | ||
| covering system | ||
| L5968 | All lower extremity prosthesis; ankle, multiaxial | 1,958.73 |
| shock absorbing system | ||
| L5970 | All lower extremity prostheses, foot, external | 78.40 |
| keel, Sach foot | ||
| L5971 | All lower extremity prosthesis, solid ankle | 128.23 |
| cushion heel (Sach) foot, replacement only | ||
| L5972 | All lower extremity prostheses, flexible keel foot | 122.40 |
| (Safe, Sten, Bock Dynamic or equal) | ||
| L5974 | All lower extremity prostheses, foot, single axis | 109.60 |
| ankle/foot | ||
| L5975 | All lower extremity prosthesis; combination single | 249.89 |
| axis ankle and flexible kneel foot | ||
| L5976 | All lower extremity prostheses, energy storing | 284.80 |
| foot (Seattle Carbon Copy II or equal) | ||
| L5978 | All lower extremity prostheses, foot, multi-axial | 135.20 |
| ankle/foot | ||
| L5979 | All lower extremity prostheses, multi-axial | 1,267.27 |
| ankle/foot, dynamic response | ||
| L5980 | All lower extremity prostheses, flex-foot system | 2,033.60 |
| L5981 | All lower extremity prostheses, flex-walk system | 1,723.48 |
| or equal | ||
| L5982 | All exoskeletal lower extremity prostheses, axial | 406.40 |
| rotation unit | ||
| L5984 | All endoskeletal lower extremity prostheses, axial | 304.80 |
| rotation unit | ||
| L5985 | All endoskeletal lower extremity prostheses, | 362.49 |
| dynamic prosthetic pylon | ||
| L5986 | All lower extremity prostheses, multi-axial | 304.80 |
| rotation unit ("MCP" or equal) | ||
| L5987 | All lower extremity prostheses, shank foot system | 4,152.19 |
| with vertical loading pylon | ||
| L5988 | All lower extremity prosthesis, combination | 1,076.78 |
| vertical shock and multiaxial rotation/torsional | ||
| force reducing pylon | ||
| L5990 | Addition to lower extremity prosthesis; user | 1,130.21 |
| adjustable heel height | ||
| L5999 | Unlisted procedures for lower extremity prosthesis | B.R. |
| (b) UPPER LIMB (L6000-L6699) | ||
| The procedures in L6000-L6699 are base procedures which may be modified | ||
| by listing procedures from the "additions" sections. The base procedures | ||
| include only standard friction wrist and control cable system, unless | ||
| otherwise specified. | ||
| 1. PARTIAL HAND | ||
| L6000 | Partial hand, Robin-aids, thumb remaining (or | 924.32 |
| equal) | ||
| L6010 | Partial hand, Robin-aids, little and/or ring | 1,000.00 |
| finger remaining (or equal) | ||
| L6020 | Partial hand, Robin-aids, no finger remaining (or | 953.27 |
| equal) | ||
| L6025 | Transcarpal/metacarpal or partial hand | 5040.17 |
| disarticulation prosthesis, external power, | ||
| self-suspended, inner socket with removable forearm | ||
| section, electrodes and cables, two batteries, | ||
| charger, myoelectric control of terminal device | ||
| 2. WRIST DISARTICULATION | ||
| L6050 | Wrist disarticulation, molded socket, flexible | 1,120.00 |
| elbow hinges, triceps pad | ||
| L6055 | Wrist disarticulation, molded socket with | 1,287.00 |
| expandable interface, flexible elbow hinges, triceps | ||
| pad | ||
| 3. BELOW ELBOW | ||
| L6100 | Below elbow, molded socket, flexible elbow hinge, | 1,120.00 |
| triceps pad | ||
| L6110 | Below elbow, molded socket (Muenster or | 1,420.00 |
| Northwestern suspension types) | ||
| L6120 | Below elbow, molded double wall split socket, | 1,520.00 |
| step-up hinges, half cuff | ||
| L6130 | Below elbow, molded double wall split socket, | 1,975.33 |
| stump activated locking hinge, half cuff | ||
| 4. ELBOW DISARTICULATION | ||
| L6200 | Elbow disarticulation, molded socket, outside | 1,504.00 |
| locking hinge, forearm | ||
| L6205 | Elbow disarticulation, molded socket with | 2,522.40 |
| expandable interface, outside locking hinges, forearm | ||
| 5. ABOVE ELBOW | ||
| L6250 | Above elbow, molded double wall socket, internal | 1,760.00 |
| locking elbow, forearm | ||
| 6. SHOULDER DISARTICULATION | ||
| L6300 | Shoulder disarticulation, molded socket, shoulder | 2,120.00 |
| bulkhead, humeral section, internal locking elbow | ||
| forearm | ||
| L6310 | Shoulder disarticulation, passive restoration | 1,840.00 |
| (complete prosthesis) | ||
| L6320 | Shoulder disarticulation, passive restoration | 1,200.00 |
| (shoulder cap only) | ||
| 7. INTERSCAPULAR THORACIC | ||
| L6350 | Interscapular thoracic, molded socket, shoulder | 2,380.00 |
| bulkhead, humeral section, internal locking elbow, | ||
| forearm | ||
| L6360 | Interscapular thoracic, passive restoration | 1,545.84 |
| (complete prosthesis) | ||
| L6370 | Interscapular thoracic, passive restoration | 1,400.00 |
| (shoulder cap only) | ||
| 8. IMMEDIATE AND EARLY POST SURGICAL PROCEDURES | ||
| L6380 | Immediate postsurgical or early fitting, | 691.56 |
| application of initial rigid dressing, including | ||
| fitting alignment and suspension of components, and | ||
| one cast change, wrist disarticulation or below elbow | ||
| L6382 | Immediate postsurgical or early fitting, | 813.60 |
| application of initial rigid dressing, including | ||
| fitting alignment and suspension of components, and | ||
| one cast change, elbow disarticulation or above elbow | ||
| L6384 | Immediate postsurgical or early fitting, | 976.00 |
| application of initial rigid dressing, including | ||
| fitting alignment and suspension of components, and | ||
| one cast change, shoulder disarticulation or | ||
| interscapular thoracic | ||
| L6386 | Immediate postsurgical or early fitting, each | 223.74 |
| additional cast change and realignment | ||
| L6388 | Immediate postsurgical or early fitting, | 203.40 |
| application of rigid dressing only | ||
| 9. ENDOSKELETAL: BELOW ELBOW | ||
| L6400 | Below elbow, molded socket, endoskeletal system, | 1,204.00 |
| including soft prosthetic tissue shaping | ||
| 10. ENDOSKELETAL: ELBOW DISARTICULATION | ||
| L6450 | Elbow disarticulation, molded socket, endoskeletal | 1,301.60 |
| system, including soft prosthetic tissue shaping | ||
| 11. ENDOSKELETAL: ABOVE ELBOW | ||
| L6500 | Above elbow, molded socket, endoskeletal system, | 1,512.00 |
| including soft prosthetic tissue shaping | ||
| 12. ENDOSKELETAL: SHOULDER DISARTICULATION | ||
| L6550 | Shoulder disarticulation, molded socket, | 1,760.00 |
| endoskeletal system, including soft prosthetic tissue | ||
| shaping | ||
| 13. ENDOSKELETAL: INTERSCAPULAR THORACIC | ||
| L6570 | Interscapular thoracic, molded socket, | 2,160.00 |
| endoskeletal system, including soft prosthetic tissue | ||
| shaping | ||
| L6580 | Preparatory, wrist disarticulation or below elbow, | 813.60 |
| single wall plastic socket, friction wrist, flexible | ||
| elbow hinges, figure of eight harness, humeral cuff, | ||
| Bowen cable control, "USMC" or equal pylon, no cover, | ||
| molded to patient model | ||
| L6582 | Preparatory, wrist disarticulation or below elbow, | 691.56 |
| single wall socket, friction wrist, flexible elbow | ||
| hinges, figure of eight harness, humeral cuff, Bowen | ||
| cable control, "USMC" or equal pylon, no cover, | ||
| direct formed | ||
| L6584 | Preparatory, elbow disarticulation or above elbow, | 1,159.38 |
| single wall plastic socket, friction wrist, locking | ||
| elbow, figure of eight harness, fair lead cable | ||
| control, "USMC" or equal pylon, no cover, molded to | ||
| patient model | ||
| L6586 | Preparatory, elbow disarticulation or below elbow, | 996.66 |
| single wall socket, friction wrist, locking elbow, | ||
| figure of eight harness, humeral cuff, fair lead | ||
| cable control, "USMC" or equal pylon, no cover, | ||
| direct formed | ||
| L6588 | Preparatory, shoulder disarticulation or | 1,732.80 |
| interscapular thoracic, single wall plastic socket, | ||
| shoulder joint, locking elbow, friction wrist, chest | ||
| strap, fair lead cable control, "USMC" or equal | ||
| pylon, no cover, molded to patient model | ||
| L6590 | Preparatory, shoulder disarticulation or | 1,586.40 |
| interscapular thoracic, single wall socket, shoulder | ||
| joint, locking elbow, friction wrist, chest strap, | ||
| fair lead cable control, "USMC" or equal pylon, no | ||
| cover, direct formed | ||
| 14. ADDITIONS: UPPER LIMB | ||
| The following procedures/modifications/components may be added to other | ||
| base procedures. The items in this section should reflect the additional | ||
| complexity of each modification procedure, in addition to base procedure, at | ||
| the time of the original order. | ||
| L6600 | Upper extremity additions, polycentric hinge, pair | 52.00 |
| L6605 | Upper extremity additions, single pivot hinge, | 116.00 |
| pair | ||
| L6610 | Upper extremity additions, flexible metal hinge, | 46.00 |
| pair | ||
| L6611 | Addition to upper extremity prosthesis, external | 255.21 |
| powered, additional switch, any type | ||
| L6615 | Upper extremity addition, disconnect locking wrist | 60.00 |
| unit | ||
| L6616 | Upper extremity addition, additional disconnect | 59.89 |
| insert for locking wrist unit, each | ||
| L6620 | Upper extremity addition, flexion-friction wrist | 211.56 |
| unit | ||
| L6621 | Flexion/extension wrist with or without friction, | 2,334.37 |
| for use with external powered terminal device | ||
| L6623 | Upper extremity addition, spring assisted | 386.40 |
| rotational wrist unit with latch release | ||
| L6624 | Flexion/extension and rotation wrist unit | 2,334.37 |
| L6625 | Upper extremity addition, rotation wrist unit with | 160.00 |
| cable lock | ||
| L6628 | Upper extremity addition, quick disconnect hook | 284.76 |
| adapter, Otto Bock or equal | ||
| L6629 | Upper extremity addition, quick disconnect | 73.22 |
| lamination collar with coupling piece, Otto Bock or | ||
| equal | ||
| L6630 | Upper extremity addition, stainless steel, any | 68.00 |
| wrist | ||
| L6632 | Upper extremity addition, latex suspension sleeve, | 32.54 |
| each | ||
| L6635 | Upper extremity addition, lift assist for elbow | 152.48 |
| L6637 | Upper extremity addition, nudge control elbow lock | 251.68 |
| L6638 | Upper extremity addition to prosthesis, electric | 1,575.48 |
| locking feature, only for use with manually powered | ||
| elbow | ||
| L6640 | Upper extremity additions, shoulder abduction | 130.40 |
| joint, pair | ||
| L6641 | Upper extremity addition, excursion amplifier, | 97.60 |
| pulley type | ||
| L6642 | Upper extremity addition, excursion amplifier, | 138.40 |
| lever type | ||
| L6645 | Upper extremity addition, shoulder | 65.00 |
| flexion-abduction joint, each | ||
| L6646 | Upper extremity addition, shoulder joint, | 1,986.49 |
| multipositional locking, flexion, adjustable | ||
| abduction friction control, for use with body powered | ||
| or external powered system | ||
| L6647 | Upper extremity addition, shoulder lock mechanism, | 327.03 |
| body powered actuator | ||
| L6648 | Upper extremity addition, shoulder lock mechanism, | 2,048.78 |
| external powered actuator | ||
| L6650 | Upper extremity addition, shoulder universal | 200.00 |
| joint, each | ||
| L6655 | Upper extremity addition, standard control cable, | 35.00 |
| extra | ||
| L6660 | Upper extremity addition, heavy duty control cable | 56.00 |
| L6665 | Upper extremity addition, Teflon, or equal, cable | 24.00 |
| lining | ||
| L6670 | Upper extremity addition, hook to hand, cable | 43.40 |
| adapter | ||
| L6672 | Upper extremity addition, harness, chest or | 108.00 |
| shoulder, saddle type | ||
| L6675 | Upper extremity addition, harness, figure of ("8") | 80.42 |
| eight type, for single control | ||
| L6676 | Upper extremity addition, harness, figure of ("8") | 86.32 |
| eight type, for dual control | ||
| L6677 | Harness, triple control, simultaneous operation of | 183.87 |
| terminal device and elbow | ||
| L6680 | Upper extremity addition, test socket, wrist | 160.00 |
| disarticulation or below elbow | ||
| L6682 | Upper extremity addition, test socket, elbow | 180.00 |
| disarticulation or above elbow | ||
| L6684 | Upper extremity addition, test socket, shoulder | 148.00 |
| disarticulation or interscapular thoracic | ||
| L6686 | Upper extremity addition, suction socket | 406.80 |
| L6687 | Upper extremity addition, frame type socket, below | 244.08 |
| elbow or wrist disarticulation | ||
| L6688 | Upper extremity addition, frame type socket, above | 284.76 |
| elbow or elbow disarticulation | ||
| L6689 | Upper extremity addition, frame type socket, | 325.60 |
| shoulder disarticulation | ||
| L6690 | Upper extremity addition, frame type socket, | 366.40 |
| interscapular-thoracic | ||
| L6691 | Upper extremity addition, removable insert, each | 244.08 |
| L6692 | Upper extremity addition, silicone gel insert or | 240.00 |
| equal, each | ||
| L6693 | Upper extremity additions; external locking elbow, | 1,530.26 |
| forearm counter balance | ||
| L6694 | Addition to upper extremity prosthesis, below | 421.90 |
| elbow/above elbow, custom fabricated from existing | ||
| mold or prefabricated, socket insert, silicone gel, | ||
| elastomeric or equal, for use with locking mechanism | ||
| L6695 | Addition to upper extremity prosthesis, below | |
| elbow/above elbow, custom fabricated from existing | 351.58 | |
| mold or prefabricated, socket insert, silicone gel, | ||
| elastomeric or equal, not for use with locking | ||
| mechanism | ||
| L6696 | Addition to upper extremity prosthesis, below | 815.32 |
| elbow/above elbow, custom fabricated socket insert | ||
| for congenital or atypical traumatic amputee, | ||
| silicone gel, elastomeric or equal, for use with or | ||
| without locking mechanism, initial only (for other | ||
| than initial, use code L6694 or L6695) | ||
| L6697 | Addition to upper extremity prosthesis, below | 815.32 |
| elbow/above elbow, custom fabricated socket insert | ||
| for other than congenital or atypical traumatic | ||
| amputee, silicone gel, elastomeric or equal, for use | ||
| with or without locking mechanism, initial only (for | ||
| other than initial, use code L6694 or L6695) | ||
| L6698 | Addition to upper extremity prosthesis, below | 314.06 |
| elbow/above elbow, lock mechanism, excludes socket | ||
| insert | ||
| (c) TERMINAL DEVICES (L6700-L6899) | ||
| 1. HOOKS | ||
| L6703 | Terminal device, passive hand/mitt, any material, | 273.68 |
| any size | ||
| L6704 | Terminal device, sport/recreational/work | 370.47 |
| attachment, any material, any size | ||
| L6706 | Terminal device, hook, mechanical, voluntary | 220.31 |
| opening, any material, any size, lined or unlined | ||
| L6707 | Terminal device, hook, mechanical, voluntary | 865.54 |
| closing, any material, any size, lined or unlined | ||
| L6708 | Terminal device, hand, mechanical, voluntary | 580.03 |
| opening, any material, any size | ||
| L6709 | Terminal device, hand, mechanical, voluntary | 776.50 |
| closing, any material, any size | ||
| L6711 | Terminal device, hook, mechanical, voluntary | 416.72 |
| opening, any material, any size, lined or unlined, | ||
| pediatric | ||
| L6712 | Terminal device, hook, mechanical, voluntary | 767.27 |
| closing, any material, any size, lined or unlined, | ||
| pediatric | ||
| L6713 | Terminal device, hand, mechanical, voluntary | 968.38 |
| opening, any material, any size, pediatric | ||
| L6714 | Terminal device, hand, mechanical, voluntary | 820.20 |
| closing, any material, any size, pediatric | ||
| L6721 | Terminal device, hook or hand, heavy duty, size, | 1,457.83 |
| mechanical, voluntary opening, any material, any | ||
| lined or unlined | ||
| L6722 | Terminal device, hook or hand, heavy duty, | 1,256.77 |
| mechanical, voluntary closing, any material, any | ||
| size, lined or unlined | ||
| L6810 | Terminal device, pincher tool, Otto Bock or equal | 104.24 |
| 2. HANDS | ||
| L6881 | Automatic grasp feature, addition to upper limb | 2,546.90 |
| electric prosthetic terminal device | ||
| L6882 | Microprocessor control feature, addition to upper | 1,931.94 |
| limb prosthetic terminal device (MCM:2133) | ||
| L6883 | Replacement socket, below elbow/wrist | 1,335.93 |
| disarticulation, molded to patient model, for use | ||
| with or without external power | ||
| L6884 | Replacement socket, above elbow/elbow with or | 1,469.13 |
| disarticulation, molded to patient model, for use | ||
| without external power | ||
| L6885 | Replacement socket, shoulder | 2,011.10 |
| disarticulation/interscapular thoracic, molded to | ||
| patient model, for use with or without external power | ||
| 3. GLOVES FOR ABOVE HANDS | ||
| L6890 | Terminal device, glove for above hands, | 84.00 |
| production, glove | ||
| L6895 | Terminal device, glove for above hands, custom | 296.00 |
| glove | ||
| (d) HAND RESTORATION (L6900-L6999) | ||
| L6900 | Hand restoration (casts, shading and measurements | 1,000.00 |
| included), partial hand, with glove, thumb or one | ||
| finger remaining | ||
| L6905 | Hand restoration (casts, shading and measurements | 1,000.00 |
| included), partial hand, with glove, multiple fingers | ||
| remaining) | ||
| L6910 | Hand restoration (casts, shading and measurements | 1,000.00 |
| included), partial hand, with glove, no fingers | ||
| remaining | ||
| L6915 | Hand restoration (shading and measurements | 320.00 |
| included), replacement glove for above | ||
| 1. EXTERNAL POWER--BASE DEVICES | ||
| L6920 | Wrist disarticulation, external power, | 3,789.90 |
| self-suspended inner socket, removable forearm shell, | ||
| Otto Bock or equal, switch, cables, two batteries and | ||
| one charger, switch control of terminal device | ||
| L6925 | Wrist disarticulation, external power, | 4,350.58 |
| self-suspended inner socket, removable forearm shell, | ||
| Otto Bock or equal, electrodes, cables, two batteries | ||
| and one charger, myoelectronic control of terminal | ||
| device | ||
| L6930 | Below elbow, external power, self-suspended inner | 3,807.50 |
| socket, removable forearm shell, Otto Bock or equal, | ||
| switch, cables, two batteries and one charger, switch | ||
| control of terminal device | ||
| L6935 | Below elbow, external power, self-suspended inner | 4,384.65 |
| socket, removable forearm shell, Otto Bock or equal, | ||
| electrodes, cables, two batteries and one charger, | ||
| myoelectronic control of terminal device | ||
| L6940 | Elbow disarticulation, external power, molded | 5,210.69 |
| 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 | ||
| L6945 | Elbow disarticulation, external power, molded | 5,780.01 |
| 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 | ||
| L6950 | Above elbow, external power, molded inner socket, | 5,761.18 |
| removable humeral shell, internal locking elbow | ||
| forearm, Otto Bock or equal, switch, cables, two | ||
| batteries and one charger, switch control of terminal | ||
| device | ||
| L6955 | Above elbow, external power, molded inner socket, | 6,850.89 |
| removable humeral shell, internal locking elbow, | ||
| forearm, Otto Bock or equal, electrodes, cables, two | ||
| batteries and one charger, myoelectronic control of | ||
| terminal device | ||
| L6960 | Shoulder disarticulation, external power, molded | 6,950.69 |
| 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 | ||
| L6965 | Shoulder disarticulation, external power, molded | 7,934.50 |
| 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 | ||
| L6970 | Interscapular-thoracic, external power, molded | 8,475.55 |
| 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 | ||
| L6975 | Interscapular-thoracic, external power, molded | 9,418.54 |
| 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 | ||
| (e) EXTERNAL POWER--TERMINAL DEVICES (L7000-L7499) | ||
| L7008 | Electric hand, switch or myoelectric controlled; | 3,880.11 |
| pediatric | ||
| L7009 | Electric hook, switch or myoelectric controlled; | 2,348.40 |
| adult | ||
| L7040 | Prehensile actuator, Hosmer or equal, switch | 1,616.36 |
| controlled | ||
| L7045 | Electronic hook, child, Michigan or equal, switch | 854.01 |
| controlled | ||
| 1. EXTERNAL POWER--ELBOW | ||
| L7170 | Electronic elbow, Hosmer or equal, switch | 3,238.90 |
| controlled | ||
| L7180 | Electronic elbow, Utah or equal, myoelectronically | 19,382.46 |
| controlled | ||
| L7181 | Electronic elbow, microprocessor simultaneous | B.R. |
| control of elbow and terminal device | ||
| L7185 | Electronic elbow, adolescent, Variety Village or | 3,625.58 |
| equal, switch controlled | ||
| L7186 | Electronic elbow, child, Variety Village or equal, | 4,800.00 |
| switch controlled | ||
| L7190 | Electronic elbow, adolescent, Variety Village or | 5,177.71 |
| equal, myoelectronically controlled | ||
| L7191 | Electronic elbow, child, Variety Village or equal, | 5,072.00 |
| myoelectronically controlled | ||
| L7260 | Electronic wrist rotator, Otto Bock or equal | 1,342.44 |
| L7261 | Electronic wrist rotator, for Utah arm | 2,000.62 |
| L7266 | Servo control, Steeper or equal | 554.90 |
| L7272 | Analogue control, UNB or equal | 1,216.24 |
| L7274 | Proportional control, 12 volt, Utah or equal | 3,666.11 |
| 2. EXTERNAL POWER--BATTERY COMPONENTS | ||
| L7360 | Six volt battery, Otto Bock or equal, each | 167.90 |
| L7362 | Battery charger, six volt, Otto Bock or equal | 150.23 |
| L7364 | Twelve volt battery, Utah or equal, each | 296.74 |
| L7366 | Battery charger, twelve volt, Utah or equal | 398.67 |
| L7367 | Lithium ion battery, replacement | 245.20 |
| L7368 | Lithium ion battery charger | 317.88 |
| L7400 | Addition to upper extremity prosthesis; below | 189.97 |
| elbow/wrist disarticulation, ultralight material | ||
| (titanium, carbon fiber or equal) | ||
| L7401 | Above elbow disarticulation, ultralight material | 212.67 |
| (titanium, carbon fiber or equal) | ||
| L7402 | Shoulder disarticulation/interscapular thoracic, | 212.67 |
| ultralight material (titanium, carbon fiber or equal) | ||
| L7403 | Below elbow/wrist disarticulation, acrylic | 228.26 |
| material | ||
| L7404 | Above elbow disarticulation, acrylic material | 344.51 |
| L7405 | Shoulder disarticulation/interscapular thoracic, | 450.58 |
| acrylic material | ||
| L7499 | Unlisted procedures for upper extremity prosthesis | B.R. |
| (f) REPAIRS (L7500-L7599 AND X3680-3690) | ||
| L7500 | Repair of prosthetic device, hourly rate | 40.72 |
| L7510 | Repair prosthetic device, repair or replace minor | B.R. |
| parts | ||
| X3680 | Travel time per round trip, per day | 40.72 |
| (g) GENERAL (L8000-L8399) | ||
| 1. BREAST PROSTHESES | ||
| L8000 | Breast prosthesis, mastectomy bra | B.R. |
| L8001 | Breast prosthesis, mastectomy bra, with integrated | B.R. |
| breast prosthesis form, unilateral (MCM: 2130.A) | ||
| L8002 | Breast prosthesis, mastectomy bra, with integrated | 102.72 |
| breast prosthesis form, bilateral (MM:2130.A) | ||
| L8010 | Breast prosthesis, mastectomy sleeve | 40.56 |
| L8015 | External breast prosthesis garment, with | 30.58 |
| mastectomy form, post mastectomy | ||
| L8020 | Breast prosthesis, mastectomy form | 132.00 |
| L8030 | Breast prosthesis, silicone or equal | B.R. |
| L8035 | Custom breast prosthesis, post mastectomy, molded | 1,974.74 |
| to patient model | ||
| L8039 | Breast prosthesis; not otherwise specified | B.R. |
| 2. TRUSSES | ||
| L8300 | Truss, single with standard pad | 51.28 |
| L8310 | Truss, double with standard pads | 101.68 |
| L8320 | Truss, addition to standard pad, water pad | 24.00 |
| L8330 | Truss, addition to standard pad, scrotal pad | 33.65 |
| (h) PROSTHETIC SOCKS (L8400-L8499) | ||
| L8400 | Prosthetic sheath, below knee, each | 12.00 |
| L8410 | Prosthetic sheath, above knee, each | 12.00 |
| L8415 | Prosthetic sheath, upper limb, each | 11.20 |
| L8417 | Prosthetic sheath/sock, including a gel cushion | 59.09 |
| layer, below knee or above knee, each | ||
| L8420 | Prosthetic sock, wool, below knee, each | 14.94 |
| L8430 | Prosthetic sock, wool, above knee, each | 18.40 |
| L8435 | Prosthetic sock, wool, upper limb, each | 8.14 |
| L8440 | Prosthetic shrinker, below knee, each | 33.60 |
| L8460 | Prosthetic shrinker, above knee, each | 41.60 |
| L8465 | Prosthetic shrinker, upper limb, each | 33.60 |
| L8470 | Stump sock, single ply, fitting, below knee, each | 2.52 |
| L8480 | Stump sock, single ply, fitting, above knee, each | 2.52 |
| L8485 | Stump sock, single ply, fitting, upper limb, each | 6.21 |
| L8499 | Unlisted procedure for miscellaneous prosthetic | B.R. |
| services | ||
| (i) HEAD (SKULL, FACIAL BONES AND TEMPEROMANDIBULAR JOINT) | ||
| L8619 | Cochlear implant external speech processor, | |
| replacement | B.R. | |
| (j) MISCELLANEOUS | ||
| L7600 | Prosthetic donning sleeve, any material, each | B.R. |
| L8470 | Orthotic and prosthetic supply, accessory and/or | |
| service component of another HCPCS "L" Code | B.R | |
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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