New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 57 - PODIATRY SERVICES
Subchapter 3 - CENTERS FOR MEDICARE AND MEDICAID SERVICES CMS HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS)
Section 10:57-3.3 - Descriptions of Level II Codes

Universal Citation: NJ Admin Code 10:57-3.3
Current through Register Vol. 56, No. 18, September 16, 2024

IND HCPCS Code Mod Description S Maximum Fee Allowance $ NS
G0001Routine venipuncture1.801.80
QUALIFIER: This service is
reimbursable in the provider office
laboratory (POL) when the specimen
is referred out to an independent
clinical laboratory for testing.
Venipuncture is not reimbursable
when billed by the independent
clinical laboratory. It is
considered all inclusive as part of
the laboratory test.
G0127Trimming dystrophic nails, 1-107.007.00
J0690 Injection, cefazolin sodium, (ancef, kefzol) up to 500 mg 2.83 2.83
J0696 Injection, ceftriaxone sodium, (rocephin) per 250 mg 12.97 12.97
J1100 Injection, dexamethasone sodium phosphate, up to 4 mg/ml 0.13 0.13
J1200Injection, diphenhydramine HCl0.550.55
(benedryl), up to 50 mg
L1902AFO, ankle gauntlet, custom fitted48.8148.81
L1906AFO, multiligaments ankle support75.0075.00
L1907Ankle-foot-orthosis(AFO)
Supramalleolar with straps, with or
without interface/pads, custom
fabricated353.71353.71
L1930AFO, custom fitted, plastic156.80156.80
L1940AFO, molded to patient model,
plastic387.94387.94
L1951AFO, Spiral, Institute of
Rehabilitative Medicine type,
Plastic or other material,
prefabricated, includes fitting and
adjustment527.61527.61
L1971AFO, Plastic or other material with
ankle joint, prefabricated, includes
fitting and adjustment294.64294.64
L2108AFO, fracture orthosis, tibial569.60569.60
fracture cast orthosis, molded to
patient model
L2112AFO, fracture orthosis, tibial244.08244.08
fracture orthosis, custom fitted
L2114AFO, fracture orthosis, tibial321.37321.37
fracture orthosis, semi-rigid custom
fitted
L2116AFO, fracture orthosis, tibial366.00366.00
fracture orthosis, rigid custom
fitted
L3000Foot insert, removable, molded to140.00140.00
patient model "UCB" type, Berkeley
shell, each
L3001Foot insert, removable, molded to76.0076.00
patient model, Spenco, each
QUALIFIER: Custom Spenco Device
L3002Foot insert, removable, molded to76.0076.00
patient model, Plastazote or equal,
each
L3003Foot insert, removable, molded to76.0076.00
patient model, silicone gel, each
L3010Foot insert, removable, molded to76.0076.00
patient model, longitudinal arch
support, each
QUALIFIER: Any Custom Leather/Metal
Device (Example: Schaeffer, Whitman)
L3020Foot insert, removable, molded to88.0088.00
patient model, longitudinal/
metatarsal support, each
QUALIFIER: Any Custom Leather/Plastic
Device, Full Foot Only
L3030Foot insert, removable, formed to48.0048.00
patient foot, each
QUALIFIER: Only Off-The Shelf Spenco
L3031 Foot, Insert/plate, removable, addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepreg composite, each 80.34 80.34
L3040Foot, arch support, removable,29.6029.60
premolded, longitudinal, each
QUALIFIER: Only Off-The Shelf
Plastazote
L3050Foot, arch support, removable,32.0032.00
premolded, metatarsal, each
L3060Foot, arch support, removable,48.0048.00
premolded, longitudinal/metatarsal,
each
L3070 Foot, arch support, nonremovable, 16.00 16.00
attached to shoe, longitudinal, each
L3080Foot, arch support, nonremovable,20.0020.00
attached to shoe, metatarsal, each
L3090Foot, arch support, nonremovable,24.0024.00
attached to shoe, longitudinal/
metatarsal, each
L3100Hallus-Valgus night dynamic splint20.0020.00
L3140Foot, rotation positioning device,56.0056.00
including shoe(s)
L3150Foot, rotation positioning device,60.0060.00
without shoe(s)
L3170Foot, plastic heel stabilizer112.00112.00
L3201Orthopedic shoe, oxford with48.0048.00
supinator or pronator, infant
L3202Orthopedic shoe, oxford with48.0048.00
supinator or pronator, child
L3203Orthopedic shoe, oxford with48.0048.00
supinator or pronator, junior
L3204Orthopedic shoe, hightop with48.0048.00
supinator or pronator, infant
L3206Orthopedic shoe, hightop with48.0048.00
supinator or pronator, child
L3207Orthopedic shoe, hightop with48.0048.00
supinator or pronator, junior
L3208Surgical boot, each, infant24.0024.00
L3209Surgical boot, each, child24.0024.00
L3211Surgical boot, each, junior24.0024.00
L3212Benesch boot, pair, infant48.0048.00
L3213Benesch boot, pair, child48.0048.00
L3214Benesch boot, pair, junior48.0048.00
L3215 Orthopedic footwear, woman's shoes, oxford 38.00 38.00
L3216 Orthopedic footwear, woman's shoes, depth inlay 50.00 50.00
L3217 Orthopedic footwear, woman's shoes, hightop, depth inlay 58.00 58.00
L3219 Orthopedic footwear, man's shoes, oxford 38.00 38.00
L3221 Orthopedic footwear, man's shoes, depth inlay 50.00 50.00
L3222 Orthopedic footwear, man's shoes, hightop, depth inlay 58.00 58.00
L3230 Orthopedic footwear, custom shoes, depth inlay 190.00 190.00
L3250Orthopedic footwear, custom molded
shoe, removable inner mold,
prosthetic shoe, each250.00250.00
L3251Foot, shoe molded to patient model,280.00280.00
silicone shoe, each
L3252Foot, shoe molded to patient model,
Plastozote (or similar), custom
fabricated, each256.00256.00
L3253Foot, molded shoe Plastazote (or
similar), custom fitted, each112.00112.00
L3254Nonstandard size or width20.0020.00
L3255Nonstandard size or length20.0020.00
L3257Orthopedic footwear, additional50.0050.00
charge for split size
L3260Ambulatory surgical boot, each88.0088.00
L3265Plastazote sandal, each56.0056.00
L3300 Lift, elevation, heel, tapered to metatarsals, per inch 32.78 32.78
L3310 Lift, elevation, heel and 51.17 51.17
sole, neoprene, per inch
L3320Lift, elevation, heel and sole, cork,100.00100.00
per inch
L3332Lift, elevation, inside shoe,44.0044.00
tapered, up to one-half inch
L3334 Lift, elevation, heel, per inch 23.98 23.98
L3340Heel wedge, Sach10.4010.40
L3350Heel wedge12.0012.00
L3360Sole wedge, outside sole12.0012.00
L3370Sole wedge, between sole14.4014.40
L3380Club foot wedge12.0012.00
L3390Outflare wedge16.0016.00
L3400Metatarsal bar wedge, rocker16.0016.00
L3410Metatarsal bar wedge, between sole16.0016.00
L3420Full sole and heel wedge, between sole24.0024.00
L3430Heel, counter, plastic reinforced24.0024.00
L3440Heel, counter, leather reinforced24.0024.00
L3450Heel, Sach cushion type64.0064.00
L3455Heel, new leather, standard8.008.00
L3460Heel, new rubber, standard8.008.00
L3465Heel, Thomas with wedge20.0020.00
L3470Heel, Thomas extended to ball24.0024.00
L3480Heel, pad and depression for spur16.0016.00
L3485Heel, pad, removable for spur32.0032.00
L3500Miscellaneous shoe addition, insole,4.004.00
leather
L3510Miscellaneous shoe addition, insole,8.008.00
rubber
L3520Miscellaneous shoe additions, insole,8.008.00
felt covered with leather
L3530Miscellaneous shoe addition, sole,12.0012.00
half
L3540Miscellaneous shoe addition, sole,36.0036.00
full
L3550Miscellaneous shoe addition, toe tap,4.004.00
standard
L3560Miscellaneous shoe addition, toe tap,6.406.40
horseshoe
L3580Miscellaneous shoe addition, convert13.6013.60
instep to Velcro closure
L358052Velcro straps, attached to a pair of14.0014.00
shoes, per pair
L364952Foot Casting50.0050.00
L364922Foot, ankle casting65.0065.00
L3649 Orthopedic shoe, modification, addition or transfer, NOS 28.00 28.00
L4205Repair of orthotic device, quarter-
hour rate10.6010.60
L5673Addition to lower extremity, below
knee/above knee, custom fabricated
from existing mold or prefabricated
socket insert, silicone gel,
elastomeric or equal, for use with
locking mechanism506.15506.15
L5679Addition to lower extremity, below
knee/above knee, custom fabricated
from existing mold or prefabricated
socket insert, silicone gel,
elastomeric or equal, not for use
with locking mechanism421.77421.77
L5681Addition to lower extremity, below
knee/above 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 L5673 or L5679)828.47828.47
L5683Addition to lower extremity, below
knee/above 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 L5673 or
L5679)828.47828.47
Q0112 All potassium hydroxide (KOH) preparations 0.10 0.10

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