Purchase of DME, orthotics, prosthetics or supplies when the allowance is more than $500 or for rental of such when the total allowance over the rental period will be more than $500 requires precertification. Please note that this list is not inclusive of all items with an allowance of more than $500. However, codes listed below require precertification regardless of allowance.
NOTE: The items in Table B do not require precertification (even if allowance is more than $500).
The following items in Table A require precertification:
| HCPCS | Description |
|---|---|
| A4606 | Oxygen probe for use with oximeter device, replacement |
| A9274 | External ambulatory insulin delivery system, disposable, each, includes all supplies and accessories (Omnipod Classic and Omnipod DASH) |
| A9276 | Sensor, invasive (e.g., subcutaneous), disposable, for use with interstitial continuous glucose monitoring system, one unit = 1-day supply |
| A9277 | Transmitter, external, for use with interstitial continuous glucose monitoring system |
| A9278 | Receiver (monitor); external, for use with interstitial continuous glucose monitoring system |
| A9900 | Misc. DME supply, accessory, and/or service component of another HCPCS code |
| A9999 | Misc. DME supply or accessory, not otherwise specific |
| E0181 | Powered pressure reducing mattress overly/pad, alternating, with pump, includes heavy duty |
| E0182 | Pump for alternating pressure pad, for replacement only |
| E0184 | Dry pressure mattress |
| E0185 | Gel or gel-like pressure pad for mattress, standard mattress length and width |
| E0186 | Air pressure mattress |
| E0187 | Water pressure mattress |
| E0188 | Synthetic sheepskin pad |
| E0189 | Lambswool sheepskin pad, any size |
| E0193 | Powered air flotation bed (low air loss therapy) |
| E0194 | Air fluidized bed |
| E0196 | Gel pressure mattress |
| E0197 | Air pressure pad for mattress, standard mattress length and width |
| E0198 | Water pressure pad for mattress, standard mattress length and width |
| E0199 | Dry pressure pad for mattress, standard mattress length and width |
| E0265 | Hospital bed, total electric (head, foot, and height adjustments), with any type side rails, with mattress |
| E0266 | Hospital bed, total electric (head, foot, and height adjustments), with any type side rails, without mattress |
| E0296 | Hospital bed, total electric (head, foot and height adjustments), without side rails, with mattress |
| E0297 | Hospital bed, total electric (head, foot and height adjustments), without side rails, without mattress |
| E0328 | Hospital bed, pediatric, manual, 360 degree side enclosures, top of headboard, footboard and side rails up to 24 inches above the spring, includes mattress |
| E0329 | Hospital bed, pediatric, electric or semi-electric, 360 degree side enclosures, top of headboard, footboard and side rails up to 24 inches above the spring, includes mattress |
| E0371 | Nonpowered advanced pressure reducing overlay for mattress, standard mattress length and width |
| E0372 | Powered air overlay for mattress, standard mattress length and width |
| E0373 | Nonpowered advanced pressure reducing mattress |
| E0424 | Stationary compressed gaseous oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing |
| E0431 | Portable gaseous oxygen system, rental; includes portable container, regulator, flowmeter, humidifier, cannula or mask, and tubing |
| E0434 | Portable liquid oxygen system, rental; includes portable container, supply reservoir, humidifier, flowmeter, refill adaptor, contents gauge, cannula or mask, and tubing |
| E0439 | Stationary liquid oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing |
| E0445 | Oximeter device for measuring blood oxygen levels non-invasively |
| E0465 | Home ventilator, any type, used with invasive interface, (e.g., tracheostomy tube) |
| E0466 | Home ventilator, any type, used with noninvasive interface, (e.g., mask, chest shell) |
| E0467 | Home ventilator, multi-function respiratory device, also performs any or all of the additional functions of oxygen concentration, drug nebulization, aspiration, and cough stimulation, includes all accessories, components and supplies for all functions |
| E0470 | Respiratory assist device, bi-level pressure capability, without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device) |
| E0471 | Respiratory assist device, bi-level pressure capability, backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device) |
| E0472 | Respiratory assist device, bi-level pressure capability, with backup rate feature, used with invasive interface, e.g., tracheostomy tube (intermittent assist device with continuous positive airway pressure device) |
| E0482 | Cough stimulating device, alternating positive and negative airway pressure |
| E0483 | High frequency chest wall oscillation air-pulse generator system, (including hoses and vest), each Oscillatory Device for Bronchial Drainage (The Vest) |
| E0485 | Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, prefabricated, includes fitting and adjustment |
| E0486 | Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, custom fabricated, includes fitting and adjustment |
| E0604 | Breast pump, hospital grade, electric (AC and/or DC), any type |
| E0618 | Apnea monitor, without recording feature |
| E0619 | Apnea monitor, with recording feature |
| E0625 | Patient lift, bathroom or toilet, not otherwise classified (effective 2/1/15) |
| E0637 | Combination sit-to-stand frame/table system, any size including pediatric, with seat lift feature, with or without wheels (effective 2/1/15) |
| E0638 | Standing frame/table system, one position (e.g., upright, supine or prone stander), any size including pediatric, with or without wheels (effective 2/1/15) |
| E0641 | Standing frame/table system, multi-position (e.g., 3-way stander), any size including pediatric, with or without wheels (effective 2/1/15) |
| E0642 | Standing frame/table system, mobile (dynamic stander), any size including pediatric (effective 2/1/15) |
| E0650 | Pneumatic Compressor, non-segmental home model |
| E0651 | Pneumatic compressor, segmental home model without calibrated gradient pressure |
| E0652 | Pneumatic Compressor, Segmental Home Model with calibrated gradient pressure |
| E0675 | Pneumatic compression device, high pressure, rapid inflation/deflation cycle, for arterial insufficiency (unilateral or bilateral system) |
| E0747 | Osteogenesis stimulator, electrical, noninvasive, other than spinal applications |
| E0748 | Osteogenesis stimulator, electrical, noninvasive, spinal applications |
| E0760 | Osteogenesis stimulator, low intensity ultrasound, noninvasive |
| E0762 | Transcutaneous electrical joint stimulation device system, includes all accessories |
| E0764 | Functional neuromuscular stimulation, transcutaneous stimulation of sequential muscle groups of ambulation with computer control, used for walking by spinal cord injured, entire system, after completion of training program |
| E0784 | External Ambulatory infusion pump, Insulin |
| E0787 | External ambulatory infusion pump, insulin, dosage rate adjustment using therapeutic continuous glucose monitoring |
| E8000 | Gait trainer, pediatric size, posterior support, includes all accessories and components (effective 2/1/15) |
| E8001 | Gait trainer, pediatric size, upright support, includes all accessories and components (effective 2/1/15) |
| E8002 | Gait trainer, pediatric size, anterior support, includes all accessories and components (effective 2/1/15) |
| E0983 | Manual wheelchair accessory, power add-on to convert manual wheelchair to motorized wheelchair, joystick controlled |
| E0984 | Manual wheelchair accessory, power add-onto convert manual wheelchair to motorized wheelchair, tiller control |
| E0986 | Manual wheelchair accessory, push activated power assist, each |
| E1083 | Hemi-wheelchair, fixed full-length arms, swing-away detachable elevating legrest |
| E1084 | Hemi-wheelchair, detachable arms desk or full-length arms, swing-away detachable elevating legrests |
| E1085 | Hemi-wheelchair, fixed full-length arms, swing-away detachable footrests |
| E1086 | Hemi-wheelchair, detachable arms, desk or full-length, swing-away detachable footrests |
| E1087 | High strength lightweight wheelchair, fixed full-length arms, swing-away detachable elevating legrests |
| E1088 | High strength lightweight wheelchair, detachable arms desk or full-length, swing-away detachable elevating legrests |
| E1089 | High-strength lightweight wheelchair, fixed-length arms, swing-away detachable footrest |
| E1090 | High-strength lightweight wheelchair, detachable arms, desk or full-length, swing-away detachable footrests |
| E1092 | Wide heavy-duty wheel chair, detachable arms (desk or full-length), swing-away detachable elevating legrests |
| E1093 | Wide heavy-duty wheelchair, detachable arms, desk or full-length arms, swing-away detachable footrests |
| E1100 | Semi-reclining wheelchair, fixed full-length arms, swing-away detachable elevating legrests |
| E1110 | Semi-reclining wheelchair, fixed full-length arms, swing-away detachable elevating legrests |
| E1130 | Standard wheelchair, fixed full-length arms, fixed or swing-away detachable footrests |
| E1140 | Wheelchair, detachable arms, desk or full-length, swing-away detachable footrests |
| E1150 | Wheelchair, detachable arms, desk or full-length swing-away detachable elevating legrests |
| E1160 | Wheelchair, fixed full-length arms, swing-away detachable elevating legrests |
| E1161 | Manual adult size wheelchair, includes tilt in space |
| E1170 | Amputee wheelchair, fixed full-length arms, swing-away detachable elevating legrests |
| E1171 | Amputee wheelchair, fixed full-length arms, without footrests or legrest |
| E1172 | Amputee wheelchair, detachable arms (desk or full-length) without footrests or legrest |
| E1180 | Amputee wheelchair, detachable arms (desk or full-length) swing-away detachable footrests |
| E1190 | Amputee wheelchair, detachable arms (desk or full-length) swing-away detachable elevating legrests |
| E1195 | Heavy-duty wheelchair, fixed full-length arms, swing-away detachable elevating legrests |
| E1200 | Amputee wheelchair, fixed full-length arms, swing-away detachable footrest |
| E1220 | Wheelchair; specially sized or constructed, (indicate brand name, model number, if any) and justification |
| E1221 | Wheelchair with fixed arm, footrests |
| E1222 | Wheelchair with fixed arm, elevating legrests |
| E1223 | Wheelchair with detachable arms, footrests |
| E1224 | Wheelchair with detachable arms, elevating legrests |
| E1229 | Wheelchair, pediatric size, not otherwise specified |
| E1230 | Power operated vehicle (3- or 4-wheel nonhighway), specify brand name and model number |
| E1231 | Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, with seating system |
| E1232 | Wheelchair, pediatric size, tilt-in-space, folding, adjustable, with seating system |
| E1233 | Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, without seating system |
| E1234 | Wheelchair, pediatric size, tilt-in-space, folding, adjustable, without seating system |
| E1235 | Wheelchair, pediatric size, rigid, adjustable, with seating system |
| E1236 | Wheelchair, pediatric size, folding, adjustable, with seating system |
| E1237 | Wheelchair, pediatric size, rigid, adjustable, without seating system |
| E1238 | Wheelchair, pediatric size, folding, adjustable, without seating system |
| E1239 | Power wheelchair, pediatric size, not otherwise specified |
| E1240 | Lightweight wheelchair, detachable arms, (desk or full-length) swing-away detachable, elevating legrest |
| E1250 | Lightweight wheelchair, fixed full-length arms, swing-away detachable footrest |
| E1260 | Lightweight wheelchair, detachable arms (desk or full-length) swing-away detachable footrest |
| E1270 | Lightweight wheelchair, fixed full-length arms, swing-away detachable elevating legrests |
| E1280 | Heavy-duty wheelchair, detachable arms (desk or full-length) elevating legrests |
| E1285 | Heavy-duty wheelchair, fixed full-length arms, swing-away detachable footrest |
| E1290 | Heavy-duty wheelchair, detachable arms (desk or full-length) swing-away detachable footrest |
| E1295 | Heavy-duty wheelchair, fixed full-length arms, elevating legrest |
| E1296 | Special wheelchair seat height from floor |
| E1297 | Special wheelchair seat depth, by upholstery |
| E1298 | Special wheelchair seat depth and/or width, by construction |
| E1353 | Oxygen related equipment regulator |
| E1390 | Oxygen concentrator, single delivery port, capable of delivering 85% or greater oxygen concentration at the prescribed flow rate, each |
| E1391 | Oxygen concentrator, dual delivery port, capable of delivering 85% or greater oxygen concentration at the prescribed flow rate, each |
| E1392 | Portable oxygen concentrator, rental |
| E1399 | DME, miscellaneous |
| E1405 | Oxygen and water vapor enriching system with heated delivery |
| E1406 | Oxygen and water vapor enriching system without heated delivery |
| E1699 | Dialysis equipment, not otherwise specified |
| E2500 | Speech generating device, digitized speech, using prerecorded messages, less than or equal to 8 minutes recording time |
| E2502 | Speech generating device, digitized speech, using prerecorded messages, greater than 8 minutes but less than or equal to 20 minutes recording time |
| E2504 | Speech generating device, digitized speech, using prerecorded messages, greater than 20 minutes but less than or equal to 40 minutes recording time |
| E2506 | Speech generating device, digitized speech, using prerecorded messages, greater than 40 minutes recording time |
| E2508 | Speech generating device, synthesized speech, requiring message formulation by spelling and access by physical contact with the device |
| E2510 | Speech generating device, synthesized speech, permitting multiple methods of message formulation and multiple methods of device access |
| E2511 | Speech generating software program, for personal computer or personal digital assistant |
| E2512 | Accessory for speech generating device, mounting system |
| E2599 | Accessory for speech generating device, not otherwise classified |
| K0001 | Standard Wheelchair |
| K0002 | Standard hemi (low seat) Wheelchair |
| K0003 | Lightweight wheelchair |
| K0004 | High strength, lightweight wheelchair |
| K0005 | Ultralightweight wheelchair |
| K0006 | Heavy-duty wheelchair |
| K0007 | Extra heavy-duty wheelchair |
| K0008 | Custom manual wheelchair/base |
| K0009 | Other manual wheelchair/base |
| K0010 | Standard-weight frame motorized/power wheelchair |
| K0011 | Standard-weight frame motorized/power wheelchair with programmable control parameters for speed adjustment, tremor dampening, acceleration control and braking |
| K0012 | Lightweight portable motorized/power wheelchair |
| K0013 | Custom motorized/power wheelchair base |
| K0014 | Other motorized/power wheelchair base |
| K0108 | Wheelchair component or accessory, not otherwise specified |
| K0553 | Supply allowance for therapeutic continuous glucose monitor (CGM), includes all supplies and accessories, 1 month suppy = 1 unit of service |
| K0554 | Receiver (monitor), dedicated, for use with therapeutic glucose continuous monitor system |
| K0738 | Portable gaseous oxygen system, rental; home compressor used to fill portable oxygen cylinders; includes portable containers, regulator, flowmeter, humidifier, cannula or mask, and tubing |
| K0800 | Power operated vehicle, group 1 standard, patient weight capacity up to and including 300 pounds |
| K0801 | Power operated vehicle, group 1 heavy-duty, patient weight capacity 301 to 450 pounds |
| K0802 | Power operated vehicle, group 1 very heavy-duty, patient weight capacity 451 to 600 pounds |
| K0806 | Power operated vehicle, group 2 standard, patient weight capacity up to and including 300 pounds |
| K0807 | Power operated vehicle, group 2 heavy-duty, patient weight capacity 301 to 450 pounds |
| K0808 | Power operated vehicle, group 2 very heavy-duty, patient weight capacity 451 to 600 pounds |
| K0812 | Power operated vehicle, not otherwise classified |
| K0813 | Power wheelchair, group 1 standard, portable, sling/solid seat and back, patient weight capacity up to and including 300 pounds |
| K0814 | Power wheelchair, group 1 standard, portable, captain’s chair, patient weight capacity up to and including 300 pounds |
| K0815 | Power wheelchair, group 1 standard, sling/solid seat and back, patient weight capacity up to and including 300 pounds |
| K0816 | Power wheelchair, group 1 standard, captain’s chair, patient weight capacity up to and including 300 pounds |
| K0820 | Power wheelchair, group 2 standard, portable, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
| K0821 | Power wheelchair, group 2 standard, portable, captain’s chair, patient weight capacity up to and including 300 pounds |
| K0822 | Power wheelchair, group 2 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
| K0823 | Power wheelchair, group 2 standard, captain’s chair, patient weight capacity up to and including 300 pounds |
| K0824 | Power wheelchair, group 2 heavy-duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds |
| K0825 | Power wheelchair, group 2 heavy-duty, captain’s chair, patient weight capacity 301 to 450 pounds |
| K0826 | Power wheelchair, group 2 very heavy-duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds |
| K0827 | Power wheelchair, group 2 very heavy-duty, captain’s chair, patient weight capacity 451 to 600 pounds |
| K0828 | Power wheelchair, group 2 extra heavy-duty, sling/solid seat/back, patient weight capacity 601 pounds or more |
| K0829 | Power wheelchair, group 2 extra heavy-duty, captain’s chair, patient weight 601 pounds or more |
| K0830 | Power wheelchair, group 2 standard, seat elevator, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
| K0831 | Power wheelchair, group 2 standard, seat elevator, captain’s chair, patient weight capacity up to and including 300 pounds |
| K0835 | Power wheelchair, group 2 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
| K0836 | Power wheelchair, group 2 standard, single power option, captain’s chair, patient weight capacity up to and including 300 pounds |
| K0837 | Power wheelchair, group 2 heavy-duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds |
| K0838 | Power wheelchair, group 2 heavy-duty, single power option, captain’s chair, patient weight capacity 301 to 450 pounds |
| K0839 | Power wheelchair, group 2 very heavy-duty, single power option sling/solid seat/back, patient weight capacity 451 to 600 pounds |
| K0840 | Power wheelchair, group 2 extra heavy-duty, single power option, sling/solid seat/back, patient weight capacity 601 pounds or more |
| K0841 | Power wheelchair, group 2 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
| K0842 | Power wheelchair, group 2 standard, multiple power option, captain’s chair, patient weight capacity up to and including 300 pounds |
| K0843 | Power wheelchair, group 2 heavy-duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds |
| K0848 | Power wheelchair, group 3 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
| K0849 | Power wheelchair, group 3 standard, captain’s chair, patient weight capacity up to and including 300 pounds |
| K0850 | Power wheelchair, group 3 heavy-duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds |
| K0851 | Power wheelchair, group 3 heavy-duty, captain’s chair, patient weight capacity 301 to 450 pounds |
| K0852 | Power wheelchair, group 3 very heavy-duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds |
| K0853 | Power wheelchair, group 3 very heavy-duty, captain’s chair, patient weight capacity 451 to 600 pounds |
| K0854 | Power wheelchair, group 3 extra heavy-duty, sling/solid seat/back, patient weight capacity 601 pounds or more |
| K0855 | Power wheelchair, group 3 extra heavy-duty, captain’s chair, patient weight capacity 601 pounds or more |
| K0856 | Power wheelchair, group 3 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
| K0857 | Power wheelchair, group 3 standard, single power option, captain’s chair, patient weight capacity up to and including 300 pounds |
| K0858 | Power wheelchair, group 3 heavy-duty, single power option, sling/solid seat/back, patient weight 301 to 450 pounds |
| K0859 | Power wheelchair, group 3 heavy-duty, single power option, captain’s chair, patient weight capacity 301 to 450 pounds |
| K0860 | Power wheelchair, group 3 very heavy-duty, single power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds |
| K0861 | Power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
| K0862 | Power wheelchair, group 3 heavy-duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds |
| K0863 | Power wheelchair, group 3 very heavy-duty, multiple power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds |
| K0864 | Power wheelchair, group 3 extra heavy-duty, multiple power option, sling/solid seat/back, patient weight capacity 601 pounds or more |
| K0868 | Power wheelchair, group 4 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
| K0869 | Power wheelchair, group 4 standard, captain’s chair, patient weight capacity up to and including 300 pounds |
| K0870 | Power wheelchair, group 4 heavy-duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds |
| K0871 | Power wheelchair, group 4 very heavy-duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds |
| K0877 | Power wheelchair, group 4 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
| K0878 | Power wheelchair, group 4 standard, single power option, captain’s chair, patient weight capacity up to and including 300 pounds |
| K0879 | Power wheelchair, group 4 heavy-duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds |
| K0880 | Power wheelchair, group 4 very heavy-duty, single power option, sling/solid seat/back, patient weight 451 to 600 pounds |
| K0884 | Power wheelchair, group 4 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
| K0885 | Power wheelchair, group 4 standard, multiple power option, captain’s chair, patient weight capacity up to and including 300 pounds |
| K0886 | Power wheelchair, group 4 heavy-duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds |
| K0890 | Power wheelchair, group 5 pediatric, single power option, sling/solid seat/back, patient weight capacity up to and including 125 pounds |
| K0891 | Power wheelchair, group 5 pediatric, multiple power option, sling/solid seat/back, patient weight capacity up to and including 125 pounds |
| K0898 | Power wheelchair, not otherwise classified |
| K0899 | Power mobility device, not coded by DME PDAC or does not meet criteria |
| K0900 | Customized durable medical equipment, other than wheelchair (start date 7/1/13) |
| K1024 | Non-pneumatic compression controller with sequential calibrated gradient pressure |
| K1025 | Non-pneumatic sequential compression garment, full arm |
| K1031 | Non-pneumatic compression controller without calibrated gradient pressure |
| K1032 | Non-pneumatic sequential compression garment, full leg |
| K1033 | Non-pneumatic sequential compression garment, half leg |
| L0456 | Thoracic-lumbar-sacral orthotic (TLSO), flexible, provides trunk support, thoracic region, rigid posterior panel and soft anterior apron, extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks, includes straps and closures, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise |
| L0457 | Thoracic-lumbar-sacral orthotic (TLSO), flexible, provides trunk support, thoracic region, rigid posterior panel and soft anterior apron, extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks, includes straps and closures, prefabricated, off-the-shelf |
| L0458 | Thoracic-lumbar-sacral orthosis (TLSO), triplanar control, modular segmented spinal system, two rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the 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 | Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, modular segmented spinal system, two rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated item that has been trimmed, bent, molded, assembled or otherwise customized to fit a specific patient by an individual with expertise |
| L0462 | Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, modular segmented spinal 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 | Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, modular segmented spinal system, 4 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 |
| L0467 | TLSO,sagittal control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, restricts gross trunk motion in sagittal plane, produces intracavitary pressure to reduce load on intervertebral disks, prefabricated, off-the-shelf |
| L0468 | Thoracic-lumbar-sacral orthotic (TLSO), sagittal-coronal control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, extends from sacrococcygeal junction over scapulae, lateral strength provided by pelvic, thoracic, and lateral frame pieces, restricts gross trunk motion in sagittal, and coronal planes, produces intracavitary pressure to reduce load on intervertebral disks, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment |
| L0469 | TLSO, sagittal-coronal control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, extends from sacrococcygeal junction over scapulae, lateral strength provided by pelvic, thoracic, and lateral frame pieces, restricts gross trunk motion in sagittal and coronal planes, produces intracavitary pressure to reduce load on intervertebral disks, prefabricated, off-the-shelf |
| L0470 | Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding extends from sacrococcygeal junction to scapula, lateral strength provided by pelvic, thoracic, and lateral frame pieces, rotational strength provided by subclavicular extensions, restricts gross trunk motion in sagittal, coronal, and transverse planes, provides intracavitary pressure to reduce load on the intervertebral disks, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment |
| L0472 | Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, hyperextension, rigid anterior and lateral frame extends from symphysis pubis to sternal notch with 2 anterior components (one pubic and one sternal), posterior and lateral pads with straps and closures, limits spinal flexion, restricts gross trunk motion in sagittal, coronal, and transverse planes, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment |
| L0480 | Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, 1 piece rigid plastic shell without interface liner, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sterk0nal 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 | Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, 1 piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal, and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated |
| L0484 | Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, 2 piece rigid plastic shell without interface liner, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, lateral strength is enhanced by overlapping plastic, restricts gross trunk motion in the sagittal, coronal, and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated |
| L0486 | Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, 2 piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, lateral strength is enhanced by overlapping plastic, restricts gross trunk motion in the sagittal, coronal, and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated |
| L0488 | Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, 1 piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal, and transverse planes, prefabricated, includes fitting and adjustment |
| L0491 | Thoracic-lumbar-sacral orthotic (TLSO), sagittal-coronal control, modular segmented spinal system, 2 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 and coronal planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment |
| L0631 | Lumbar-sacral orthotic (LSO), sagittal control, with rigid anterior and posterior panels, 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, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment |
| L0635 | Lumbar-sacral orthotic (LSO), sagittal-coronal control, lumbar flexion, rigid posterior frame/panel(s), lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal 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, anterior panel, pendulous abdomen design, prefabricated, includes fitting and adjustment |
| L0636 | Lumbar-sacral orthotic (LSO), sagittal-coronal control, lumbar flexion, rigid posterior frame/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 orthotic (LSO), sagittal-coronal control, with rigid anterior and posterior frame/panels, 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, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment |
| L0638 | Lumbar-sacral orthotic (LSO), sagittal-coronal control, with rigid anterior and posterior frame/panels, 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, shoulder straps, pendulous abdomen design, custom fabricated |
| L0639 | Lumbar-sacral orthotic (LSO), sagittal-coronal control, 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, prefabricated, includes fitting and adjustment |
| L0640 | Lumbar-sacral orthotic (LSO), sagittal-coronal control, 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 fabricated |
| L0641 | Lumbar orthosis, sagittal control, with rigid posterior panel(s), 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 padding, stays, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf |
| L0642 | Lumbar orthosis, sagittal control, with rigid anterior and posterior panels, 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 padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf |
| L0643 | Lumbar-sacral orthosis, sagittal control, with 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, off-the-shelf |
| L0648 | Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, 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, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf |
| L0650 | Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panel(s), posterior extends from sacrococcygeal 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, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf |
| L0651 | Lumbar-sacral orthosis, sagittal-coronal control, 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, prefabricated, off-the-shelf |
| L0700 | Cervical-thoracic-lumbar-sacral orthotic (CTLSO), anterior-posterior-lateral control, molded to patient model, (Minerva type) |
| L0710 | Cervical-thoracic-lumbar-sacral orthotic (CTLSO), anterior-posterior-lateral-control, molded to patient model, with interface material, (Minerva type) |
| L1685 | Hip orthosis, abduction control of hip joint, postoperative hip abduction type, custom fabricated |
| L1686 | Hip orthosis, abduction control of hip joint, postoperative hip abduction type, prefabricated, includes fitting and adjustment |
| L1832 | Knee orthosis (KO), adjustable knee joints (unicentric or polycentric), positional orthotic, rigid support, prefabricated, includes fitting and adjustment |
| L1833 | Knee orthosis (KO), adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the-shelf |
| L1834 | Knee orthosis (KO), without knee joint, rigid, custom fabricated |
| L1840 | Knee orthosis (KO), derotation, medial-lateral, anterior cruciate ligament, custom fabricated |
| L1843 | Knee orthosis (KO), single upright, thight and calf, with adjustable flexion and extension (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise |
| L1844 | Knee orthosis (KO), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated |
| L1845 | Knee orthosis (KO), double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, includes fitting and adjustment |
| L1846 | Knee orthosis (KO), double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated |
| L1847 | Knee orthosis (KO), double upright with adjustable joint, with inflatable air support chamber(s), prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise |
| L1848 | Knee orthosis (KO), double upright with adjustable joint, with inflatable air support chamber(s), prefabricated, off-the-shelf |
| L1851 | Knee orthosis (KO), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment |
| L1852 | Knee orthosis (KO), double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment |
| L1860 | Knee orthosis (KO), modification of supracondylar prosthetic socket, custom fabricated (SK) |
| L1907 | Ankle orthosis, supramalleolar with straps, with or without interface/pads, custom fabricated |
| L1930 | Ankle-foot orthotic (AFO), plastic or other material, prefabricated, includes fitting and adjustment |
| L1932 | Ankle-foot orthotic (AFO), rigid anterior tibial section, total carbon fiber or equal material, prefabricated, includes fitting and adjustment |
| L1940 | Ankle-foot orthotic (AFO), plastic or other material, custom fabricated |
| L1945 | Ankle-foot orthotic (AFO), plastic, rigid anterior tibial section (floor reaction), custom fabricated |
| L1950 | Ankle foot orthosis, spiral, (institute of rehabilitative medicine type), plastic, custom fabricated |
| L1951 | Ankle foot orthosis, spiral, (institute of rehabilitative medicine type), plastic or other material, prefabricated, includes fitting and adjustment |
| L1960 | Ankle-foot orthotic (AFO), posterior solid ankle, plastic, custom fabricated |
| L1970 | Ankle foot orthosis, plastic with ankle joint, custom fabricated |
| L1971 | Ankle-foot orthotic (AFO), plastic or other material with ankle joint, prefabricated, includes fitting and adjustment |
| L1980 | Ankle foot orthosis, single upright free plantar dorsiflexion, solid stirrup, calf band/cuff (single bar 'bk' orthosis), custom fabricated |
| L1990 | Ankle foot orthosis, double upright free plantar dorsiflexion, solid stirrup, calf band/cuff (double bar 'bk' orthosis), custom fabricated |
| L2005 | Knee ankle foot orthosis, any material, single or double upright, stance control, automatic lock and swing phase release, any type activation, includes ankle joint, any type, custom fabricated |
| L2036 | Knee ankle foot orthosis, full plastic, double upright, with or without free motion knee, with or without free motion ankle, custom fabricated |
| L2250 | Addition to lower extremity, foot plate, molded to patient model, stirrup attachment |
| L2280 | Addition to lower extremity, molded inner boot |
| L2300 | Addition to lower extremity, abduction bar (bilateral hip involvement), jointed, adjustable |
| L2330 | Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only |
| L2340 | Addition to lower extremity, pre-tibial shell, molded to patient model |
| L2350 | Addition to lower extremity, prosthetic type, (bk) socket, molded to patient model, (used for ‘ptb’ ‘afo’ orthoses) |
| L3230 | Orthopedic footwear, custom shoe, depth inlay, each |
| L3330 | Lift, elevation, metal extension (skate) |
| L3678 | Shoulder orthosis, shoulder joint design, without joints, may include soft interface, straps, prefabricated, off-the-shelf |
| L3806 | Wrist-hand-finger orthotic (WHFO), includes one or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, custom fabricated, includes fitting and adjustment |
| L3808 | Wrist-hand-finger orthotic (WHFO), rigid without joints, may include soft interface material; straps, custom fabricated, includes fitting and adjustment |
| L3900 | Wrist-hand-finger orthotic (WHFO), dynamic flexor hinge, reciprocal wrist extension/ flexion, finger flexion/extension, wrist or finger driven, custom fabricated |
| L3901 | Wrist-hand-finger orthotic (WHFO), dynamic flexor hinge, reciprocal wrist extension/ flexion, finger flexion/extension, cable driven, custom fabricated |
| L3904 | Wrist-hand-finger orthotic (WHFO), external powered, electric, custom fabricated |
| L3905 | Wrist-hand orthotic (WHO), includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
| L3906 | Wrist-hand orthosis (WHO), without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
| L3916 | Wrist hand orthosis, includes one or more nontorsion joints(s), elastic bands, turnbuckles, may include soft interface, straps, prefabricated, off-the-shelf |
| L3921 | Hand finger orthotic (HFO), includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
| L4631 | Ankle-foot orthotic, walking boot type, varus/valgus correction, rocker bottom, anterior tibial shell, soft interface, custom arch support, plastic or other material, includes straps and closures, custom fabricated |
| L5000 | Partial foot, shoe insert with longitudinal arch, toe filler |
| L5010 | Partial foot, molded socket, ankle height, with toe filler |
| L5020 | Partial foot, molded socket, tibial tubercle height, with toe filler |
| L5050 | Ankle, Symes, molded socket, SACH foot |
| L5060 | Ankle, Symes, metal frame, molded leather socket, articulated ankle/foot |
| L5100 | Below knee, molded socket, shin, SACH foot |
| L5105 | Below knee, plastic socket, joints and thigh lacer, SACH foot |
| L5150 | Knee disarticulation (or through knee), molded socket, external knee joints, shin, SACH foot |
| L5160 | Knee disarticulation (or through knee), molded socket, bent knee configuration, external knee joints, shin, SACH foot |
| L5200 | Above knee, molded socket, single axis constant friction knee, shin, SACH foot |
| L5210 | Above knee, short prosthesis, no knee joint (stubbies), with foot blocks, no ankle joints, each |
| L5220 | Above knee, short prosthesis, no knee joint (stubbies), with articulated ankle/foot, dynamically aligned, each |
| L5230 | Above knee, for proximal femoral focal deficiency, constant friction knee, shin, SACH foot |
| L5250 | Hip disarticulation, Canadian type; molded socket, hip joint, single axis constant friction knee, shin, SACH foot |
| L5270 | Hip disarticulation, tilt table type; molded socket, locking hip joint, single axis constant friction knee, shin, SACH foot |
| L5280 | Hemipelvectomy, Canadian type; molded socket, hip joint, single axis constant friction knee, shin, SACH foot |
| L5301 | Below knee, molded socket, shin, SACH foot, endoskeletal system |
| L5312 | Knee disarticulation (or through knee), molded socket, single axis knee, pylon, SACH foot, endoskeletal system |
| L5321 | Above knee, molded socket, open end, SACH foot, endoskeletal system, single axis knee |
| L5331 | Hip disarticulation, Canadian type, molded socket, endoskeletal system, hip joint, single axis knee, SACH foot |
| L5341 | Hemipelvectomy, Canadian type, molded socket, endoskeletal system, hip joint, single axis knee, SACH foot |
| L5400 | Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting, alignment, suspension, and one cast change, below knee |
| L5410 | Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension, below knee, each additional cast change and realignment |
| L5420 | Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension and one cast change AK or knee disarticulation |
| L5430 | Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension, AK or knee disarticulation, each additional cast change and realignment |
| L5450 | Immediate postsurgical or early fitting, application of nonweight bearing rigid dressing, below knee |
| L5460 | Immediate postsurgical or early fitting, application of nonweight bearing rigid dressing, above knee |
| L5500 | Initial, below knee PTB type socket, nonalignable system, pylon, no cover, SACH foot, plaster socket, direct formed |
| L5505 | Initial, above knee, knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, SACH foot, plaster socket, direct formed |
| L5510 | Preparatory, below knee PTB type socket, nonalignable system, pylon, no cover, SACH foot, plaster socket, molded to model |
| L5520 | Preparatory, below knee PTB type socket, nonalignable system, pylon, no cover, SACH foot, thermoplastic or equal, direct formed |
| L5530 | Preparatory, below knee PTB type socket, nonalignable system, pylon, no cover, SACH foot, thermoplastic or equal, molded to model |
| L5535 | Preparatory, below knee PTB type socket, nonalignable system, no cover, SACH foot, prefabricated, adjustable open end socket |
| L5540 | Preparatory, below knee PTB type socket, nonalignable system, pylon, no cover, SACH foot, laminated socket, molded to model |
| L5560 | Preparatory, above knee, knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, SACH foot, plaster socket, molded to model |
| L5570 | Preparatory, above knee – knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, SACH foot, thermoplastic or equal, direct formed |
| L5580 | Preparatory, above knee, knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, SACH foot, thermoplastic or equal, molded to model |
| L5585 | Preparatory, above knee – knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, SACH foot, prefabricated adjustable open end socket |
| L5590 | Preparatory, above knee, knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, SACH foot, laminated socket, molded to model |
| L5595 | Preparatory, hip disarticulation/hemipelvectomy, pylon, no cover, SACH foot, thermoplastic or equal, molded to patient model |
| L5600 | Preparatory, hip disarticulation/hemipelvectomy, pylon, no cover, SACH foot, laminated socket, molded to patient model |
| L5610 | Addition to lower extremity, endoskeletal system, above knee, hydracadence system |
| L5611 | Addition to lower extremity, endoskeletal system, above knee, knee disarticulation, 4-bar linkage, with friction swing phase control |
| L5613 | Addition to lower extremity, endoskeletal system, above knee, knee disarticulation, 4-bar linkage, with hydraulic swing phase control |
| L5614 | Addition to lower extremity, exoskeletal system, above knee-knee disarticulation, 4 bar linkage, with pneumatic swing phase control |
| L5616 | Addition to lower extremity, endoskeletal system, above knee, universal multiplex system, friction swing phase control |
| L5617 | Addition to lower extremity, quick change self-aligning unit, above knee or below knee, each |
| L5618 | Addition to lower extremity, test socket, Symes |
| L5620 | Addition to lower extremity, test socket, below knee |
| L5622 | Addition to lower extremity, test socket, knee disarticulation |
| L5624 | Addition to lower extremity, test socket, above knee |
| L5626 | Addition to lower extremity, test socket, hip disarticulation |
| L5628 | Addition to lower extremity, test socket, hemipelvectomy |
| L5629 | Addition to lower extremity, below knee, acrylic socket |
| L5630 | Addition to lower extremity, Symes type, expandable wall socket |
| L5631 | Addition to lower extremity, above knee or knee disarticulation, acrylic socket |
| L5632 | Addition to lower extremity, Symes type, PTB brim design socket |
| L5634 | Addition to lower extremity, Symes type, posterior opening (Canadian) socket |
| L5636 | Addition to lower extremity, Symes type, medial opening socket |
| L5637 | Addition to lower extremity, below knee, total contact |
| L5638 | Addition to lower extremity, below knee, leather socket |
| L5639 | Addition to lower extremity, below knee, wood socket |
| L5640 | Addition to lower extremity, knee disarticulation, leather socket |
| L5642 | Addition to lower extremity, above knee, leather socket |
| L5643 | Addition to lower extremity, hip disarticulation, flexible inner socket, external frame |
| L5644 | Addition to lower extremity, above knee, wood socket |
| L5645 | Addition to lower extremity, below knee, flexible inner socket, external frame |
| L5646 | Addition to lower extremity, below knee, air, fluid, gel or equal, cushion socket |
| L5647 | Addition to lower extremity, below knee, suction socket |
| L5648 | Addition to lower extremity, above knee, air, fluid, gel or equal, cushion socket |
| L5649 | Addition to lower extremity, ischial containment/narrow M-L socket |
| L5650 | Additions to lower extremity, total contact, above knee or knee disarticulation socket |
| L5651 | Addition to lower extremity, above knee, flexible inner socket, external frame |
| L5652 | Addition to lower extremity, suction suspension, above knee or knee disarticulation socket |
| L5653 | Addition to lower extremity, knee disarticulation, expandable wall socket |
| L5654 | Addition to lower extremity, socket insert, Symes, (Kemblo, Pelite, Aliplast, Plastazote or equal) |
| L5655 | Addition to lower extremity, socket insert, below knee (Kemblo, Pelite, Aliplast, Plastazote or equal) |
| L5656 | Addition to lower extremity, socket insert, knee disarticulation (Kemblo, Pelite, Aliplast, Plastazote or equal) |
| L5658 | Addition to lower extremity, socket insert, above knee (Kemblo, Pelite, Aliplast, Plastazote or equal) |
| L5661 | Addition to lower extremity, socket insert, multidurometer Symes |
| L5665 | Addition to lower extremity, socket insert, multidurometer, below knee |
| L5666 | Addition to lower extremity, below knee, cuff suspension |
| L5668 | Addition to lower extremity, below knee, molded distal cushion |
| L5670 | Addition to lower extremity, below knee, molded supracondylar suspension (PTS or similar) |
| L5671 | Addition to lower extremity, below knee/above knee suspension locking mechanism (shuttle, lanyard, or equal), excludes socket insert |
| L5672 | Addition to lower extremity, below knee, removable medial brim suspension |
| L5673 | Addition 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 mechanism |
| L5676 | Additions to lower extremity, below knee, knee joints, single axis, pair |
| L5677 | Additions to lower extremity, below knee, knee joints, polycentric, pair |
| L5678 | Additions to lower extremity, below knee, joint covers, pair |
| L5679 | Addition 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 mechanism |
| L5680 | Addition to lower extremity, below knee, thigh lacer, nonmolded |
| L5681 | Addition 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 |
| L5682 | Addition to lower extremity, below knee, thigh lacer, gluteal/ischial, molded |
| L5683 | Addition 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 |
| L5684 | Addition to lower extremity, below knee, fork strap |
| L5685 | Addition to lower extremity prosthesis, below knee, suspension/sealing sleeve, with or without valve, any material, each |
| L5686 | Addition to lower extremity, below knee, back check (extension control) |
| L5688 | Addition to lower extremity, below knee, waist belt, webbing |
| L5690 | Addition to lower extremity, below knee, waist belt, padded and lined |
| L5692 | Addition to lower extremity, above knee, pelvic control belt, light |
| L5694 | Addition to lower extremity, above knee, pelvic control belt, padded and lined |
| L5695 | Addition to lower extremity, above knee, pelvic control, sleeve suspension, neoprene or equal, each |
| L5696 | Addition to lower extremity, above knee or knee disarticulation, pelvic joint |
| L5697 | Addition to lower extremity, above knee or knee disarticulation, pelvic band |
| L5698 | Addition to lower extremity, above knee or knee disarticulation, Silesian bandage |
| L5699 | All lower extremity prostheses, shoulder harness |
| L5700 | Replacement, socket, below knee, molded to patient model |
| L5701 | Replacement, socket, above knee/knee disarticulation, including attachment plate, molded to patient model |
| L5702 | Replacement, socket, hip disarticulation, including hip joint, molded to patient model |
| L5703 | Ankle, Symes, molded to patient model, socket without solid ankle cushion heel (SACH) foot, replacement only |
| L5704 | Custom shaped protective cover, below knee |
| L5705 | Custom shaped protective cover, above knee |
| L5706 | Custom shaped protective cover, knee disarticulation |
| L5707 | Custom shaped protective cover, hip disarticulation |
| L5710 | Addition, exoskeletal knee-shin system, single axis, manual lock |
| L5711 | Additions exoskeletal knee-shin system, single axis, manual lock, ultra-light material |
| L5712 | Addition, exoskeletal knee-shin system, single axis, friction swing and stance phase control (safety knee) |
| L5714 | Addition, exoskeletal knee-shin system, single axis, variable friction swing phase control |
| L5716 | Addition, exoskeletal knee-shin system, polycentric, mechanical stance phase lock |
| L5718 | Addition, exoskeletal knee-shin system, polycentric, friction swing and stance phase control |
| L5722 | Addition, exoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase control |
| L5724 | Addition, exoskeletal knee-shin system, single axis, fluid swing phase control |
| L5726 | Addition, exoskeletal knee-shin system, single axis, external joints, fluid swing phase control |
| L5728 | Addition, exoskeletal knee-shin system, single axis, fluid swing and stance phase control |
| L5780 | Addition, exoskeletal knee-shin system, single axis, pneumatic/hydra pneumatic swing phase control |
| L5781 | Addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system |
| L5782 | Addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system, heavy-duty |
| L5785 | Addition, exoskeletal system, below knee, ultra-light material (titanium, carbon fiber or equal) |
| L5790 | Addition, exoskeletal system, above knee, ultra-light material (titanium, carbon fiber or equal) |
| L5795 | Addition, exoskeletal system, hip disarticulation, ultra-light material (titanium, carbon fiber or equal) |
| L5810 | Addition, endoskeletal knee-shin system, single axis, manual lock |
| L5811 | Addition, endoskeletal knee-shin system, single axis, manual lock, ultra-light material |
| L5812 | Addition, endoskeletal knee-shin system, single axis, friction swing and stance phase control (safety knee) |
| L5814 | Addition, endoskeletal knee-shin system, polycentric, hydraulic swing phase control, mechanical stance phase lock |
| L5816 | Addition, endoskeletal knee-shin system, polycentric, mechanical stance phase lock |
| L5818 | Addition, endoskeletal knee-shin system, polycentric, friction swing and stance phase control |
| L5822 | Addition, endoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase control |
| L5824 | Addition, endoskeletal knee-shin system, single axis, fluid swing phase control |
| L5826 | Addition, endoskeletal knee-shin system, single axis, hydraulic swing phase control, with miniature high activity frame |
| L5828 | Addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control |
| L5830 | Addition, endoskeletal knee-shin system, single axis, pneumatic/swing phase control |
| L5840 | Addition, endoskeletal knee-shin system, 4-bar linkage or multiaxial, pneumatic swing phase control |
| L5845 | Addition, endoskeletal knee-shin system, stance flexion feature, adjustable |
| L5848 | Addition to endoskeletal knee-shin system, fluid stance extension, dampening feature, with or without adjustability |
| L5850 | Addition, endoskeletal system, above knee or hip disarticulation, knee extension assist |
| L5855 | Addition, endoskeletal system, hip disarticulation, mechanical hip extension assist |
| L5856 | Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type |
| L5857 | Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing phase only, includes electronic sensor(s), any type |
| L5858 | Addition to lower extremity prosthesis, endoskeletal knee shin system, microprocessor control feature, stance phase only, includes electronic sensor(s), any type |
| L5859 | Addition to lower extremity prosthesis, endoskeletal knee-shin system, powered and programmable flexion/extension assist control, includes any type motor(s) |
| L5910 | Addition, endoskeletal system, below knee, alignable system |
| L5920 | Addition, endoskeletal system, above knee or hip disarticulation, alignable system |
| L5925 | Addition, endoskeletal system, above knee, knee disarticulation or hip disarticulation, manual lock |
| L5930 | Addition, endoskeletal system, high activity knee control frame |
| L5940 | Addition, endoskeletal system, below knee, ultra-light material (titanium, carbon fiber or equal) |
| L5950 | Addition, endoskeletal system, above knee, ultra-light material (titanium, carbon fiber or equal) |
| L5960 | Addition, endoskeletal system, hip disarticulation, ultra-light material (titanium, carbon fiber or equal) |
| L5961 | Addition, endoskeletal system, polycentric hip joint, pneumatic or hydraulic control, rotation control, with or without flexion and/or extension control |
| L5962 | Addition, endoskeletal system, below knee, flexible protective outer surface covering system |
| L5964 | Addition, endoskeletal system, above knee, flexible protective outer surface covering system |
| L5966 | Addition, endoskeletal system, hip disarticulation, flexible protective outer surface covering system |
| L5968 | Addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature |
| L5969 | Addition, endoskeletal ankle-foot or ankle-system, power assist, includes any type motor(s) |
| L5970 | All lower extremity prostheses, foot, external keel, SACH foot |
| L5971 | All lower extremity prostheses, solid ankle cushion heel (SACH) foot, replacement only |
| L5972 | All lower extremity prostheses, foot, flexible keel |
| L5973 | Endoskeletal ankle foot system, microprocessor controlled feature, dorsiflexion and/or plantar flexion control, includes power source |
| L5974 | All lower extremity prostheses, foot, single axis ankle/foot |
| L5975 | All lower extremity prostheses, combination single axis ankle and flexible keel foot |
| L5976 | All lower extremity prostheses, energy storing foot (Seattle Carbon Copy II or equal) |
| L5978 | All lower extremity prostheses, foot, multiaxial ankle/foot |
| L5979 | All lower extremity prostheses, multiaxial ankle, dynamic response foot, one piece system |
| L5980 | All lower extremity prostheses, flex-foot system |
| L5981 | All lower extremity prostheses, flex-walk system or equal |
| L5982 | All exoskeletal lower extremity prostheses, axial rotation unit |
| L5984 | All endoskeletal lower extremity prostheses, axial rotation unit, with or without adjustability |
| L5985 | All endoskeletal lower extremity prostheses, dynamic prosthetic pylon |
| L5986 | All lower extremity prostheses, multiaxial rotation unit (MCP or equal) |
| L5987 | All lower extremity prostheses, shank foot system with vertical loading pylon |
| L5988 | Addition to lower limb prosthesis, vertical shock reducing pylon feature |
| L5990 | Addition to lower extremity prosthesis, user adjustable heel height |
| L5999 | Lower extremity prosthesis, not otherwise specified |
| L6000 | Partial hand, thumb remaining |
| L6010 | Partial hand, little and/or ring finger remaining |
| L6020 | Partial hand, no finger remaining |
| L6050 | Wrist disarticulation, molded socket, flexible elbow hinges, triceps pad |
| L6055 | Wrist disarticulation, molded socket with expandable interface, flexible elbow hinges, triceps pad |
| L6100 | Below elbow, molded socket, flexible elbow hinge, triceps pad |
| L6110 | Below elbow, molded socket (Muenster or Northwestern suspension types) |
| L6120 | Below elbow, molded double wall split socket, step-up hinges, half cuff |
| L6130 | Below elbow, molded double wall split socket, stump activated locking hinge, half cuff |
| L6200 | Elbow disarticulation, molded socket, outside locking hinge, forearm |
| L6205 | Elbow disarticulation, molded socket with expandable interface, outside locking hinges, forearm |
| L6250 | Above elbow, molded double wall socket, internal locking elbow, forearm |
| L6300 | Shoulder disarticulation, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearm |
| L6310 | Shoulder disarticulation, passive restoration (complete prosthesis) |
| L6320 | Shoulder disarticulation, passive restoration (shoulder cap only) |
| L6350 | Interscapular thoracic, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearm |
| L6360 | Interscapular thoracic, passive restoration (complete prosthesis) |
| L6370 | Interscapular thoracic, passive restoration (shoulder cap only) |
| L6380 | Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting alignment and suspension of components, and one cast change, wrist disarticulation or below elbow |
| L6382 | Immediate postsurgical or early fitting, application of initial rigid dressing including fitting alignment and suspension of components, and one cast change, elbow disarticulation or above elbow |
| L6384 | Immediate postsurgical or early fitting, application of initial rigid dressing including fitting alignment and suspension of components, and one cast change, shoulder disarticulation or interscapular thoracic |
| L6386 | Immediate postsurgical or early fitting, each additional cast change and realignment |
| L6388 | Immediate postsurgical or early fitting, application of rigid dressing only |
| L6400 | Below elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping |
| L6450 | Elbow disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue shaping |
| L6500 | Above elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping |
| L6550 | Shoulder disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue shaping |
| L6570 | Interscapular thoracic, molded socket, endoskeletal system, including soft prosthetic tissue shaping |
| L6580 | Preparatory, wrist disarticulation or below elbow, single wall plastic socket, friction wrist, flexible elbow hinges, figure of eight harness, humeral cuff, Bowden cable control, USMC or equal pylon, no cover, molded to patient model |
| L6582 | Preparatory, wrist disarticulation or below elbow, single wall socket, friction wrist, flexible elbow hinges, figure of eight harness, humeral cuff, Bowden cable control, USMC or equal pylon, no cover, direct formed |
| L6584 | Preparatory, elbow disarticulation or above elbow, single wall plastic socket, friction wrist, locking elbow, figure of eight harness, fair lead cable control, USMC or equal pylon, no cover, molded to patient model |
| L6586 | Preparatory, elbow disarticulation or above elbow, single wall socket, friction wrist, locking elbow, figure of eight harness, fair lead cable control, USMC or equal pylon, no cover, direct formed |
| L6588 | Preparatory, shoulder disarticulation or interscapular thoracic, single wall plastic socket, shoulder joint, locking elbow, friction wrist, chest strap, fair lead cable control, USMC or equal pylon, no cover, molded to patient model |
| L6590 | Preparatory, shoulder disarticulation or interscapular thoracic, single wall socket, shoulder joint, locking elbow, friction wrist, chest strap, fair lead cable control, USMC or equal pylon, no cover, direct formed |
| L6600 | Upper extremity additions, polycentric hinge, pair |
| L6605 | Upper extremity additions, single pivot hinge, pair |
| L6610 | Upper extremity additions, flexible metal hinge, pair |
| L6611 | Addition to upper extremity prosthesis, external powered, additional switch, any type |
| L6615 | Upper extremity addition, disconnect locking wrist unit |
| L6616 | Upper extremity addition, additional disconnect insert for locking wrist unit, each |
| L6620 | Upper extremity addition, flexion/extension wrist unit, with or without friction |
| L6621 | Upper extremity prosthesis addition, flexion/extension wrist with or without friction, for use with external powered terminal device |
| L6623 | Upper extremity addition, spring assisted rotational wrist unit with latch release |
| L6624 | Upper extremity addition, flexion/extension and rotation wrist unit |
| L6625 | Upper extremity addition, rotation wrist unit with cable lock |
| L6628 | Upper extremity addition, quick disconnect hook adapter, Otto Bock or equal |
| L6629 | Upper extremity addition, quick disconnect lamination collar with coupling piece, Otto Bock or equal |
| L6630 | Upper extremity addition, stainless steel, any wrist |
| L6632 | Upper extremity addition, latex suspension sleeve, each |
| L6635 | Upper extremity addition, lift assist for elbow |
| L6637 | Upper extremity addition, nudge control elbow lock |
| L6638 | Upper extremity addition to prosthesis, electric locking feature, only for use with manually powered elbow |
| L6640 | Upper extremity additions, shoulder abduction joint, pair |
| L6641 | Upper extremity addition, excursion amplifier, pulley type |
| L6642 | Upper extremity addition, excursion amplifier, lever type |
| L6645 | Upper extremity addition, shoulder flexion-abduction joint, each |
| L6646 | Upper extremity addition, shoulder joint, multipositional locking, flexion, adjustable abduction friction control, for use with body powered or external powered system |
| L6647 | Upper extremity addition, shoulder lock mechanism, body powered actuator |
| L6648 | Upper extremity addition, shoulder lock mechanism, external powered actuator |
| L6650 | Upper extremity addition, shoulder universal joint, each |
| L6655 | Upper extremity addition, standard control cable, extra |
| L6660 | Upper extremity addition, heavy-duty control cable |
| L6665 | Upper extremity addition, Teflon, or equal, cable lining |
| L6670 | Upper extremity addition, hook to hand, cable adapter |
| L6672 | Upper extremity addition, harness, chest or shoulder, saddle type |
| L6675 | Upper extremity addition, harness, (e.g., figure of eight type), single cable design |
| L6676 | Upper extremity addition, harness, (e.g., figure of eight type), dual cable design |
| L6677 | Upper extremity addition, harness, triple control, simultaneous operation of terminal device and elbow |
| L6680 | Upper extremity addition, test socket, wrist disarticulation or below elbow |
| L6682 | Upper extremity addition, test socket, elbow disarticulation or above elbow |
| L6684 | Upper extremity addition, test socket, shoulder disarticulation or interscapular thoracic |
| L6686 | Upper extremity addition, suction socket |
| L6687 | Upper extremity addition, frame type socket, below elbow or wrist disarticulation |
| L6688 | Upper extremity addition, frame type socket, above elbow or elbow disarticulation |
| L6689 | Upper extremity addition, frame type socket, shoulder disarticulation |
| L6690 | Upper extremity addition, frame type socket, interscapular-thoracic |
| L6691 | Upper extremity addition, removable insert, each |
| L6692 | Upper extremity addition, silicone gel insert or equal, each |
| L6693 | Upper extremity addition, locking elbow, forearm counterbalance |
| L6694 | Addition to upper extremity prosthesis, below 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 mold or prefabricated, socket insert, silicone gel, elastomeric or equal, not for use with locking mechanism |
| L6696 | Addition to upper extremity prosthesis, below 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 |
| L6697 | Addition to upper extremity prosthesis, below 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 |
| L6698 | Addition to upper extremity prosthesis, below elbow/above elbow, lock mechanism, excludes socket insert |
| L6703 | Terminal device, passive hand/mitt, any material, any size |
| L6704 | Terminal device, sport/recreational/work attachment, any material, any size |
| L6706 | Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined |
| L6707 | Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined |
| L6708 | Terminal device, hand, mechanical, voluntary opening, any material, any size |
| L6709 | Terminal device, hand, mechanical, voluntary closing, any material, any size |
| L6711 | Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined, pediatric |
| L6712 | Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined, pediatric |
| L6713 | Terminal device, hand, mechanical, voluntary opening, any material, any size, pediatric |
| L6714 | Terminal device, hand, mechanical, voluntary closing, any material, any size, pediatric |
| L6715 | Terminal device, multiple articulating digit, includes motor(s), initial issue or replacement |
| L6721 | Terminal device, hook or hand, heavy-duty, mechanical, voluntary opening, any material, any size, lined or unlined |
| L6722 | Terminal device, hook or hand, heavy-duty, mechanical, voluntary closing, any material, any size, lined or unlined |
| L6805 | Addition to terminal device, modifier wrist unit |
| L6810 | Addition to terminal device, precision pinch device |
| L6880 | Electric hand, switch or myolelectric controlled, independently articulating digits, any grasp pattern or combination of grasp patterns, includes motor(s) |
| L6881 | Automatic grasp feature, addition to upper limb electric prosthetic terminal device |
| L6882 | Microprocessor control feature, addition to upper limb prosthetic terminal device |
| L6883 | Replacement socket, below elbow/wrist disarticulation, molded to patient model, for use with or without external power |
| L6884 | Replacement socket, above elbow/elbow disarticulation, molded to patient model, for use with or without external power |
| L6885 | Replacement socket, shoulder disarticulation/interscapular thoracic, molded to patient model, for use with or without external power |
| L6890 | Addition to upper extremity prosthesis, glove for terminal device, any material, prefabricated, includes fitting and adjustment |
| L6895 | Addition to upper extremity prosthesis, glove for terminal device, any material, custom fabricated |
| L6900 | Hand restoration (casts, shading and measurements included), partial hand, with glove, thumb or one finger remaining |
| L6905 | Hand restoration (casts, shading and measurements included), partial hand, with glove, multiple fingers remaining |
| L6910 | Hand restoration (casts, shading and measurements included), partial hand, with glove, no fingers remaining |
| L6915 | Hand restoration (shading and measurements included), replacement glove for above |
| L6920 | Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal switch, cables, 2 batteries and 1 charger, switch control of terminal device |
| L6925 | Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal electrodes, cables, 2 batteries and one charger, myoelectronic control of terminal device |
| L6930 | Below elbow, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal switch, cables, 2 batteries and one charger, switch control of terminal device |
| L6935 | Below elbow, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal electrodes, cables, 2 batteries and one charger, myoelectronic control of terminal device |
| L6940 | Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, Otto Bock or equal switch, cables, 2 batteries and one charger, switch control of terminal device |
| L6945 | Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, Otto Bock or equal electrodes, cables, 2 batteries and one charger, myoelectronic control of terminal device |
| L6950 | Above elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, Otto Bock or equal switch, cables, 2 batteries and one charger, switch control of terminal device |
| L6955 | Above elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, Otto Bock or equal electrodes, cables, 2 batteries and one charger, myoelectronic control of terminal device |
| L6960 | Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal switch, cables, 2 batteries and one charger, switch control of terminal device |
| L6965 | Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal electrodes, cables, 2 batteries and one charger, myoelectronic control of terminal device |
| L6970 | Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal switch, cables, 2 batteries and one charger, switch control of terminal device |
| L6975 | Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal electrodes, cables, 2 batteries and one charger, myoelectronic control of terminal device |
| L7007 | Electric hand, switch or myoelectric controlled, adult |
| L7008 | Electric hand, switch or myoelectric, controlled, pediatric |
| L7009 | Electric hook, switch or myoelectric controlled, adult |
| L7040 | Prehensile actuator, switch controlled |
| L7045 | Electric hook, switch or myoelectric controlled, pediatric |
| L7170 | Electronic elbow, Hosmer or equal, switch controlled |
| L7180 | Electronic elbow, microprocessor sequential control of elbow and terminal device |
| L7181 | Electronic elbow, microprocessor simultaneous control of elbow and terminal device |
| L7185 | Electronic elbow, adolescent, Variety Village or equal, switch controlled |
| L7186 | Electronic elbow, child, Variety Village or equal, switch controlled |
| L7190 | Electronic elbow, adolescent, Variety Village or equal, myoelectronically controlled |
| L7191 | Electronic elbow, child, Variety Village or equal, myoelectronically controlled |
| L7360 | Six volt battery, each |
| L7362 | Battery charger, 6 volt, each |
| L7364 | Twelve volt battery, each |
| L7366 | Battery charger, twelve volt, each |
| L7367 | Lithium ion battery, replacement |
| L7368 | Lithium ion battery charger, replacement only |
| L7400 | Addition to upper extremity prosthesis, below elbow/wrist disarticulation, ultralight material (titanium, carbon fiber or equal) |
| L7401 | Addition to upper extremity prosthesis, above elbow disarticulation, ultralight material (titanium, carbon fiber or equal) |
| L7402 | Addition to upper extremity prosthesis, shoulder disarticulation/interscapular thoracic, ultralight material (titanium, carbon fiber or equal) |
| L7403 | Addition to upper extremity prosthesis, below elbow/wrist disarticulation, acrylic material |
| L7404 | Addition to upper extremity prosthesis, above elbow disarticulation, acrylic material |
| L7405 | Addition to upper extremity prosthesis, shoulder disarticulation/interscapular thoracic, acrylic material |
| L7499 | Upper extremity prosthesis, not otherwise specified |
| L7510 | Repair of prosthetic device, repair or replace minor parts |
| L7520 | Repair prosthetic device, labor component, per 15 minutes |
| L7600 | Prosthetic donning sleeve, any material, each |
| L8400 | Prosthetic sheath, below knee, each |
| L8410 | Prosthetic sheath, above knee, each |
| L8415 | Prosthetic sheath, upper limb, each |
| L8417 | Prosthetic sheath/sock, including a gel cushion layer, below knee or above knee, each |
| L8420 | Prosthetic sock, multiple ply, below knee, each |
| L8430 | Prosthetic sock, multiple ply, above knee, each |
| L8440 | Prosthetic shrinker, below knee, each |
| L8460 | Prosthetic shrinker, above knee, each |
| L8470 | Prosthetic sock, single ply, fitting, below knee, each |
| L8480 | Prosthetic sock, single ply, fitting, above knee, each |
| L8465 | Prosthetic sock, single ply, fitting, upper limb, each |
| L8499 | Unlisted procedure for misc. prosthetic services |
| L8614 | Cochlear device, includes all internal and external components |
| L8615 | Headset/headpiece for use with cochlear implant device, replacement |
| L8616 | Microphone for use with cochlear implant device, replacement |
| L8617 | Transmitting coil for use with cochlear implant device, replacement |
| L8618 | Transmitter cable for use with cochlear implant device, replacement |
| L8619 | Cochlear implant, external speech processor and controller, integrated system, replacement |
| L8621 | Zinc air battery for use with cochlear implant device, replacement, each |
| L8622 | Alkaline battery for use with cochlear implant device, any size, replacement, each |
| L8623 | Lithium ion battery for use with cochlear implant device speech processor, other than ear level, replacement, each |
| L8624 | Lithium ion battery for use with cochlear implant device speech processor, ear level, replacement, each |
| L8627 | Cochlear implant, external speech processor, component, replacement |
| L8628 | Cochlear implant, external controller component, replacement |
| L8679 | Implantable neurostimulator, pulse generator, any type |
| L8680 | Implantable neurostimulator electrode, each |
| L8685 | Implantable neurostimulator pulse generator, single array, rechargeable, includes extension |
| L8686 | Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension |
| L8687 | Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension |
| L8688 | Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension |
| L8690 | Auditory osseointegrated device, includes all internal and external components |
| L8692 | Auditory osseointegrated device, external sound processor, used without osseointegration, body worn, includes headband or other means of external attachment |
| L8693 | Auditory osseointegrated device abutment, any length, replacement only |
| L8695 | External recharging system for battery (external) for use with implantable neurostimulator, replacement only |
| L9900 | Orthotic and prosthetic supply, accessory, and/or service component of another HCPCS L code |
| V2600 | Hand held low vision aids and other nonspectacle mounted aids (effective 2/1/15) |
| V2610 | Single lens spectacle mounted low vision aids (effective 2/1/15) |
| V2615 | Telescopic and other compound lens system, including distance vision telescopic, near vision telescopes and compound microscopic lens system (effective 2/1/15) |
| V5030 | Hearing aid, monaural, body worn, air conduction (effective 1/1/15) |
| V5040 | Hearing aid, monaural, body worn, bone conduction (effective 1/1/15) |
| V5050 | Hearing aid, monaural, in the ear (effective 1/1/15) |
| V5060 | Hearing aid, monaural, behind the ear (effective 1/1/15) |
| V5070 | Glasses, air conduction (effective 1/1/15) |
| V5080 | Glasses, bone conduction (effective 1/1/15) |
| V5090 | Dispensing fee, unspecified hearing aid (effective 1/1/15) |
| V5095 | Semi-implantable middle ear hearing prosthesis (effective 1/1/15) |
| V5100 | Hearing aid, bilateral body worn (effective 1/1/15) |
| V5110 | Dispensing fee, bilateral (effective 1/1/15) |
| V5120 | Hearing aid, binaural, body (effective 1/1/15) |
| V5130 | Hearing aid, binaural, in the ear (effective 1/1/15) |
| V5140 | Hearing aid, binaural, behind the ear (effective 1/1/15) |
| V5150 | Hearing aid, binaural, glasses (effective 1/1/15) |
| V5160 | Dispensing fee, binaural (effective 1/1/15) |
| V5170 | Hearing aid, CROS, in the ear (effective 1/1/15) |
| V5180 | Hearing aid, CROS, behind the ear (effective 1/1/15) |
| V5190 | Hearing aid, CROS, glasses (effective 1/1/15) |
| V5200 | Dispensing fee, CROS (effective 1/1/15) |
| V5210 | Hearing aid, BICROS, in the ear (effective 1/1/15) |
| V5220 | Hearing aid, BICROS, behind the ear (effective 1/1/15) |
| V5230 | Hearing aid, BICROS, glasses (effective 1/1/15) |
| V5240 | Dispensing fee, BICROS (effective 1/1/15) |
| V5241 | Dispensing fee, monaural hearing aid, any type (effective 1/1/15) |
| V5242 | Hearing aid, analog, monaural, CIC (completely in the ear canal) (effective 1/1/15) |
| V5243 | Hearing aid, analog, monaural, ITC (in the canal) (effective 1/1/15) |
| V5244 | Hearing aid, digitally programmable analog, monaural, CIC (effective 1/1/15) |
| V5245 | Hearing aid, digitally programmable, analog, monaural, ITC (effective 1/1/15) |
| V5246 | Hearing aid, digitally programmable, analog, monaural, ITE (in the ear) (effective 1/1/15) |
| V5247 | Hearing aid, digitally programmable analog, monaural, BTE (behind the ear) |
| V5248 | Hearing aid, analog, binaural, CIC |
| V5249 | Hearing aid, analog, binaural, ITC (effective 1/1/15) |
| V5250 | Hearing aid, digitally programmable analog, binaural, CIC (effective 1/1/15) |
| V5251 | Hearing aid, digitally programmable analog, binaural, ITC (effective 1/1/15) |
| V5252 | Hearing aid, digitally programmable, binaural, ITE (effective 1/1/15) |
| V5253 | Hearing aid, digitally programmable, binaural, BTE (effective 1/1/15) |
| V5254 | Hearing aid, digital, monaural, CIC (effective 1/1/15) |
| V5255 | Hearing aid, digital, monaural, ITC (effective 1/1/15) |
| V5256 | Hearing aid, digital, monaural, ITE (effective 1/1/15) |
| V5257 | Hearing aid, digital, monaural, BTE (effective 1/1/15) |
| V5258 | Hearing aid, digital, binaural, CIC (effective 1/1/15) |
| V5259 | Hearing aid, digital, binaural, ITC (effective 1/1/15) |
| V5260 | Hearing aid, digital, binaural, ITE (effective 1/1/15) |
| V5261 | Hearing aid, digital, binaural, BTE (effective 1/1/15) |
| V5262 | Hearing aid, disposable, any type, monaural (effective 1/1/15) |
| V5263 | Hearing aid, disposable, any type, binaural (effective 1/1/15) |
| V5264 | Ear mold/insert, not disposable, any type (effective 1/1/15) |
| V5265 | Ear mold/insert, disposable, any type (effective 1/1/15) |
| V5266 | Battery for use in hearing device (effective 1/1/15) |
| V5267 | Hearing aid or assistive listening device/supplies/accessories, not otherwise specified (effective 1/1/15) |
| V5268 | Assistive listening device, telephone amplifier, any type |
| V5269 | Assistive listening device, alerting, any type |
| V5270 | Assistive listening device, television amplifier, any type |
| V5271 | Assistive listening device, television caption decoder |
| V5272 | Assistive listening device, TDD |
| V5273 | Assistive listening device, for use with cochlear implant |
| V5274 | Assistive listening device, not otherwise specified |
| V5275 | Ear impression, each (effective 1/1/15) |
| V5281 | Assistive listening device, personal FM/DM system, monaural (1 receiver, transmitter, microphone), any type (effective 1/1/15) |
| V5282 | Assistive listening device, personal FM/DM system, binaural (2 receivers, transmitter, microphone), any type (effective 1/1/15) |
| V5283 | Assistive listening device, personal FM/DM neck, loo induction receiver (effective 1/1/15) |
| V5284 | Assistive listening device, personal FM/DM, ear level receiver (effective 1/1/15) |
| V5285 | Assistive listening device, personal FM/DM, direct audio input receiver (effective 1/1/15) |
| V5286 | Assistive listening device, personal blue tooth FM/DM receiver (effective 1/1/15) |
| V5287 | Assistive listening device, personal FM/DM receiver, not otherwise specified (effective 1/1/15) |
| V5288 | Assistive listening device, personal FM/DM transmitter assistive listening device (effective 1/1/15) |
| V5289 | Assistive listening device, personal FM/DM adapter/boot coupling device for receiver, any type (effective 1/1/15) |
| V5290 | Assistive listening device, transmitter microphone, any type (effective 1/1/15) |
| V5298 | Hearing aid, not otherwise classified |
| V5299 | Hearing service, miscellaneous (effective 1/1/15) |
| V5336 | Repair/modification of augmentative communicative system or device (excludes adaptive hearing aid) (effective 1/1/15) |
Revision History
| Date | Nature of Revision |
|---|---|
| 08/03/2026 | Migrated to new platform. |