revenue codes with special procedure code linkages

INDIANA HEALTH COVERAGE PROGRAMS

PROVIDER CODE TABLES

Published: January 4, 2022 1

Revenue Codes With Special Procedure Code Linkages

Note: Due to possible changes in Indiana Health Coverage Programs (IHCP) policy or national

coding updates, inclusion of a code on the code tables does not necessarily indicate

current coverage. See IHCP Banner Pages and Bulletins and the IHCP Fee Schedules

for updates to coding, coverage, and benefit information.

For information about using this code table, see the Claim Submission and Processing

provider reference module.

Table 1 – Procedure Codes Linked to Revenue Code 260 – IV Therapy – General

Table 2 – Procedure Codes Linked to Revenue Code 274 – Prosthetic/Orthotic Devices

Table 3 – Procedure Codes Linked to Revenue Code 636 – Drugs Requiring Detailed Coding

Table 4 – Procedure Code Linked to Revenue Code 724 – Labor Room/Delivery – Birthing Center

Table 5 – Procedure Codes Linked to Revenue Code 920 – Other Diagnostic Services – General

Table 6 – Procedure Codes Linked to Revenue Code 929 – Other Diagnostic Services

Table 7 – Procedure Codes Linked to Revenue Code 940 – Other Therapeutic Services – General

Table 8 – Procedure Codes Linked to Revenue Codes for Managed Care Billing Only

(Revenue Codes 912, 913, and 960)

https://www.in.gov/medicaid/providers/provider-references/news-bulletins-and-banner-pages/

http://provider.indianamedicaid.com/ihcp/Publications/MaxFee/fee_schedule.asp

https://www.in.gov/medicaid/providers/files/claim-submission-and-processing.pdf

Indiana Health Coverage Programs Revenue Codes With Special Procedure Code Linkages



Reviewed/Updated: October 19, 2021

Note: The procedure codes in this table may be billed with revenue code 260 to receive separate

reimbursement when billed on the same date of service as a treatment room revenue code. Injection

administration (including vaccine administration) is included in the reimbursement for treatment

rooms. See the Outpatient Facility Services module for more information. All claims are subject to

postpayment review.

Procedure Code Description

96360 Intravenous infusion, hydration; initial, 31 minutes to 1 hour

96361 Intravenous infusion, hydration; each additional hour (List separately in addition to code for

primary procedure)

96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug);

initial, up to 1 hour

96366 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each

additional hour (List separately in addition to code for primary procedure)


additional sequential infusion of a new drug/substance, up to 1 hour (List separately in

addition to code for primary procedure)


concurrent infusion (List separately in addition to code for primary procedure)

96369 Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); initial, up to

1 hour, including pump set-up and establishment of subcutaneous infusion site(s)

96370 Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); each

additional hour (List separately in addition to code for primary procedure)

96371 Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); additional

pump set-up with establishment of new subcutaneous infusion site(s) (List separately in

addition to code for primary procedure)

96372 Injection beneath the skin or into muscle for therapy, diagnosis, or prevention

96373 Injection into artery for therapy, diagnosis, or prevention

96374 Injection of drug or substance into a vein for therapy, diagnosis, or prevention

96375 Injection of different drug or substance into a vein for therapy, diagnosis, or prevention

96521 Refilling and maintenance of portable pump

96522 Refilling and maintenance of implantable pump or reservoir for drug delivery

96523 Irrigation of implanted venous access drug delivery device

J1745 Injection, infliximab, excludes biosimilar, 10 mg

M0240 Intravenous infusion or subcutaneous injection, casirivimab and imdevimab includes

infusion or injection, and post administration monitoring, subsequent repeat doses


infusion or injection, and post administration monitoring in the home or residence; this

includes a beneficiary's home that has been made provider-based to the hospital during the

COVID-19 public health emergency, subsequent repeat doses


infusion or injection, and post administration monitoring

M0245 Intravenous infusion, bamlanivimab and etesevimab, includes infusion and post

administration monitoring

M0247 Intravenous infusion, sotrovimab, includes infusion and post administration monitoring

https://www.in.gov/medicaid/providers/files/outpatient-facility-services.pdf





Note: The procedure codes in this table may be billed with revenue code 260 to receive separate

reimbursement when billed on the same date of service as a treatment room revenue code. Injection

administration (including vaccine administration) is included in the reimbursement for treatment

rooms. See the Outpatient Facility Services module for more information. All claims are subject to

postpayment review.


M0248 Intravenous infusion, sotrovimab, includes infusion and post administration monitoring in

the home or residence; this includes a beneficiary's home that has been made provider-based

to the hospital during the COVID-19 public health emergency

M0249 Intravenous infusion, tocilizumab, for hospitalized adults and pediatric patients (2 years of

age and older) with COVID-19 who are receiving systemic corticosteroids and require

supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal

membrane oxygenation (ECMO) only, includes infusion and post administration monitoring,

first dose





second dose

Q0081 Infusion therapy, using other than chemotherapeutic drugs, per visit

Table 1 Revision History

October 19, 2021, update:

Added (effective October 1, 2021): M0240, M0241, M0247–M0250

Added (effective July 1, 2021): M0245

Added (effective April 1, 2021): J1745, M0243

June 8, 2021, update:

Added (correction): 96372–96375, 96521–96523, Q0081





Reviewed/Updated: December 16, 2021

Note: The procedure codes in this table may be separately reimbursed in the outpatient setting when billed

with revenue code 274. No other procedure codes will be reimbursed when billed with revenue code 274,

and revenue code 274 will not be reimbursed when billed without a procedure code on this list.


L0112 Cranial cervical orthotic, congenital torticollis type, with or without soft interface material,

adjustable range of motion joint, custom fabricated

L0113 Cranial cervical orthotic, torticollis type, with or without joint, with or without soft interface

material, prefabricated, includes fitting and adjustment

L0120 Cervical, flexible, nonadjustable, prefabricated, off-the-shelf (foam collar)

L0130 Cervical, flexible, thermoplastic collar, molded to patient

L0140 Cervical, semi-rigid, adjustable (plastic collar)

L0150 Cervical, semi-rigid, adjustable molded chin cup (plastic collar with mandibular/occipital

piece)

L0160 Cervical, semi-rigid, wire frame occipital/mandibular support, prefabricated, off-the-shelf

L0170 Cervical, collar, molded to patient model

L0172 Cervical, collar, semi-rigid thermoplastic foam, two-piece, prefabricated, off-the-shelf

L0174 Cervical, collar, semi-rigid, thermoplastic foam, two piece with thoracic extension,

prefabricated, off-the-shelf

L0180 Cervical, multiple post collar, occipital/mandibular supports, adjustable

L0190 Cervical, multiple post collar, occipital/mandibular supports, adjustable cervical bars

(SOMI, Guilford, Taylor types)

L0200 Cervical, multiple post collar, occipital/mandibular supports, adjustable cervical bars, and

thoracic extension

L0220 Thoracic, rib belt, custom fabricated

L0450 TLSO, flexible, provides trunk support, upper thoracic region, produces intracavitary

pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes

shoulder straps and closures, prefabricated, off-the-shelf

L0452 Thoracic-lumbar-sacral orthotic (TLSO), flexible, provides trunk support, upper thoracic

region, produces intracavitary pressure to reduce load on the intervertebral disks with rigid

stays or panel(s), includes shoulder straps and closures, custom fabricated

L0454 Thoracic-lumbar-sacral orthotic (TLSO), flexible, provides trunk support, extends from

sacrococcygeal junction to above T-9 vertebra, restricts gross trunk motion in the sagittal

plane, produces intracavitary pressure to reduce load on the intervertebral disks with rigid

stays or panel(s), includes shoulder straps and closures, prefabricated item that has been

trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an

individual with expertise

L0455 Thoracic-lumbar-sacral orthotic (TLSO), flexible, provides trunk support, extends from

sacrococcygeal junction to above T-9 vertebra, restricts gross trunk motion in the sagittal

plane, produces intracavitary pressure to reduce load on the intervertebral disks with rigid

stays or panel(s), includes shoulder straps and closures, prefabricated, off-the-shelf

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 orthotic (TLSO), triplanar 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, coronal, and transverse

planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes

straps and closures, prefabricated, includes fitting and adjustment


system, two rigid plastic shells, posterior extends from the sacrococcygeal junction and


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


system, 3 rigid plastic shells, posterior extends from the sacrococcygeal junction and


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


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

L0466 Thoracic-lumbar-sacral orthotic (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

item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a

specific patient by an individual with expertise

L0467 Thoracic-lumbar-sacral orthotic (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, prefabricated item that has been trimmed,

bent, molded, assembled, or otherwise customized to fit a specific patient by an individual

with expertise

L0469 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, 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 sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal,

coronal, and transverse planes, includes a carved plaster or CAD-CAM model, custom

fabricated

L0482 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












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




sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal,

and transverse planes, prefabricated, includes fitting and adjustment

L0490 Thoracic-lumbar-sacral orthotic (TLSO), sagittal-coronal control, 1 piece rigid plastic shell,

with overlapping reinforced anterior, with multiple straps and closures, posterior extends

from sacrococcygeal junction and terminates at or before the T-9 vertebra, anterior extends

from symphysis pubis to xiphoid, anterior opening, restricts gross trunk motion in sagittal

and coronal planes, prefabricated, includes fitting and adjustment

L0491 Thoracic-lumbar-sacral orthotic (TLSO), sagittal-coronal control, modular segmented

spinal system, 2 rigid plastic shells, posterior extends from the sacrococcygeal junction and


the xiphoid, soft liner, restricts gross trunk motion in the sagittal and coronal planes, lateral



L0492 Thoracic-lumbar-sacral orthotic (TLSO), sagittal-coronal control, modular segmented

spinal system, 3 rigid plastic shells, posterior extends from the sacrococcygeal junction and


the xiphoid, soft liner, restricts gross trunk motion in the sagittal and coronal planes, lateral



L0621 Sacroiliac orthosis, flexible, provides pelvic-sacral support, reduces motion about the

sacroiliac joint, includes straps, closures, may include pendulous abdomen design,


L0622 Sacroiliac orthotic, flexible, provides pelvic-sacral support, reduces motion about the

sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom

fabricated

L0623 Sacroiliac orthosis, provides pelvic-sacral support, with rigid or semi-rigid panels over the

sacrum and abdomen, reduces motion about the sacroiliac joint, includes straps, closures,

may include pendulous abdomen design, prefabricated, off-the-shelf

L0624 Sacroiliac orthotic, provides pelvic-sacral support, with rigid or semi-rigid panels placed

over the sacrum and abdomen, reduces motion about the sacroiliac joint, includes straps,

closures, may include pendulous abdomen design, custom fabricated

L0625 Lumbar orthosis, flexible, provides lumbar support, posterior extends from L-1 to below L-

5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs,

includes straps, closures, may include pendulous abdomen design, shoulder straps, stays,










L0626 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 item that has been trimmed, bent, molded, assembled, or


L0627 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 item that has been trimmed, bent, molded,

assembled, or otherwise customized to fit a specific patient by an individual with expertise

L0628 Lumbar-sacral orthosis, flexible, provides lumbo-sacral support, posterior extends from

sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on

the intervertebral discs, includes straps, closures, may include stays, shoulder straps,

pendulous abdomen design, prefabricated, off-the-shelf

L0629 Lumbar-sacral orthotic, flexible, provides lumbo-sacral support, posterior extends from

sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on

the intervertebral discs, includes straps, closures, may include stays, shoulder straps,

pendulous abdomen design, custom fabricated

L0630 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 item that has been trimmed, bent,


expertise

L0631 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 item that has been trimmed, bent,


expertise

L0632 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, custom fabricated

L0633 Lumbar-sacral orthosis, sagittal-coronal control, with rigid posterior frame/panel(s),

posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by

rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral


abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or


L0634 Lumbar-sacral orthotic (LSO), sagittal-coronal control, with rigid 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


abdomen design, custom fabricated









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 orthosis, 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 item that has been trimmed, bent, molded,


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


pendulous abdomen design, custom fabricated

L0639 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 item that has

been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by

an individual with expertise

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


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,










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









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



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)

L0810 Halo procedure, cervical halo incorporated into jacket vest

L0820 Halo procedure, cervical halo incorporated into plaster body jacket

L0830 Halo procedure, cervical halo incorporated into Milwaukee type orthotic

L0859 Addition to halo procedure, magnetic resonance image compatible systems, rings and pins,

any material

L0861 Addition to halo procedure, replacement liner/interface material

L0970 Thoracic-lumbar-sacral orthotic (TLSO), corset front

L0972 Lumbar-sacral orthotic (LSO), corset front

L0974 Thoracic-lumbar-sacral orthotic (TLSO), full corset

L0976 Lumbar-sacral orthotic (LSO), full corset

L0978 Axillary crutch extension

L0999 Addition to spinal orthotic, not otherwise specified

L1000 Cervical-thoracic-lumbar-sacral orthotic (CTLSO) (Milwaukee), inclusive of furnishing

initial orthotic, including model

L1001 Cervical-thoracic-lumbar-sacral orthotic (CTLSO), immobilizer, infant size, prefabricated,

includes fitting and adjustment









L1005 Tension based scoliosis orthotic and accessory pads, includes fitting and adjustment

L1010 Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, axilla

sling

L1020 Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic,

kyphosis pad


kyphosis pad, floating

L1030 Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, lumbar

bolster pad


or lumbar rib pad

L1050 Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, sternal

pad

L1060 Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, thoracic

pad


trapezius sling


outrigger


outrigger, bilateral with vertical extensions


sling

L1100 Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, ring

flange, plastic or leather

L1110 Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, ring

flange, plastic or leather, molded to patient model

L1120 Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO), scoliosis orthotic, cover for

upright, each

L1200 Thoracic-lumbar-sacral orthotic (TLSO), inclusive of furnishing initial orthotic only

L1210 Addition to thoracic-lumbar-sacral orthotic (TLSO), (low profile), lateral thoracic extension

L1220 Addition to thoracic-lumbar-sacral orthotic (TLSO), (low profile), anterior thoracic

extension

L1230 Addition to thoracic-lumbar-sacral orthotic (TLSO), (low profile), Milwaukee type

superstructure

L1240 Addition to thoracic-lumbar-sacral orthotic (TLSO), (low profile), lumbar derotation pad

L1250 Addition to thoracic-lumbar-sacral orthotic (TLSO), (low profile), anterior ASIS pad

L1260 Addition to thoracic-lumbar-sacral orthotic (TLSO), (low profile), anterior thoracic

derotation pad

L1270 Addition to thoracic-lumbar-sacral orthotic (TLSO), (low profile), abdominal pad









L1280 Addition to thoracic-lumbar-sacral orthotic (TLSO), (low profile), rib gusset (elastic), each

L1290 Addition to thoracic-lumbar-sacral orthotic (TLSO), (low profile), lateral trochanteric pad

L1300 Other scoliosis procedure, body jacket molded to patient model

L1310 Other scoliosis procedure, postoperative body jacket

L1499 Spinal orthotic, not otherwise specified

L1600 Hip orthosis, abduction control of hip joints, flexible, Frejka type with cover, prefabricated



L1610 Hip orthosis, abduction control of hip joints, flexible, (Frejka cover only), prefabricated



L1620 Hip orthosis, abduction control of hip joints, flexible, (Pavlik harness), prefabricated item

that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific

patient by an individual with expertise

L1630 Hip orthotic (HO), abduction control of hip joints, semi-flexible (Von Rosen type), custom

fabricated

L1640 Hip orthotic (HO), abduction control of hip joints, static, pelvic band or spreader bar, thigh

cuffs, custom fabricated

L1650 Hip orthotic (HO), abduction control of hip joints, static, adjustable, (Ilfled type),


L1652 Hip orthotic (HO), bilateral thigh cuffs with adjustable abductor spreader bar, adult size,

prefabricated, includes fitting and adjustment, any type

L1660 Hip orthotic (HO), abduction control of hip joints, static, plastic, prefabricated, includes

fitting and adjustment

L1680 Hip orthotic (HO), abduction control of hip joints, dynamic, pelvic control, adjustable hip

motion control, thigh cuffs (Rancho hip action type), custom fabricated

L1685 Hip orthosis, abduction control of hip joint, postoperative hip abduction type, custom

fabricated

L1686 Hip orthotic (HO), abduction control of hip joint, postoperative hip abduction type,


L1690 Combination, bilateral, lumbo-sacral, hip, femur orthotic providing adduction and internal

rotation control, prefabricated, includes fitting and adjustment

L1700 Legg Perthes orthotic, (Toronto type), custom fabricated

L1710 Legg Perthes orthotic, (Newington type), custom fabricated

L1720 Legg Perthes orthotic, trilateral, (Tachdijan type), custom fabricated

L1730 Legg Perthes orthotic, (Scottish Rite type), custom fabricated

L1755 Legg Perthes orthotic, (Patten bottom type), custom fabricated

L1810 Knee orthosis, elastic with joints, prefabricated item that has been trimmed, bent, molded,


L1812 Knee orthosis, elastic with joints, prefabricated, off-the-shelf









L1820 Knee orthotic, elastic with condylar pads and joints, with or without patellar control,


L1830 Knee orthosis, immobilizer, canvas longitudinal, prefabricated, off-the-shelf

L1831 Knee orthotic, locking knee joint(s), positional orthotic, prefabricated, includes fitting and

adjustment

L1832 Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid

support, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise

customized to fit a specific patient by an individual with expertise

L1833 Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid

support, prefabricated, off-the shelf

L1834 Knee orthotic (KO), without knee joint, rigid, custom fabricated

L1836 Knee orthosis, rigid, without joint(s), includes soft interface material, prefabricated, off-the-

shelf

L1840 Knee orthotic (KO), derotation, medial-lateral, anterior cruciate ligament, custom fabricated

L1843 Knee orthosis, 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, prefabricated item that has been trimmed, bent, molded, assembled, or


L1844 Knee orthotic (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, double upright, thigh and calf, with adjustable flexion and extension joint


adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or


L1846 Knee orthotic (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, double upright with adjustable joint, with inflatable air support chamber(s),

prefabricated item that has been trimmed, bent, molded, assembled, or otherwise


L1848 Knee orthosis, double upright with adjustable joint, with inflatable air support chamber(s),


L1850 Knee orthosis, swedish type, prefabricated, off-the-shelf

L1851 Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint


adjustment, prefabricated, off-the-shelf

L1852 Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint


adjustment, prefabricated, off-the-shelf

L1860 Knee orthotic (KO), modification of supracondylar prosthetic socket, custom fabricated

(SK)









L1900 Ankle-foot orthotic (AFO), spring wire, dorsiflexion assist calf band, custom fabricated

L1902 Ankle foot orthosis, ankle gauntlet, prefabricated, off-the-shelf

L1904 Ankle orthosis, ankle gauntlet, custom-fabricated

L1906 Ankle foot orthosis, multiligamentus ankle support, prefabricated, off-the-shelf

L1907 Ankle orthosis, supramalleolar with straps, with or without interface/pads, custom

fabricated

L1910 Ankle-foot orthotic (AFO), posterior, single bar, clasp attachment to shoe counter,


L1920 Ankle-foot orthotic (AFO), single upright with static or adjustable stop (Phelps or Perlstein

type), 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,


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 orthotic (AFO), spiral, (Institute of Rehabilitative Medicine type), plastic,

custom fabricated

L1951 Ankle-foot orthotic (AFO), 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 orthotic (AFO), plastic with ankle joint, custom fabricated

L1971 Ankle-foot orthotic (AFO), plastic or other material with ankle joint, prefabricated, includes


L1980 Ankle-foot orthotic (AFO), single upright free plantar dorsiflexion, solid stirrup, calf

band/cuff (single bar ‘BK’ orthotic), custom fabricated

L1990 Ankle-foot orthotic (AFO), double upright free plantar dorsiflexion, solid stirrup, calf

band/cuff (double bar ‘BK’ orthotic), custom fabricated

L2000 Knee-ankle-foot orthotic (KAFO), single upright, free knee, free ankle, solid stirrup, thigh

and calf bands/cuffs (single bar ‘AK’ orthotic), custom fabricated

L2005 Knee-ankle-foot orthotic (KAFO), any material, single or double upright, stance control,

automatic lock and swing phase release, any type activation, includes ankle joint, any type,

custom fabricated

L2006 Knee ankle foot device, any material, single or double upright, swing and/or stance phase

microprocessor control with adjustability, includes all components (e.g., sensors, batteries,

charger), any type activation, with or without ankle joint(s), custom fabricated

L2010 Knee-ankle-foot orthotic (KAFO), single upright, free ankle, solid stirrup, thigh and calf

bands/cuffs (single bar ‘AK’ orthotic), without knee joint, custom fabricated









L2020 Knee-ankle-foot orthotic (KAFO), double upright, free ankle, solid stirrup, thigh and calf

bands/cuffs (double bar ‘AK’ orthotic), custom fabricated

L2030 Knee-ankle-foot orthotic (KAFO), double upright, free ankle, solid stirrup, thigh and calf

bands/cuffs, (double bar ‘AK’ orthotic), without knee joint, custom fabricated

L2034 Knee-ankle-foot orthotic (KAFO), full plastic, single upright, with or without free motion

knee, medial-lateral rotation control, with or without free motion ankle, custom fabricated

L2035 Knee-ankle-foot orthotic (KAFO), full plastic, static (pediatric size), without free motion

ankle, prefabricated, includes fitting and adjustment

L2036 Knee-ankle-foot orthotic (KAFO), full plastic, double upright, with or without free motion

knee, with or without free motion ankle, custom fabricated

L2037 Knee-ankle-foot orthotic (KAFO), full plastic, single upright, with or without free motion

knee, with or without free motion ankle, custom fabricated

L2038 Knee-ankle-foot orthotic (KAFO), full plastic, with or without free motion knee, multi-axis

ankle, custom fabricated

L2040 Hip-knee-ankle-foot orthotic (HKAFO), torsion control, bilateral rotation straps, pelvic

band/belt, custom fabricated

L2050 Hip-knee-ankle-foot orthotic (HKAFO), torsion control, bilateral torsion cables, hip joint,

pelvic band/belt, custom fabricated

L2060 Hip-knee-ankle-foot orthotic (HKAFO), torsion control, bilateral torsion cables, ball

bearing hip joint, pelvic band/ belt, custom fabricated

L2070 Hip-knee-ankle-foot orthotic (HKAFO), torsion control, unilateral rotation straps, pelvic

band/belt, custom fabricated

L2080 Hip-knee-ankle-foot orthotic (HKAFO), torsion control, unilateral torsion cable, hip joint,

pelvic band/belt, custom fabricated

L2090 Hip-knee-ankle-foot orthotic (HKAFO), torsion control, unilateral torsion cable, ball

bearing hip joint, pelvic band/ belt, custom fabricated

L2106 Ankle-foot orthotic (AFO), fracture orthotic, tibial fracture cast orthotic, thermoplastic type

casting material, custom fabricated

L2108 Ankle-foot orthotic (AFO), fracture orthotic, tibial fracture cast orthotic, custom fabricated

L2112 Ankle-foot orthotic (AFO), fracture orthotic, tibial fracture orthotic, soft, prefabricated,


L2114 Ankle-foot orthotic (AFO), fracture orthotic, tibial fracture orthotic, semi-rigid,


L2116 Ankle-foot orthotic (AFO), fracture orthotic, tibial fracture orthotic, rigid, prefabricated,


L2126 Knee-ankle-foot orthotic (KAFO), fracture orthotic, femoral fracture cast orthotic,

thermoplastic type casting material, custom fabricated

L2128 Knee-ankle-foot orthotic (KAFO), fracture orthotic, femoral fracture cast orthotic, custom

fabricated

L2132 Knee-ankle-foot orthotic (KAFO), fracture orthotic, femoral fracture cast orthotic, soft,










L2134 Knee-ankle-foot orthotic (KAFO), fracture orthotic, femoral fracture cast orthotic, semi-

rigid, prefabricated, includes fitting and adjustment

L2136 Knee-ankle-foot orthotic (KAFO), fracture orthotic, femoral fracture cast orthotic, rigid,


L2180 Addition to lower extremity fracture orthotic, plastic shoe insert with ankle joints

L2182 Addition to lower extremity fracture orthotic, drop lock knee joint

L2184 Addition to lower extremity fracture orthotic, limited motion knee joint

L2186 Addition to lower extremity fracture orthotic, adjustable motion knee joint, Lerman type

L2188 Addition to lower extremity fracture orthotic, quadrilateral brim

L2190 Addition to lower extremity fracture orthotic, waist belt

L2192 Addition to lower extremity fracture orthotic, hip joint, pelvic band, thigh flange, and pelvic

belt

L2200 Addition to lower extremity, limited ankle motion, each joint

L2210 Addition to lower extremity, dorsiflexion assist (plantar flexion resist), each joint

L2220 Addition to lower extremity, dorsiflexion and plantar flexion assist/resist, each joint

L2230 Addition to lower extremity, split flat caliper stirrups and plate attachment

L2232 Addition to lower extremity orthotic, rocker bottom for total contact ankle-foot orthotic

(AFO), for custom fabricated orthotic only

L2240 Addition to lower extremity, round caliper and plate attachment

L2250 Addition to lower extremity, foot plate, molded to patient model, stirrup attachment

L2260 Addition to lower extremity, reinforced solid stirrup (Scott-Craig type)

L2265 Addition to lower extremity, long tongue stirrup

L2270 Addition to lower extremity, varus/valgus correction (T) strap, padded/lined or malleolus

pad

L2275 Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined

L2280 Addition to lower extremity, molded inner boot

L2300 Addition to lower extremity, abduction bar (bilateral hip involvement), jointed, adjustable

L2310 Addition to lower extremity, abduction bar, straight

L2320 Addition to lower extremity, nonmolded lacer, for custom fabricated orthotic only

L2330 Addition to lower extremity, lacer molded to patient model, for custom fabricated orthotic

only

L2335 Addition to lower extremity, anterior swing band

L2340 Addition to lower extremity, pretibial shell, molded to patient model

L2350 Addition to lower extremity, prosthetic type, (BK) socket, molded to patient model, (used

for PTB, AFO orthoses)

L2360 Addition to lower extremity, extended steel shank

L2370 Addition to lower extremity, Patten bottom









L2375 Addition to lower extremity, torsion control, ankle joint and half solid stirrup

L2380 Addition to lower extremity, torsion control, straight knee joint, each joint

L2385 Addition to lower extremity, straight knee joint, heavy-duty, each joint

L2387 Addition to lower extremity, polycentric knee joint, for custom fabricated knee-ankle-foot

orthotic (KAFO), each joint

L2390 Addition to lower extremity, offset knee joint, each joint

L2395 Addition to lower extremity, offset knee joint, heavy-duty, each joint

L2397 Addition to lower extremity orthotic, suspension sleeve

L2405 Addition to knee joint, drop lock, each

L2415 Addition to knee lock with integrated release mechanism (bail, cable, or equal), any

material, each joint

L2425 Addition to knee joint, disc or dial lock for adjustable knee flexion, each joint

L2430 Addition to knee joint, ratchet lock for active and progressive knee extension, each joint

L2492 Addition to knee joint, lift loop for drop lock ring

L2500 Addition to lower extremity, thigh/weight bearing, gluteal/ischial weight bearing, ring

L2510 Addition to lower extremity, thigh/weight bearing, quadri-lateral brim, molded to patient

model

L2520 Addition to lower extremity, thigh/weight bearing, quadri-lateral brim, custom fitted

L2525 Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim

molded to patient model

L2526 Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim,

custom fitted

L2530 Addition to lower extremity, thigh/weight bearing, lacer, nonmolded

L2540 Addition to lower extremity, thigh/weight bearing, lacer, molded to patient model

L2550 Addition to lower extremity, thigh/weight bearing, high roll cuff

L2570 Addition to lower extremity, pelvic control, hip joint, Clevis type 2 position joint, each

L2580 Addition to lower extremity, pelvic control, pelvic sling

L2600 Addition to lower extremity, pelvic control, hip joint, Clevis type, or thrust bearing, free,

each

L2610 Addition to lower extremity, pelvic control, hip joint, Clevis or thrust bearing, lock, each

L2620 Addition to lower extremity, pelvic control, hip joint, heavy-duty, each

L2622 Addition to lower extremity, pelvic control, hip joint, adjustable flexion, each

L2624 Addition to lower extremity, pelvic control, hip joint, adjustable flexion, extension,

abduction control, each

L2627 Addition to lower extremity, pelvic control, plastic, molded to patient model, reciprocating

hip joint and cables

L2628 Addition to lower extremity, pelvic control, metal frame, reciprocating hip joint and cables

L2630 Addition to lower extremity, pelvic control, band and belt, unilateral









L2640 Addition to lower extremity, pelvic control, band and belt, bilateral

L2650 Addition to lower extremity, pelvic and thoracic control, gluteal pad, each

L2660 Addition to lower extremity, thoracic control, thoracic band

L2670 Addition to lower extremity, thoracic control, paraspinal uprights

L2680 Addition to lower extremity, thoracic control, lateral support uprights

L2750 Addition to lower extremity orthotic, plating chrome or nickel, per bar

L2755 Addition to lower extremity orthotic, high strength, lightweight material, all hybrid

lamination/prepreg composite, per segment, for custom fabricated orthotic only

L2760 Addition to lower extremity orthotic, extension, per extension, per bar (for lineal adjustment

for growth)

L2768 Orthotic side bar disconnect device, per bar

L2780 Addition to lower extremity orthotic, noncorrosive finish, per bar

L2785 Addition to lower extremity orthotic, drop lock retainer, each

L2795 Addition to lower extremity orthotic, knee control, full kneecap

L2800 Addition to lower extremity orthotic, knee control, knee cap, medial or lateral pull, for use

with custom fabricated orthotic only

L2810 Addition to lower extremity orthotic, knee control, condylar pad

L2820 Addition to lower extremity orthotic, soft interface for molded plastic, below knee section

L2830 Addition to lower extremity orthotic, soft interface for molded plastic, above knee section

L2840 Addition to lower extremity orthotic, tibial length sock, fracture or equal, each

L2850 Addition to lower extremity orthotic, femoral length sock, fracture or equal, each

L2861 Addition to lower extremity joint, knee or ankle, concentric adjustable torsion style

mechanism for custom fabricated orthotics only, each

L2999 Lower extremity orthotic, not otherwise specified

L3000 Foot insert, removable, molded to patient model, UCB type, Berkeley shell, each

L3001 Foot, insert, removable, molded to patient model, Spenco, each

L3002 Foot insert, removable, molded to patient model, Plastazote or equal, each

L3003 Foot insert, removable, molded to patient model, silicone gel, each

L3010 Foot insert, removable, molded to patient model, longitudinal arch support, each

L3020 Foot insert, removable, molded to patient model, longitudinal/metatarsal support, each

L3030 Foot insert, removable, formed to patient foot, each

L3031 Foot, insert/plate, removable, addition to lower extremity orthotic, high strength,

lightweight material, all hybrid lamination/prepreg composite, each

L3140 Foot, abduction rotation bar, including shoes

L3150 Foot, abduction rotation bar, without shoes

L3160 Foot, adjustable shoe-styled positioning device

L3170 Foot, plastic, silicone or equal, heel stabilizer, prafabricated, off-the-shelf, each









L3201 Orthopedic shoe, Oxford with supinator or pronator, infant

L3202 Orthopedic shoe, Oxford with supinator or pronator, child

L3203 Orthopedic shoe, Oxford with supinator or pronator, junior

L3204 Orthopedic shoe, hightop with supinator or pronator, infant

L3206 Orthopedic shoe, hightop with supinator or pronator, child

L3207 Orthopedic shoe, hightop with supinator or pronator, junior

L3208 Surgical boot, each, infant

L3209 Surgical boot, each, child

L3211 Surgical boot, each, junior

L3212 Benesch boot, pair, infant

L3213 Benesch boot, pair, child

L3214 Benesch boot, pair, junior

L3215 Orthopedic footwear, ladies shoe, oxford, each

L3216 Orthopedic footwear, ladies shoe, depth inlay, each

L3217 Orthopedic footwear, ladies shoe, hightop, depth inlay, each

L3219 Orthopedic footwear, mens shoe, oxford, each

L3221 Orthopedic footwear, mens shoe, depth inlay, each

L3222 Orthopedic footwear, mens shoe, hightop, depth inlay, each

L3224 Orthopedic footwear, woman's shoe, oxford, used as an integral part of a brace (orthotic)

L3225 Orthopedic footwear, man's shoe, oxford, used as an integral part of a brace (orthotic)

L3230 Orthopedic footwear, custom shoe, depth inlay, each

L3250 Orthopedic footwear, custom molded shoe, removable inner mold, prosthetic shoe, each

L3251 Foot, shoe molded to patient model, silicone shoe, each

L3252 Foot, shoe molded to patient model, Plastazote (or similar), custom fabricated, each

L3253 Foot, molded shoe, Plastazote (or similar), custom fitted, each

L3254 Nonstandard size or width

L3255 Nonstandard size or length

L3257 Orthopedic footwear, additional charge for split size

L3260 Surgical boot/shoe, each

L3265 Plastazote sandal, each

L3600 Transfer of an orthotic from one shoe to another, caliper plate, existing

L3610 Transfer of an orthotic from one shoe to another, caliper plate, new

L3620 Transfer of an orthotic from one shoe to another, solid stirrup, existing

L3630 Transfer of an orthotic from one shoe to another, solid stirrup, new

L3640 Transfer of an orthotic from one shoe to another, Dennis Browne splint (Riveton), both

shoes









L3649 Orthopedic shoe, modification, addition or transfer, not otherwise specified

L3650 Shoulder orthosis, figure of eight design abduction restrainer, prefabricated, off-the-shelf

L3660 Shoulder orthosis, figure of eight design abduction restrainer, canvas and webbing,


L3670 Shoulder orthosis, acromio/clavicular (canvas and webbing type), prefabricated, off-the-

shelf

L3671 Shoulder orthotic (SO), shoulder joint design, without joints, may include soft interface,

straps, custom fabricated, includes fitting and adjustment

L3674 Shoulder orthotic, abduction positioning (airplane design), thoracic component and support

bar, with or without nontorsion joint/turnbuckle, may include soft interface, straps, custom

fabricated, includes fitting and adjustment

L3675 Shoulder orthosis, vest type abduction restrainer, canvas webbing type or equal,


L3677 Shoulder orthosis, shoulder joint design, without joints, may include soft interface, straps,



L3678 Shoulder orthosis, shoulder joint design, without joints, may include soft interface, straps,


L3702 Elbow orthotic (EO), without joints, may include soft interface, straps, custom fabricated,


L3710 Elbow orthosis, elastic with metal joints, prefabricated, off-the-shelf

L3720 Elbow orthotic (EO), double upright with forearm/arm cuffs, free motion, custom fabricated

L3730 Elbow orthotic (EO), double upright with forearm/arm cuffs, extension/ flexion assist,

custom fabricated

L3740 Elbow orthotic (EO), double upright with forearm/arm cuffs, adjustable position lock with

active control, custom fabricated

L3760 Elbow orthotic (EO), with adjustable position locking joint(s), prefabricated, item that has

been trimmed, bent, molded, assembled, or otherwise

L3761 Elbow orthosis (EO), with adjustable position locking joint(s), prefabricated, off-the-shelf

L3762 Elbow orthosis, rigid, without joints, includes soft interface material, prefabricated, off-the-

shelf

L3763 Elbow-wrist-hand orthotic (EWHO), rigid, without joints, may include soft interface, straps,

custom fabricated, includes fitting and adjustment

L3764 Elbow-wrist-hand orthotic (EWHO), includes one or more nontorsion joints, elastic bands,

turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and

adjustment

L3765 Elbow-wrist-hand-finger orthotic (EWHFO), rigid, without joints, may include soft

interface, straps, custom fabricated, includes fitting and adjustment

L3766 Elbow-wrist-hand-finger orthotic (EWHFO), includes one or more nontorsion joints, elastic

bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting

and adjustment









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,


L3807 Wrist hand finger orthosis, without joint(s), prefabricated item that has been trimmed, bent,


expertise

L3808 Wrist-hand-finger orthotic (WHFO), rigid without joints, may include soft interface

material; straps, custom fabricated, includes fitting and adjustment

L3809 Wrist hand finger orthosis, without joint(s), prefabricated, off-the-shelf, any type

L3891 Addition to upper extremity joint, wrist or elbow, concentric adjustable torsion style

mechanism for custom fabricated orthotics only, each

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,


adjustment

L3906 Wrist-hand orthosis (WHO), without joints, may include soft interface, straps, custom


L3908 Wrist hand orthosis, wrist extension control cock-up, non molded, prefabricated, off-the-

shelf

L3912 Hand finger orthosis (HFO), flexion glove with elastic finger control, prefabricated, off-the-

shelf

L3913 Hand finger orthotic (HFO), without joints, may include soft interface, straps, custom


L3915 Wrist hand orthosis, includes one or more nontorsion joint(s), elastic bands, turnbuckles,

may include soft interface, straps, prefabricated item that has been trimmed, bent, molded,


L3916 Wrist hand orthosis, includes one or more nontorsion joint(s), elastic bands, turnbuckles,

may include soft interface, straps, prefabricated, off-the-shelf

L3917 Hand orthosis, metacarpal fracture orthosis, prefabricated item that has been trimmed, bent,


expertise

L3918 Hand orthosis, metacarpal fracture orthosis, prefabricated, off-the-shelf

L3919 Hand orthotic (HO), without joints, may include soft interface, straps, custom fabricated,


L3921 Hand finger orthotic (HFO), includes one or more nontorsion joints, elastic bands,


adjustment









L3923 Hand finger orthosis, without joints, may include soft interface, straps, prefabricated item

that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific

patient by an individual with expertise

L3924 Hand finger orthosis, without joints, may include soft interface, straps, prefabricated, off-

the-shelf

L3925 Finger orthosis, proximal interphalangeal (PIP)/distal interphalangeal (DIP), non-torsion

joint/spring, extension/flexion, may include soft interface material, prefabricated, off-the-

shelf

L3927 Finger orthosis, proximal interphalangeal (PIP)/distal interphalangeal (DIP), without

joint/spring, extension/flexion (e.g., static or ring type), may include soft interface material,


L3929 Hand finger orthosis, includes one or more nontorsion joint(s), turnbuckles, elastic

bands/springs, may include soft interface material, straps, prefabricated item that has been

trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an

individual with expertise

L3930 Hand finger orthosis, includes one or more nontorsion joint(s), turnbuckles, elastic

bands/springs, may include soft interface material, straps, prefabricated, off-the-shelf

L3931 Wrist-hand-finger orthotic (WHFO), includes one or more nontorsion joint(s), turnbuckles,

elastic bands/springs, may include soft interface material, straps, prefabricated, includes


L3933 Finger orthotic (FO), without joints, may include soft interface, custom fabricated, includes


L3935 Finger orthotic, nontorsion joint, may include soft interface, custom fabricated, includes


L3956 Addition of joint to upper extremity orthotic, any material; per joint

L3960 Shoulder-elbow-wrist-hand orthotic (SEWHO), abduction positioning, airplane design,


L3961 Shoulder elbow wrist hand orthotic (SEWHO), shoulder cap design, without joints, may

include soft interface, straps, custom fabricated, includes fitting and adjustment

L3962 Shoulder-elbow-wrist-hand orthotic (SEWHO), abduction positioning, Erb's palsy design,


L3967 Shoulder-elbow-wrist-hand orthotic (SEWHO), abduction positioning (airplane design),

thoracic component and support bar, without joints, may include soft interface, straps,


L3971 Shoulder-elbow-wrist-hand orthotic (SEWHO), shoulder cap design, includes one or more

nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom


L3973 Shoulder-elbow-wrist-hand orthotic (SEWHO), abduction positioning (airplane design),

thoracic component and support bar, includes one or more nontorsion joints, elastic bands,


adjustment

L3975 Shoulder-elbow-wrist-hand-finger orthotic (SEWHO), shoulder cap design, without joints,

may include soft interface, straps, custom fabricated, includes fitting and adjustment









L3976 Shoulder-elbow-wrist-hand-finger orthotic (SEWHO), abduction positioning (airplane

design), thoracic component and support bar, without joints, may include soft interface,

straps, custom fabricated, includes fitting and adjustment

L3977 Shoulder-elbow-wrist-hand-finger orthotic (SEWHO), shoulder cap design, includes one or

more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps,


L3978 Shoulder-elbow-wrist-hand-finger orthotic (SEWHO), abduction positioning (airplane

design), thoracic component and support bar, includes one or more nontorsion joints, elastic

bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting

and adjustment

L3980 Upper extremity fracture orthotic, humeral, prefabricated, includes fitting and adjustment

L3981 Upper extremity fracture orthosis, humeral, prefabricated, includes shoulder cap design,

with or without joints, forearm section, may include soft interface, straps, includes fitting

and adjustments

L3982 Upper extremity fracture orthotic, radius/ulnar, prefabricated, includes fitting and

adjustment

L3984 Upper extremity fracture orthotic, wrist, prefabricated, includes fitting and adjustment

L3995 Addition to upper extremity orthotic, sock, fracture or equal, each

L3999 Upper limb orthotic, not otherwise specified

L4000 Replace girdle for spinal orthotic (cervical-thoracic-lumbar-sacral orthotic (CTLSO) or

spinal orthotic SO)

L4002 Replacement strap, any orthotic, includes all components, any length, any type

L4010 Replace trilateral socket brim

L4020 Replace quadrilateral socket brim, molded to patient model

L4030 Replace quadrilateral socket brim, custom fitted

L4040 Replace molded thigh lacer, for custom fabricated orthotic only

L4045 Replace nonmolded thigh lacer, for custom fabricated orthotic only

L4050 Replace molded calf lacer, for custom fabricated orthotic only

L4055 Replace nonmolded calf lacer, for custom fabricated orthotic only

L4060 Replace high roll cuff

L4070 Replace proximal and distal upright for KAFO

L4080 Replace metal bands KAFO, proximal thigh

L4090 Replace metal bands KAFO-AFO, calf or distal thigh

L4100 Replace leather cuff KAFO, proximal thigh

L4110 Replace leather cuff KAFO-AFO, calf or distal thigh

L4130 Replace pretibial shell

L4205 Repair of orthotic device, labor component, per 15 minutes

L4210 Repair of orthotic device, repair or replace minor parts









L4350 Ankle control orthosis, stirrup style, rigid, includes any type interface (e.g., pneumatic, gel),


L4360 Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface

material, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise


L4361 Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface

material, prefabricated, off-the-shelf

L4370 Pneumatic full leg splint, prefabricated, off-the-shelf

L4386 Walking boot, non-pneumatic, with or without joints, with or without interface material,



L4387 Walking boot, non-pneumatic, with or without joints, with or without interface material,


L4392 Replacement, soft interface material, static AFO

L4394 Replace soft interface material, foot drop splint

L4396 Static or dynamic ankle foot orthosis, including soft interface material, adjustable for fit, for

positioning, may be used for minimal ambulation, prefabricated item that has been trimmed,

bent, molded, assembled, or otherwise customized to fit a specific patient by an individual

with expertise

L4397 Static or dynamic ankle foot orthosis, including soft interface material, adjustable for fit, for

positioning, may be used for minimal ambulation, prefabricated, off-the-shelf

L4398 Foot drop splint, recumbent positioning device, prefabricated, off-the-shelf

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


alignment and suspension, below knee, each additional cast change and realignment


alignment and suspension and one cast change AK or knee disarticulation


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


foot, thermoplastic or equal, direct formed


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


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


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


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

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

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

L6026 Transcarpal/metacarpal or partial hand disarticulation prosthesis, external power, self-

suspended, inner socket with removable forearm section, electrodes and cables, two

batteries, charger, myoelectric control of terminal device, excludes terminal device(s)

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 myoelectric 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,


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

L7259 Electronic wrist rotator, any type









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

L7700 Gasket or seal, for use with prosthetic socket insert, any type, each

L8000 Breast prosthesis, mastectomy bra, without integrated breast prosthesis form, any size, any

type

L8001 Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, unilateral, any

size, any type

L8002 Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, bilateral, any

size, any type

L8010 Breast prosthesis, mastectomy sleeve

L8015 External breast prosthesis garment, with mastectomy form, post mastectomy

L8020 Breast prosthesis, mastectomy form

L8030 Breast prosthesis, silicone or equal, without integral adhesive

L8031 Breast prosthesis, silicone or equal, with integral adhesive

L8035 Custom breast prosthesis, post mastectomy, molded to patient model

L8039 Breast prosthesis, not otherwise specified

L8040 Nasal prosthesis, provided by a nonphysician

L8041 Midfacial prosthesis, provided by a nonphysician

L8042 Orbital prosthesis, provided by a nonphysician









L8043 Upper facial prosthesis, provided by a nonphysician

L8044 Hemi-facial prosthesis, provided by a nonphysician

L8045 Auricular prosthesis, provided by a nonphysician

L8046 Partial facial prosthesis, provided by a nonphysician

L8047 Nasal septal prosthesis, provided by a nonphysician

L8048 Unspecified maxillofacial prosthesis, by report, provided by a nonphysician

L8049 Repair or modification of maxillofacial prosthesis, labor component, 15 minute increments,

provided by a nonphysician

L8499 Unlisted procedure for miscellaneous prosthetic services

L8500 Artificial larynx, any type

L8501 Tracheostomy speaking valve

L8505 Artificial larynx replacement battery/accessory, any type

L8507 Tracheo-esophageal voice prosthesis, patient inserted, any type, each

L8509 Tracheo-esophageal voice prosthesis, inserted by a licensed health care provider, any type

L8510 Voice amplifier

L8511 Insert for indwelling tracheoesophageal prosthesis, with or without valve, replacement only,

each

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 or auditory osseointegrated device,

replacement

L8619 Cochlear implant, external speech processor and controller, integrated system, replacement

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 or auditory osseointegrated device speech

processor, ear level, replacement, each

L8625 External recharging system for battery for use with cochlear implant or auditory

osseointegrated device, replacement only, each

L8627 Cochlear implant, external speech processor, component, replacement

L8628 Cochlear implant, external controller component, replacement

L8629 Transmitting coil and cable, integrated, for use with cochlear implant device, replacement

L8681 Patient programmer (external) for use with implantable programmable neurostimulator

pulse generator, replacement only

L8683 Radiofrequency transmitter (external) for use with implantable neurostimulator

radiofrequency receiver

L8684 Radiofrequency transmitter (external) for use with implantable sacral root neurostimulator

receiver for bowel and bladder management, replacement









L8689 External recharging system for battery (internal) for use with implantable neurostimulator,

replacement only

L8691 Auditory osseointegrated device, external sound processor, excludes transducer/actuator,

replacement only, each

L8692 Auditory osseointegrated device, external sound processor, used without osseointegration,

body worn, includes headband or other means of external attachment

L8694 Auditory osseointegrated device, transducer/actuator, replacement only, each

L8695 External recharging system for battery (external) for use with implantable neurostimulator,

replacement only

L8696 Antenna (external) for use with implantable diaphragmatic/phrenic nerve stimulation

device, replacement, each

L8701 Powered upper extremity range of motion assist device, elbow, wrist, hand with single or

double upright(s), includes microprocessor, sensors, all components, and accessories,

custom fabricated

L8702 Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or

double upright(s), includes microprocessor, sensors, all components and accessories,

custom fabricated

L9900 Orthotic and prosthetic supply, accessory, and/or service component of another HCPCS L

code

Q0477 Power module patient cable for use with electric or electric/pneumatic ventricular assist

device, replacement only

Q0478 Power adapter for use with electric or electric/pneumatic ventricular assist device, vehicle

type

Q0479 Power module for use with electric or electric/pneumatic ventricular assist device,

replacement only

Q0480 Driver for use with pneumatic ventricular assist device, replacement only

Q0481 Microprocessor control unit for use with electric ventricular assist device, replacement only

Q0482 Microprocessor control unit for use with electric/pneumatic combination ventricular assist


Q0483 Monitor/display module for use with electric ventricular assist device, replacement only

Q0484 Monitor/display module for use with electric or electric/pneumatic ventricular assist device,

replacement only

Q0485 Monitor control cable for use with electric ventricular assist device, replacement only

Q0486 Monitor control cable for use with electric/pneumatic ventricular assist device, replacement

only

Q0487 Leads (pneumatic/electrical) for use with any type electric/pneumatic ventricular assist


Q0488 Power pack base for use with electric ventricular assist device, replacement only

Q0489 Power pack base for use with electric/pneumatic ventricular assist device, replacement only

Q0490 Emergency power source for use with electric ventricular assist device, replacement only









Q0491 Emergency power source for use with electric/pneumatic ventricular assist device,

replacement only

Q0492 Emergency power supply cable for use with electric ventricular assist device, replacement

only

Q0493 Emergency power supply cable for use with electric/pneumatic ventricular assist device,

replacement only

Q0494 Emergency hand pump for use with electric or electric/pneumatic ventricular assist device,

replacement only

Q0495 Battery/power pack charger for use with electric or electric/pneumatic ventricular assist


Q0496 Battery, other than lithium-ion, for use with electric or electric/pneumatic ventricular assist


Q0497 Battery clips for use with electric or electric/pneumatic ventricular assist device,

replacement only

Q0498 Holster for use with electric or electric/pneumatic ventricular assist device, replacement

only

Q0499 Belt/vest/bag for use to carry external peripheral components of any type ventricular assist


Q0500 Filters for use with electric or electric/pneumatic ventricular assist device, replacement only

Q0501 Shower cover for use with electric or electric/pneumatic ventricular assist device,

replacement only

Q0502 Mobility cart for pneumatic ventricular assist device, replacement only

Q0503 Battery for pneumatic ventricular assist device, replacement only, each

Q0504 Power adapter for pneumatic ventricular assist device, replacement only, vehicle type

Q0506 Battery, lithium-ion, for use with electric or electric/pneumatic ventricular assist device,

replacement only

Q0507 Miscellaneous supply or accessory for use with an external ventricular assist device

Q0508 Miscellaneous supply or accessory for use with an implanted ventricular assist device

Q0509 Miscellaneous supply or accessory for use with any implanted ventricular assist device for

which payment was not made under Medicare Part A

S1040 Cranial remolding orthotic, pediatric, rigid, with soft interface material, custom fabricated,

includes fitting and adjustment(s)




December 16, 2021, update:

Added (effective December 16, 2021): L8701, L8702

July 1, 2020, update:

Added (correction): L3260, L3265

February 18, 2020, update:

Added (effective January 1, 2020): L2006

January 1, 2019, update:

Removed (effective January 1, 2019): K0903


Added (effective October 4, 2018): L3923

April 1, 2018, update:

Added (effective April 1, 2018): K0903


Added (effective January 1, 2018): L3761, L7700, L8625, L8694, Q0477

Updated description (effective January 1, 2018): L3760, L8618, L8624, L8691


Added (effective January 1, 2015): L3981, L6026, L7259, L8696


Added (effective January 1, 2017): L1851, L1852


Removed (effective January 1, 2015): L7260, L7261


Reviewed/Updated: January 1, 2022

Note: The procedure codes on this table may be separately reimbursed in the outpatient setting when billed


and revenue code 636 will not be reimbursed when billed without a procedure code on this list. See the

Outpatient Facility Services module for more information.


90283 Immune globulin (IgIV), human, for intravenous use

90287 Botulinum antitoxin, equine, any route

90288 Botulism immune globulin, human, for intravenous use

90291 Cytomegalovirus immune globulin (CMV-IgIV), human, for intravenous use

90371 Hepatitis B immune globulin (HBIg), human, for intramuscular use

90375 Rabies immune globulin (RIg), human, for intramuscular and/or subcutaneous use

90376 Rabies immune globulin, heat-treated (RIg-HT), human, for intramuscular and/or

subcutaneous use

90377 Rabies immune globulin for injection beneath the skin and/or into muscle

90384 Rho(D) immune globulin (RhIg), human, full-dose, for intramuscular use

90389 Tetanus immune globulin (TIg), human, for intramuscular use

90396 Varicella-zoster immune globulin, human, for intramuscular use

90399 Unlisted immune globulin

90585 Bacillus Calmette-Guerin vaccine (BCG) for tuberculosis, live, for percutaneous use

90586 Bacillus Calmette-Guerin vaccine (BCG) for bladder cancer, live, for intravesical use











90619 Meningococcal conjugate vaccine, serogroups A, C, W, Y, quadrivalent, tetanus toxoid

carrier (MenACWY-TT), for intramuscular use

90620 Vaccine for meningococcus for injection into muscle

90621 Vaccine for meningococcus for injection into muscle

90636 Hepatitis A and hepatitis B vaccine (HepA-HepB), adult dosage, for intramuscular use

90644 Meningococcal conjugate vaccine, serogroups C & Y and Haemophilus influenzae type b

vaccine (Hib-MenCY), 4 dose schedule, when administered to children 6 weeks-18 months

of age, for intramuscular use

90649 Human papilloma virus (HPV) vaccine, types 6, 11, 16, 18 (quadrivalent), 3 dose schedule,

for intramuscular use

90650 Human papilloma virus (HPV) vaccine, types 16, 18, bivalent, 3 dose schedule, for

intramuscular use

90651 Vaccine for human papilloma virus (3 dose schedule) injection into muscle

90670 Pneumococcal conjugate vaccine, 13 valent, for intramuscular use

90675 Rabies vaccine, for intramuscular use

90680 Rotavirus vaccine, pentavalent, 3 dose schedule, live, for oral use

90698 Diphtheria, tetanus toxoids, acellular pertussis vaccine, Haemophilus influenzae type b, and

inactivated poliovirus vaccine, (DTaP-IPV/Hib), for intramuscular use

90710 Measles, mumps, rubella, and varicella vaccine (MMRV), live, for subcutaneous use

90716 Varicella virus vaccine, live, for subcutaneous use

90723 Diphtheria, tetanus toxoids, acellular pertussis vaccine, hepatitis B, and inactivated poliovirus

vaccine (DTaP-HepB-IPV), for intramuscular use

90732 Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage,

when administered to individuals 2 years or older, for subcutaneous or intramuscular use

90733 Meningococcal polysaccharide vaccine (any group(s)), for subcutaneous use

90734 Meningococcal conjugate vaccine, serogroups A, C, Y and W-135, quadrivalent

(MenACWY), for intramuscular use

90736 Zoster (shingles) vaccine, live, for subcutaneous injection

90740 Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (3 dose schedule), for

intramuscular use

90747 Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (4 dose schedule), for

intramuscular use

90749 Unlisted vaccine/toxoid

90750 Shingrix (zoster vaccine recombinant, adjuvanted)

91300 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease

[COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage,

diluent reconstituted, for intramuscular use











91301 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease

[COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage,

for intramuscular use

91303 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) (coronavirus disease

[COVID-19]) vaccine, DNA, spike protein, adenovirus type 26 (Ad26) vector, preservative

free, 5x1010 viral particles/0.5mL dosage, for intramuscular use

91306 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) (coronavirus disease

[COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 50 mcg/0.25 mL

dosage, for intramuscular use

91307 Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease

[COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 10 mcg/0.2 mL dosage,

diluent reconstituted, tris-sucrose formulation, for intramuscular use

A2001 InnovaMatrix AC, per square centimeter

A2002 Mirragen advanced wound matrix, per square centimeter

A2003 Bio-ConneKt wound matrix, per square centimeter

A2004 XCelliStem, per square centimeter

A2005 Microlyte matrix, per square centimeter

A2006 NovoSorb SynPath dermal matrix, per square centimeter

A2007 Restrata, per square centimeter

A2008 TheraGenesis, per square centimeter

A2009 Symphony, per square centimeter

A2010 Apis, per square centimeter

A9513 Lutetium Lu 177, dotatate, therapeutic, 1 millicurie

A9527 Iodine I-125, sodium iodide solution, therapeutic, per millicurie

A9606 Radium RA-223 dichloride, therapeutic, per microcurie

C1716 Brachytherapy source, non-stranded, gold-198, per source

C1717 Brachytherapy source, non-stranded, high dose rate iridium 192, per source

C1719 Brachytherapy source, non-stranded, non-high dose rate iridium-192, per source

C2616 Brachytherapy source, non-stranded, yttium-90, per source

C2634 Brachytherapy source, non-stranded, high activity, iodine-125, greater than 1.01 mci (NIST),

per source

C2635 Brachytherapy source, non-stranded, high activity, palladium-103, greater than 2.2 mci

(NIST), per source

C2636 Brachytherapy linear source, non-stranded, palladium-103, per 1 mm

C2637 Brachytherapy source, non-stranded, Ytterbium-169, per source

C2638 Brachytherapy source, stranded, iodine-125, per source

C2639 Brachytherapy source, non-stranded, iodine-125, per source











C2640 Brachytherapy source, stranded, palladium-103, per source

C2641 Brachytherapy source, non-stranded, palladium-103, per source

C2642 Brachytherapy source, stranded, cesium-131, per source

C2643 Brachytherapy source, non-stranded, cesium-131, per source

C2644 Brachytherapy source, cesium-131 chloride solution, per millicurie

C2645 Brachytherapy planar source, palladium-103, per square millimeter

C2698 Brachytherapy source, stranded, not otherwise specified, per source

C2699 Brachytherapy source, non-stranded, not otherwise specified, per source

C9046 Cocaine hydrochloride nasal solution for topical administration, 1 mg

C9047 Injection, caplacizumab-yhdp, 1 mg.

C9084 Injection, loncastuximab tesirine-lpyl, 0.1 mg

C9085 Injection, avalglucosidase alfa-ngpt, 4 mg

C9086 Injection, anifrolumab-fnia, 1 mg

C9087 Injection, cyclophosphamide, (AuroMedics), 10 mg

C9248 Injection, clevidipine butyrate, 1 mg

C9250 Human plasma fibrin sealant, vapor-heated, solvent-detergent (Artiss), 2 ml

C9254 Injection, lacosamide, 1 mg

C9257 Injection, bevacizumab, 0.25 mg

C9358 Dermal substitute, native, nondenatured collagen, fetal bovine origin (SurgiMend Collagen

Matrix), per 0.5 sq cm

C9360 Dermal substitute, native, nondenatured collagen, neonatal bovine origin (SurgiMend

Collagen Matrix), per 0.5 sq cm

C9460 Injection, cangrelor, 1 mg

C9462 Injection, delafloxacin, 1 mg

C9488 Injection, conivaptan hydrochloride, 1 mg

J0121 Injection, omadacycline, 1 mg

J0129 Injection, abatacept, 10 mg (code may be used for Medicare when drug administered under

the direct supervision of a physician, not for use when drug is self-administered)

J0130 Injection abciximab, 10 mg

J0132 Injection, acetylcysteine, 100 mg

J0135 Injection, adalimumab, 20 mg

J0172 Injection, aducanumab-avwa, 2 mg

J0178 Injection, aflibercept, 1 mg

J0179 Injection, brolucizumab-dbll, 1 mg

J0180 Injection, agalsidase beta, 1 mg











J0185 Injection, aprepitant, 1 mg

J0202 Injection, alemtuzumab, 1 mg

J0207 Injection, amifostine, 500 mg

J0215 Injection, alefacept, 0.5 mg

J0220 Injection, alglucosidase alfa, 10 mg, not otherwise specified

J0221 Injection, alglucosidase alfa, (Lumizyme), 10 mg

J0222 Injection, patisiran, 0.1 mg

J0223 Injection, givosiran, 0.5 mg

J0256 Injection, alpha 1-proteinase inhibitor (human), not otherwise specified, 10 mg

J0257 Injection, alpha 1 proteinase inhibitor (human), (GLASSIA), 10 mg

J0288 Injection, amphotericin B cholesteryl sulfate complex, 10 mg

J0291 Injection, plazomicin, 5 mg

J0300 Injection, amobarbital, up to 125 mg

J0348 Injection, anidulafungin, 1 mg

J0350 Injection, anistreplase, per 30 units

J0364 Injection, apomorphine HCl, 1 mg

J0395 Injection, arbutamine HCl, 1 mg

J0400 Injection, aripiprazole, intramuscular, 0.25 mg

J0401 Injection, aripiprazole, extended release, 1 mg

J0475 Injection, baclofen, 10 mg

J0476 Injection, baclofen, 50 mcg for intrathecal trial

J0480 Injection, basiliximab, 20 mg

J0485 Injection, belatacept, 1 mg

J0490 Injection, belimumab, 10 mg

J0517 Injection, benralizumab, 1 mg

J0565 Injection, bezlotoxumab, 10 mg

J0567 Injection, cerliponase alfa, 1 mg

J0570 Buprenorphine implant 74.2mg

J0571 Buprenorphine, oral, 1 mg

J0572 Buprenorphine/naloxone, oral, less than or equal to 3 mg

J0573 Buprenorphine/naloxone, oral, greater than 3 mg, but less than or equal to 6 mg

J0574 Buprenorphine/naloxone, oral, greater than 6 mg, but less than or equal to 10 mg

J0575 Buprenorphine/naloxone, oral, greater than 10 mg

J0583 Injection, bivalirudin, 1 mg

J0584 Injection, burosumab-twza 1 mg











J0585 Injection, onabotulinumtoxinA, 1 unit

J0586 Injection, abobotulinumtoxinA, 5 units

J0587 Injection, rimabotulinumtoxinB, 100 units

J0588 Injection, incobotulinumtoxinA, 1 unit

J0593 Injection, lanadelumab-flyo, 1 mg (code may be used for Medicare when drug administered

under direct supervision of a physician, not for use when drug is self-administered)

J0594 Injection, busulfan, 1 mg

J0596 Injection, C1 esterase inhibitor (recombinant), Ruconest, 10 units

J0597 Injection, C-1 esterase inhibitor (human), Berinert, 10 units

J0599 Injection, C-1 esterase inhibitor (human), (Haegarda), 10 units

J0600 Injection, edetate calcium disodium, up to 1,000 mg

J0606 Injection, etelcalcetide, 0.1 mg

J0630 Injection, calcitonin salmon, up to 400 units

J0637 Injection, caspofungin acetate, 5 mg

J0638 Injection, canakinumab, 1 mg

J0641 Injection, levoleucovorin calcium, 0.5 mg

J0691 Injection, lefamulin, 1 mg

J0699 Injection, cefiderocol, 10 mg

J0712 Injection, ceftaroline fosamil, 10 mg

J0714 Injection, ceftazidime and avibactam, 0.5 g/0.125 gm

J0716 Injection, Centruroides immune F(ab)2, up to 120 mg

J0717 Injection, certolizumab pegol, 1 mg (code may be used for Medicare when drug administered

under the direct supervision of a physician, not for use when drug is self administered)

J0740 Injection, cidofovir, 375 mg

J0741 Injection, cabotegravir and rilpivirine, 2mg/3mg

J0775 Injection, collagenase, clostridium histolyticum, 0.01 mg

J0791 Injection, crizanlizumab-tmca, 5 mg

J0800 Injection, corticotropin, up to 40 units

J0834 Injection, cosyntropin (Cortrosyn), 0.25 mg

J0840 Injection, crotalidae polyvalent immune fab (ovine), up to 1 g

J0841 Injection, crotalidae immune F(ab')2 (equine), 120 mg

J0850 Injection, cytomegalovirus immune globulin intravenous (human), per vial

J0875 Injection, dalbavancin, 5 mg

J0878 Injection, daptomycin, 1 mg

J0881 Injection, darbepoetin alfa, 1 mcg (non-ESRD use)











J0882 Injection, darbepoetin alfa, 1 mcg (for ESRD on dialysis)

J0883 Argatroban nonesrd use 1mg

J0884 Argatroban esrd dialysis 1mg

J0885 Injection, epoetin alfa, (for non-ESRD use), 1000 units

J0887 Injection, epoetin beta, 1 microgram, (for ESRD on dialysis)

J0888 Injection, epoetin beta, 1 microgram, (for non-ESRD use)

J0890 Injection, peginesatide, 0.1 mg (for ESRD on dialysis)

J0894 Injection, decitabine, 1 mg

J0896 Injection, luspatercept-aamt, 0.25 mg

J0897 Injection, denosumab, 1 mg

J1095 Injection, dexamethasone 9 percent, intraocular, 1 microgram

J1096 Dexamethasone, lacrimal ophthalmic insert, 0.1 mg

J1097 Phenylephrine 10.16 mg/ml and ketorolac 2.88 mg/ml ophthalmic irrigation solution, 1 ml

J1110 Injection, dihydroergotamine mesylate, per 1 mg

J1162 Injection, digoxin immune fab (ovine), per vial

J1190 Injection, dexrazoxane HCl, per 250 mg

J1212 Injection, DMSO, dimethyl sulfoxide, 50%, 50 ml

J1267 Injection, doripenem, 10 mg

J1270 Injection, doxercalciferol, 1 mcg

J1290 Injection, ecallantide, 1 mg

J1300 Injection, eculizumab, 10 mg

J1301 Injection, edaravone, 1 mg

J1303 Injection, ravulizumab-cwvz, 10 mg

J1305 Injection, evinacumab-dgnb, 5mg

J1322 Injection, elosulfase alfa, 1 mg

J1324 Injection, enfuvirtide, 1 mg

J1335 Injection, ertapenem sodium, 500 mg

J1410 Injection, estrogen conjugated, per 25 mg

J1426 Injection, casimersen, 10 mg

J1427 Injection, viltolarsen, 10 mg

J1428 Injection, eteplirsen, 10 mg

J1429 Injection, golodirsen, 10 mg

J1430 Injection, ethanolamine oleate, 100 mg

J1438 Injection, etanercept, 25 mg (code may be used for Medicare when drug administered under

the direct supervision of a physician, not for use when drug is self-administered)











J1439 Injection, ferric carboxymaltose, 1 mg

J1442 Injection, filgrastim (G-CSF), 1 microgram

J1443 Injection, ferric pyrophosphate citrate solution, 0.1 mg of iron

J1444 Injection, ferric pyrophosphate citrate powder, 0.1 mg of iron

J1447 Injection, tbo-filgrastim, 1 microgram

J1448 Injection, trilaciclib, 1mg

J1451 Injection, fomepizole, 15 mg

J1452 Injection, fomivirsen sodium, intraocular, 1.65 mg

J1453 Injection, fosaprepitant, 1 mg

J1454 Injection, fosnetupitant 235 mg and palonosetron 0.25 mg

J1457 Injection, gallium nitrate, 1 mg

J1458 Injection, galsulfase, 1 mg

J1459 Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg

J1554 Injection, immune globulin (Asceniv), 500 mg

J1555 Injection, immune globulin (Cuvitru), 100 mg

J1556 Injection, immune globulin (Bivigam), 500 mg

J1557 Injection, immune globulin, (Gammaplex), intravenous, nonlyophilized (e.g., liquid), 500 mg

J1558 Injection, immune globulin (Xembify), 100 mg

J1559 Injection, immune globulin (Hizentra), 100 mg

J1560 Injection, gamma globulin, intramuscular, over 10 cc

J1561 Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized

(e.g., liquid), 500 mg

J1566 Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified,

500 mg

J1568 Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg

J1569 Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg

J1570 Injection, ganciclovir sodium, 500 mg

J1572 Injection, immune globulin, (Flebogamma/Flebogamma DIF), intravenous, nonlyophilized

(e.g., liquid), 500 mg

J1573 Injection, hepatitis b immune globulin (HepaGam B), intravenous, 0.5 ml

J1575 Injection, immune globulin/hyaluronidase, (HyQvia), 100 mg immuneglobulin

J1595 Injection, glatiramer acetate, 20 mg

J1599 Injection, immune globulin, intravenous, nonlyophilized (e.g., liquid), not otherwise

specified, 500 mg

J1602 Injection, golimumab, 1 mg, for intravenous use

J1610 Injection, glucagon HCl, per 1 mg











J1627 Injection, granisetron, extended-release, 0.1 mg

J1628 Injection, guselkumab, 1 mg

J1632 Injection, brexanolone, 1 mg

J1640 Injection, hemin, 1 mg

J1652 Injection, fondaparinux sodium, 0.5 mg

J1655 Injection, tinzaparin sodium, 1000 i.u.

J1670 Injection, tetanus immune globulin, human, up to 250 units

J1726 Injection, hydroxyprogesterone caproate, (Makena), 10 mg

J1730 Injection, diazoxide, up to 300 mg

J1738 Injection, meloxicam, 1 mg

J1740 Injection, ibandronate sodium, 1 mg

J1742 Injection, ibutilide fumarate, 1 mg

J1743 Injection, idursulfase, 1 mg

J1744 Injection, icatibant, 1 mg

J1745 Injection infliximab, 10 mg

J1746 Injection, ibalizumab-uiyk, 10 mg

J1756 Injection, iron sucrose, 1 mg

J1786 Injection, imiglucerase, 10 units

J1823 Injection, inebilizumab-cdon, 1 mg

J1826 Injection, interferon beta-1a, 30 mcg

J1830 Injection interferon beta-1b, 0.25 mg (code may be used for Medicare when drug

administered under the direct supervision of a physician, not for use when drug is self-

administered)

J1833 Injection, isavuconazonium, 1 mg

J1930 Injection, lanreotide, 1 mg

J1931 Injection, laronidase, 0.1 mg

J1943 Injection, aripiprazole lauroxil, (Aristada Initio), 1 mg

J1944 Injection, aripiprazole lauroxil, (Aristada), 1 mg

J1945 Injection, lepirudin, 50 mg

J1950 Injection, leuprolide acetate (for depot suspension), per 3.75 mg

J1951 Injection, leuprolide acetate for depot suspension (Fensolvi), 0.25 mg

J1953 Injection, levetiracetam, 10 mg

J2062 Loxapine for inhalation, 1 mg

J2170 Injection, mecasermin, 1 mg

J2182 Injection, mepolizumab, 1mg











J2186 Injection, meropenem, vaborbactam

J2212 Injection, methylnaltrexone, 0.1 mg

J2248 Injection, micafungin sodium, 1 mg

J2278 Injection, ziconotide, 1 mcg

J2280 Injection, moxifloxacin, 100 mg

J2310 Injection, naloxone HCl, per 1 mg

J2315 Injection, naltrexone, depot form, 1 mg

J2323 Injection, natalizumab, 1 mg

J2325 Injection, nesiritide, 0.1 mg

J2326 Injection, nusinersen, 0.1 mg

J2350 Injection, ocrelizumab, 1 mg

J2353 Injection, octreotide, depot form for intramuscular injection, 1 mg

J2355 Injection, oprelvekin, 5 mg

J2357 Injection, omalizumab, 5 mg

J2358 Injection, olanzapine, long-acting, 1 mg

J2370 Injection, phenylephrine HCl, up to 1 ml

J2406 Injection, oritavancin (Kimyrsa), 10 mg

J2407 Injection, oritavancin, 10 mg

J2425 Injection, palifermin, 50 mcg

J2426 Injection, paliperidone palmitate extended release, 1 mg

J2469 Injection, palonosetron HCl, 25 mcg

J2502 Injection, pasireotide long acting, 1 mg

J2503 Injection, pegaptanib sodium, 0.3 mg

J2504 Injection, pegademase bovine, 25 i.u.

J2506 Injection, pegfilgrastim, excludes biosimilar, 0.5 mg

J2507 Injection, pegloticase, 1 mg

J2515 Injection, pentobarbital sodium, per 50 mg

J2545 Pentamidine isethionate, inhalation solution, FDA-approved final product, noncompounded,

administered through DME, unit dose form, per 300 mg

J2547 Injection, peramivir, 1 mg

J2562 Injection, plerixafor, 1 mg

J2724 Injection, protein C concentrate, intravenous, human, 10 i.u.

J2730 Injection, pralidoxime chloride, up to 1 gm

J2760 Injection, phentolamine mesylate, up to 5 mg

J2770 Injection, quinupristin/dalfopristin, 500 mg (150/350)











J2778 Injection, ranibizumab, 0.1 mg

J2783 Injection, rasburicase, 0.5 mg

J2785 Injection, regadenoson, 0.1 mg

J2786 Injection, reslizumab, 1mg

J2790 Injection, Rho D immune globulin, human, full dose, 300 mcg (1500 i.u.)

J2791 Injection, Rho( D) immune globulin (human), (Rhophylac), intramuscular or intravenous,

100 i.u.

J2794 Injection, risperidone, long acting, 0.5 mg

J2795 Injection, ropivacaine HCl, 1 mg

J2796 Injection, romiplostim, 10 mcg

J2797 Injection, rolapitant, 0.5 mg

J2798 Injection, risperidone, (Perseris), 0.5 mg

J2820 Injection, sargramostim (GM-CSF), 50 mcg

J2840 Injection, sebelipase alfa 1 mg

J2850 Injection, secretin, synthetic, human, 1 mcg

J2860 Injection, siltuximab, 10 mg

J2916 Injection, sodium ferric gluconate complex in sucrose injection, 12.5 mg

J2920 Injection, methylprednisolone sodium succinate, up to 40 mg

J2993 Injection, reteplase, 18.1 mg

J2995 Injection, streptokinase, per 250,000 i.u.

J2997 Injection, alteplase recombinant, 1 mg

J3031 Injection, fremanezumab-vfrm, 1 mg (code may be used for Medicare when drug

administered under the direct supervision of a physician, not for use when drug is self-

administered)

J3032 Injection, eptinezumab-jjmr, 1 mg

J3060 Injection, taliglucerace alfa, 10 units

J3070 Injection, pentazocine, 30 mg

J3090 Injection, tedizolid phosphate, 1 mg

J3095 Injection, telavancin, 10 mg

J3101 Injection, tenecteplase, 1 mg

J3110 Injection, teriparatide, 10 mcg

J3111 Injection, romosozumab-aqqg, 1 mg

J3145 Injection, testosterone undecanoate, 1 mg

J3240 Injection, thyrotropin alpha, 0.9 mg, provided in 1.1 mg vial

J3241 Injection, teprotumumab-trbw, 10 mg











J3243 Injection, tigecycline, 1 mg

J3245 Injection, tildrakizumab, 1 mg

J3262 Injection, tocilizumab, 1 mg

J3285 Injection, treprostinil, 1 mg

J3300 Injection, triamcinolone acetonide, preservative free, 1 mg

J3304 Injection, triamcinolone acetonide, preservative-free, extended-release, microsphere

formulation, 1 mg

J3305 Injection, trimetrexate glucuronate, per 25 mg

J3315 Injection, triptorelin pamoate, 3.75 mg

J3316 Injection, triptorelin, extended-release, 3.75 mg

J3357 Injection, ustekinumab, 1 mg

J3358 Ustekinumab, for intravenous injection, 1 mg

J3364 Injection, urokinase, 5,000 i.u. vial

J3365 Injection, IV, urokinase, 250,000 i.u. vial

J3380 Injection, vedolizumab, 1 mg

J3385 Injection, velaglucerase alfa, 100 units

J3397 Injection, vestronidase alfa-vjbk, 1 mg

J3398 Injection, voretigene neparvovec-rzyl, 1 billion vector genomes

J3399 Injection, onasemnogene abeparvovec-xioi, per treatment, up to 5x1015 vector genomes

J3465 Injection, voriconazole, 10 mg

J3471 Injection, hyaluronidase, ovine, preservative free, per 1 USP unit (up to 999 USP units)

J3472 Injection, hyaluronidase, ovine, preservative free, per 1,000 USP units

J3473 Injection, hyaluronidase, recombinant, 1 USP unit

J3486 Injection, ziprasidone mesylate, 10 mg

J3489 Injection, zoledronic acid, 1 mg

J3490 Unclassified drugs

J3590 Unclassified biologics

J7168 Prothrombin complex concentrate (human), Kcentra, per i.u. of factor IX activity

J7169 Injection, coagulation factor Xa (recombinant), inactivated-zhzo (Andexxa), 10 mg

J7170 Injection, emicizumab-kxwh, 0.5 mg

J7175 Injection, factor X, (human), 1 i.u.

J7177 Injection, human fibrinogen concentrate (Fibryga), 1 mg

J7178 Injection, human fibrinogen concentrate, 1 mg

J7179 Vonvendi injection 1 i.u. VWF:RCo

J7180 Injection, factor XIII (antihemophilic factor, human), 1 i.u.











J7181 Injection, factor XIII A-subunit, (recombinant), per i.u.

J7182 Injection, factor VIII, (antihemophilic factor, recombinant), (NovoEight), per i.u.

J7183 Injection, von Willebrand factor complex (human), Wilate, 1 i.u. VWF:RCo

J7185 Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha), per i.u.

J7186 Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per factor VIII

i.u.

J7187 Injection, von Willebrand factor complex (Humate-P), per i.u. VWF:RCo

J7188 Injection, factor VIII (antihemophilic factor, recombinant), (Obizur), per i.u.

J7189 Factor VIIa (antihemophilic factor, recombinant), per 1 mcg

J7190 Factor VIII (antihemophilic factor, human) per i.u.

J7191 Factor VIII (antihemophilic factor [porcine]), per i.u.

J7192 Factor VIII (antihemophilic factor, recombinant) per i.u., not otherwise specified

J7193 Factor IX (antihemophilic factor, purified, nonrecombinant) per i.u.

J7194 Factor IX complex, per i.u.

J7195 Injection, factor IX (antihemophilic factor, recombinant) per i.u., not otherwise specified

J7196 Injection, antithrombin recombinant, 50 i.u.

J7198 Antiinhibitor, per i.u.

J7199 Hemophilia clotting factor, not otherwise classified

J7200 Injection, factor IX, (antihemophilic factor, recombinant), Rixubis, per i.u.

J7201 Injection, factor IX, FC fusion protein (recombinant), per i.u.

J7202 Injection, factor IX Idelvion

J7203 Injection factor IX, (antihemophilic factor, recombinant), glycopegylated, (Rebinyn), 1 i.u.

J7204 Injection, factor VIII, antihemophilic factor (recombinant), (Esperoct), glycopegylated-exei,

per i.u.

J7205 Injection, factor VIII FC fusion (recombinant), per i.u.

J7207 Factor VIII pegylated recomb

J7208 Injection, factor VIII, (antihemophilic factor, recombinant), PEGylated-aucl, (Jivi), 1 i.u.

J7209 Factor VIII NUWIQ recomb 1 i.u.

J7210 Injection, factor VIII, (antihemophilic factor, recombinant), (Afstyla), 1 i.u.

J7211 Injection, factor VIII, (antihemophilic factor, recombinant), (Kovaltry), 1 i.u.

J7212 Factor VIIa (antihemophilic factor, recombinant)-jncw (Sevenfact), 1 microgram

J7294 Segesterone acetate and ethinyl estradiol 0.15mg, 0.013mg per 24 hours; yearly vaginal

system, each

J7295 Ethinyl estradiol and etonogestrel 0.015mg, 0.12mg per 24 hours; monthly vaginal ring, each

J7296 Levonorgestrel-releasing intrauterine contraceptive system, (Kyleena), 19.5 mg











J7297 Levonorgestrel-releasing intrauterine contraceptive system, 52mg, 3 year duration

J7298 Levonorgestrel-releasing intrauterine contraceptive system, 52 mg, 5 year duration

J7300 Intrauterine copper contraceptive

J7301 Levonorgestrel-releasing intrauterine contraceptive system, 13.5 mg

J7304 Contraceptive supply, hormone containing patch, each

J7306 Levonorgestrel (contraceptive) implant system, including implants and supplies

J7307 Etonogestrel (contraceptive) implant system, including implant and supplies

J7308 Aminolevulinic acid HCl for topical administration, 20%, single unit dosage form (354 mg)

J7309 Methyl aminolevulinate (MAL) for topical administration, 16.8%, 1 g

J7310 Ganciclovir, 4.5 mg, long-acting implant

J7311 Fluocinolone acetonide, intravitreal implant

J7312 Injection, dexamethasone, intravitreal implant, 0.1 mg

J7313 Injection, fluocinolone acetonide, intravitreal implant, 0.01 mg

J7314 Injection, fluocinolone acetonide, intravitreal implant (Yutiq), 0.01 mg

J7316 Injection, ocriplasmin, 0.125 mg

J7321 Hyaluronan or derivative, Hyalgan or Supartz, for intra-articular injection, per dose

J7323 Hyaluronan or derivative, Euflexxa, for intra-articular injection, per dose

J7324 Hyaluronan or derivative, Orthovisc, for intra-articular injection, per dose

J7325 Hyaluronan or derivative, Synvisc or Synvisc-One, for intra-articular injection, 1 mg

J7326 Hyaluronan or derivative, Gel-One, for intra-articular injection, per dose

J7327 Hyaluronan or derivative, Monovisc, for intra-articular injection, per dose

J7330 Autologous cultured chondrocytes, implant

J7340 Carbidopa 5 mg/levodopa 20 mg enteral suspension, 100 ml

J7351 Injection, bimatoprost, intracameral implant, 1 microgram

J7402 Mometasone furoate sinus implant, (Sinuva), 10 micrograms

J7501 Azathioprine, parenteral, 100 mg

J7503 Tacrolimus, extended release, oral, 0.25 mg

J7504 Lymphocyte immune globulin, antithymocyte globulin, equine, parenteral, 250 mg

J7505 Muromonab-CD3, parenteral, 5 mg

J7508 Tacrolimus, extended release, oral, 0.1 mg

J7511 Lymphocyte immune globulin, antithymocyte globulin, rabbit, parenteral, 25 mg

J7513 Daclizumab, parenteral, 25 mg

J7525 Tacrolimus, parenteral, 5 mg

J7677 Revefenacin inhalation solution, FDA-approved final product, non-compounded,

administered through DME, 1 microgram











J7686 Treprostinil, inhalation solution, FDA-approved final product, noncompounded, administered

through DME, unit dose form, 1.74 mg

J7799 Not otherwise classified drugs, other than inhalation drugs, administered through DME

J8499 Prescription drug, oral, nonchemotherapeutic, not otherwise specified

J8510 Busulfan, oral, 2 mg

J8520 Capecitabine, oral, 150 mg

J8521 Capecitabine, oral, 500 mg

J8530 Cyclophosphamide, oral, 25 mg

J8560 Etoposide, oral, 50 mg

J8565 Gefitinib, oral, 250 mg

J8600 Melphalan, oral, 2 mg

J8610 Methotrexate, oral, 2.5 mg

J8655 Netupitant 300 mg and Palonosetron 0.5 mg

J8670 Rolapitant, oral, 1mg

J8700 Temozolomide, oral, 5 mg

J8999 Prescription drug, oral, chemotherapeutic, not otherwise specified

J9000 Injection, doxorubicin HCl, 10 mg

J9015 Injection, aldesleukin, per single use vial

J9017 Injection, arsenic trioxide, 1 mg

J9019 Injection, asparaginase (Erwinaze), 1,000 i.u.

J9020 Injection, asparaginase, not otherwise specified, 10,000 units

J9021 Injection, asparaginase, recombinant, (Rylaze), 0.1 mg

J9022 Injection, atezolizumab, 10 mg

J9023 Injection, avelumab, 10 mg

J9025 Injection, azacitidine, 1 mg

J9027 Injection, clofarabine, 1 mg

J9030 BCG Live intravesical 1mg

J9032 Injection, belinostat, 10 mg

J9033 Injection, bendamustine HCl, 1 mg

J9034 Injection, bendeka 1 mg

J9035 Injection, bevacizumab, 10 mg

J9036 Injection, bendamustine hydrochloride, (Belrapzo/bendamustine), 1 mg

J9037 Injection, belantamab mafodontin-blmf, 0.5 mg

J9039 Injection, blinatumomab, 1 microgram

J9040 Injection, bleomycin sulfate, 15 units











J9041 Injection, bortezomib, 0.1 mg

J9042 Injection, brentuximab vedotin, 1 mg

J9043 Injection, cabazitaxel, 1 mg

J9044 Injection, bortezomib, not otherwise specified, 0.1 mg

J9045 Injection, carboplatin, 50 mg

J9047 Injection, carfilzomib, 1 mg

J9050 Injection, carmustine, 100 mg

J9055 Injection, cetuximab, 10 mg

J9057 Injection, copanlisib, 1 mg

J9060 Injection, cisplatin, powder or solution, 10 mg

J9061 Injection, amivantamab-vmjw, 2 mg

J9065 Injection, cladribine, per 1 mg

J9070 Cyclophosphamide, 100 mg

J9098 Injection, cytarabine liposome, 10 mg

J9100 Injection, cytarabine, 100 mg

J9118 Injection, calaspargase pegol-mknl, 10 units

J9119 Injection, cemiplimab-rwlc, 1 mg

J9120 Injection, dactinomycin, 0.5 mg

J9130 Dacarbazine, 100 mg

J9144 Injection, daratumumab, 10 mg and hyaluronidase-fihj

J9145 Injection, daratumumab 10 mg

J9150 Injection, daunorubicin, 10 mg

J9153 Injection, liposomal, 1 mg daunorubicin and 2.27 mg cytarabine

J9155 Injection, degarelix, 1 mg

J9160 Injection, denileukin diftitox, 300 mcg

J9165 Injection, diethylstilbestrol diphosphate, 250 mg

J9171 Injection, docetaxel, 1 mg

J9173 Injection, durvalumab, 10 mg

J9176 Injection, elotuzumab, 1mg

J9177 Injection, enfortumab vedotin-ejfv, 0.25 mg

J9178 Injection, epirubicin HCl, 2 mg

J9179 Injection, eribulin mesylate, 0.1 mg

J9181 Injection, etoposide, 10 mg

J9185 Injection, fludarabine phosphate, 50 mg

J9190 Injection, fluorouracil, 500 mg











J9198 Injection, gemcitabine hydrochloride, (Infugem), 100 mg

J9200 Injection, floxuridine, 500 mg

J9201 Injection, gemcitabine HCl, 200 mg

J9202 Goserelin acetate implant, per 3.6 mg

J9203 Injection, gemtuzumab ozogamicin, 0.1 mg

J9204 Injection, mogamulizumab-kpkc, 1 mg

J9205 Injection, irinotecan liposome 1 mg

J9206 Injection, irinotecan, 20 mg

J9207 Injection, ixabepilone, 1 mg

J9208 Injection, ifosfamide, 1 g

J9209 Injection, mesna, 200 mg

J9210 Injection, emapalumab-lzsg, 1 mg

J9211 Injection, idarubicin HCl, 5 mg

J9212 Injection, interferon alfacon-1, recombinant, 1 mcg

J9213 Injection, interferon, alfa-2a, recombinant, 3 million units

J9214 Injection, interferon, alfa-2b, recombinant, 1 million units

J9216 Injection, interferon, gamma 1-b, 3 million units

J9217 Leuprolide acetate (for depot suspension), 7.5 mg

J9218 Leuprolide acetate, per 1 mg

J9219 Leuprolide acetate implant, 65 mg

J9223 Injection, lurbinectedin, 0.1 mg

J9225 Histrelin implant (Vantas), 50 mg

J9226 Histrelin implant (Supprelin LA), 50 mg

J9227 Injection, isatuximab-irfc, 10 mg

J9228 Injection, ipilimumab, 1 mg

J9229 Injection, inotuzumab ozogamicin, 0.1 mg

J9230 Injection, mechlorethamine HCl, (nitrogen mustard), 10 mg

J9245 Injection, melphalan hydrochloride, not otherwise specified, 50 mg

J9246 Injection, melphalan (Evomela), 1 mg

J9247 Injection, melphalan flufenamide, 1mg

J9250 Methotrexate sodium, 5 mg

J9260 Methotrexate sodium, 50 mg

J9261 Injection, nelarabine, 50 mg

J9262 Injection, omacetaxine mepesuccinate, 0.01 mg

J9263 Injection, oxaliplatin, 0.5 mg











J9264 Injection, paclitaxel protein-bound particles, 1 mg

J9266 Injection, pegaspargase, per single dose vial

J9267 Injection, paclitaxel, 1 mg

J9268 Injection, pentostatin, 10 mg

J9269 Injection, tagraxofusp-erzs, 10 micrograms

J9270 Injection, plicamycin, 2.5 mg

J9271 Injection, pembrolizumab, 1 mg

J9272 Injection, dostarlimab-gxly, 10 mg

J9280 Injection, mitomycin, 5 mg

J9281 Mitomycin pyelocalyceal instillation, 1 mg

J9285 Injection, olaratumab, 10 mg

J9293 Injection, mitoxantrone HCl, per 5 mg

J9295 Injection, necitumumab, 1 mg

J9299 Injection, nivolumab, 1mg

J9301 Injection, obinutuzumab, 10 mg

J9302 Injection, ofatumumab, 10 mg

J9303 Injection, panitumumab, 10 mg

J9305 Injection, pemetrexed, 10 mg

J9306 Injection, pertuzumab, 1 mg

J9307 Injection, pralatrexate, 1 mg

J9308 Injection, ramucirumab, 5mg

J9309 Injection, polatuzumab vedotin-piiq, 1 mg

J9311 Injection, rituximab 10 mg and hyaluronidase

J9312 Injection, rituximab, 10 mg

J9313 Injection, moxetumomab pasudotox-tdfk, 0.01 mg

J9316 Injection, pertuzumab, trastuzumab, and hyaluronidase-zzxf, per 10 mg

J9317 Injection, sacituzumab govitecan-hziy, 2.5 mg

J9318 Injection, romidepsin, non-lyophilized, 0.1 mg

J9319 Injection, romidepsin, lyophilized, 0.1 mg

J9320 Injection, streptozocin, 1 g.

J9325 Injection, talimogene laherparepvec

J9328 Injection, temozolomide, 1 mg

J9330 Injection, temsirolimus, 1 mg

J9340 Injection, thiotepa, 15 mg

J9348 Injection, naxitamab-gqgk, 1 mg











J9349 Injection, tafasitamab-cxix, 2 mg

J9351 Injection, topotecan, 0.1 mg

J9352 Injection trabectedin 0.1mg

J9353 Injection, margetuximab-cmkb, 5 mg

J9354 Injection, ado-trastuzumab emtansine, 1 mg

J9355 Injection, trastuzumab, 10 mg

J9356 Injection, trastuzumab, 10 mg and hyaluronidase-oysk

J9357 Injection, valrubicin, intravesical, 200 mg

J9358 Injection, fam-trastuzumab deruxtecan-nxki, 1 mg

J9360 Injection, vinblastine sulfate, 1 mg

J9370 Vincristine sulfate, 1 mg

J9371 Injection, vincristine sulfate liposome, 1 mg

J9390 Injection, vinorelbine tartrate, 10 mg

J9395 Injection, fulvestrant, 25 mg

J9400 Injection, ziv-aflibercept, 1 mg

J9600 Injection, porfimer sodium, 75 mg

J9999 Not otherwise classified, antineoplastic drugs

M0201 COVID-19 vaccine administration inside a patient’s home; reported only once per individual

home per date of service when only COVID-19 vaccine administration is performed at the

patient’s home

M0240 Intravenous infusion or subcutaneous injection, casirivimab and imdevimab includes infusion

or injection, and post administration monitoring, subsequent repeat doses

M0241 Intravenous infusion or subcutaneous injection, casirivimab and imdevimab includes infusion

or injection, and post administration monitoring in the home or residence; this includes a

beneficiary's home that has been made provider-based to the hospital during the COVID-19

public health emergency, subsequent repeat doses

M0243 Intravenous infusion, casirivimab and imdevimab includes infusion and post administration

monitoring

M0244 Intravenous infusion, casirivimab and imdevimab includes infusion and post administration

monitoring in the home or residence; this includes a beneficiary’s home that has been made

provider based to the hospital during the COVID-19 public health emergency


administration monitoring


administration monitoring in the home or residence; this includes a beneficiary’s home that

has been made provider based to the hospital during the COVID-19 public health emergency

M0247 Intravenous infusion, sotrovimab, includes infusion and post administration monitoring











M0248 Intravenous infusion, sotrovimab, includes infusion and post administration monitoring in the

home or residence; this includes a beneficiary’s home that has been made provider-based to

the hospital during the COVID-19 public health emergency





first dose





second dose

P9045 Infusion, albumin (human), 5%, 250 ml



Q0138 Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (non-ESRD use)

Q0139 Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (for ESRD on dialysis)

Q0167 Dronabinol, 2.5 mg, oral, FDA approved prescription antiemetic, for use as a complete

therapeutic substitute for an IV antiemetic at the time of chemotherapy treatment, not to

exceed a 48-hour dosage regimen

Q0180 Dolasetron mesylate, 100 mg, oral, FDA approved prescription antiemetic, for use as a

complete therapeutic substitute for an IV antiemetic at the time of chemotherapy treatment,

not to exceed a 24-hour dosage regimen

Q0181 Unspecified oral dosage form, FDA approved prescription antiemetic, for use as a complete

therapeutic substitute for an IV antiemetic at the time of chemotherapy treatment, not to

exceed a 48-hour dosage regimen

Q0240 Injection, casirivimab and imdevimab, 600 mg



Q0245 Injection, bamlanivimab and etesevimab, 2100 mg

Q0247 Injection, sotrovimab, 500 mg

Q0249 Injection, tocilizumab, for hospitalized adults and pediatric patients (2 years of age and older)

with COVID-19 who are receiving systemic corticosteroids and require supplemental

oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane

oxygenation (ECMO) only, 1 mg

Q2017 Injection, teniposide, 50 mg

Q2041 Axicabtagene ciloleucel, up to 200 million autologous anti-CD19 CAR T cells, including

leukapheresis and dose preparationprocedures, perinfusion

Q2042 Tisagenlecleucel, up to 600 million CAR-positive viable T cells, including leukapheresis and

dose preparation procedures, per therapeutic dose











Q2043 Sipuleucel-T, minimum of 50 million autologous CD54+ cells activated with PAP-GM-CSF,

including leukapheresis and all other preparatory procedures, per infusion (Provenge)

Q2049 Injection, doxorubicin hydrochloride, liposomal, imported Lipodox, 10 mg

Q2050 Injection, doxorubicin hydrochloride, liposomal, not otherwise specified, 10 mg

Q2053 Brexucabtagene autoleucel, up to 200 million autologous anti-CD19 CAR positive viable

T cells, including leukapheresis and dose preparation procedures, per therapeutic dose

Q2054 Lisocabtagene maraleucel, up to 110 million autologous anti-CD19 CAR-positive viable

T cells, including leukapheresis and dose preparation procedures, per therapeutic dose

Q2055 Idecabtagene vicleucel, up to 460 million autologous B-cell maturation antigen (BCMA)

directed CAR-positive T cells, including leukapheresis and dose preparation procedures, per

therapeutic dose

Q3027 Injection, interferon beta-1a, 1 mcg for intramuscular use

Q3028 Injection, interferon beta-1a, 1 mcg for subcutaneous use

Q4100 Skin substitute, not otherwise specified

Q4101 Apligraf, per sq cm

Q4102 Oasis wound matrix, per sq cm

Q4103 Oasis burn matrix, per sq cm

Q4104 Integra bilayer matrix wound dressing (BMWD), per sq cm

Q4105 Integra dermal regeneration template (DRT), per sq cm

Q4106 Dermagraft, per sq cm

Q4107 GRAFTJACKET, per sq cm

Q4108 Integra matrix, per sq cm

Q4110 PriMatrix, per sq cm

Q4111 GammaGraft, per sq cm

Q4112 Cymetra, injectable, 1 cc

Q4113 GRAFTJACKET XPRESS, injectable, 1 cc

Q4114 Integra flowable wound matrix, injectable, 1 cc

Q4115 AlloSkin, per sq cm

Q4116 AlloDerm, per sq cm

Q4117 Hyalomatrix, per sq cm

Q4118 MatriStem micromatrix, 1 mg

Q4121 TheraSkin, per sq cm

Q4122 DermACELL, per sq cm

Q4123 AlloSkin RT, per sq cm

Q4124 OASIS ultra tri-layer wound matrix, per sq cm

Q4125 ArthroFlex, per sq cm











Q4126 MemoDerm, DermaSpan, TranZgraft or InteguPly, per sq cm

Q4127 Talymed, per sq cm

Q4128 FlexHD, AllopatchHD, or Matrix HD, per sq cm

Q4130 Strattice TM, per sq cm

Q4132 Grafix Core and GrafixPL Core, per sq cm

Q4133 Grafix Prime and GrafixPL Prime, per sq cm

Q4134 HMatrix, per sq cm

Q4135 Mediskin, per sq cm

Q4136 E-Z Derm, per sq cm

Q4137 Amnioexcel or biodexcel, per sq cm

Q4138 Biodfence dryflex, per sq cm

Q4139 Amniomatrix or biodmatrix, injectable, 1 cc

Q4140 Biodfence, per sq cm

Q4141 Alloskin AC, per sq cm

Q4142 XCM biologic tissue matrix, per sq cm

Q4143 Repriza, per sq cm

Q4145 EpiFix, injectable, 1 mg

Q4146 Tensix, per sq cm

Q4147 Architect, Architect PX, or Architect FX, extracellular matrix, per sq cm

Q4148 NEOX CORD 1K, NEOX CORD RT, or CLARIX CORD 1K, per sq cm

Q4149 Excellagen, 0.1 cc

Q4150 AlloWrap DS or dry, per sq cm

Q4151 AmnioBand or Guardian, per sq cm

Q4152 DermaPure, per sq cm

Q4153 Dermavest and Plurivest, per sq cm

Q4154 Biovance, per sq cm

Q4155 NEOX FLO or CLARIX FLO 1 mg

Q4156 NEOX 100 or CLARIX 100, per sq cm

Q4157 Revitalon, per sq cm

Q4158 Kerecis Omega3, per sq cm

Q4159 Affinity, per sq cm

Q4160 Nushield, per sq cm

Q4161 Bio-ConneKt wound matrix, per sq cm

Q4162 WoundEx Flow, BioSkin Flow, 0.5 cc

Q4163 WoundEx, BioSkin, per sq cm











Q4164 Helicoll, per sq cm

Q4165 Keramatrix, per sq cm

Q4166 Cytal, per sq cm

Q4167 Truskin, per sq cm

Q4168 AmnioBand, 1 mg

Q4169 Artacent wound, per sq cm

Q4170 Cygnus, per sq cm

Q4171 Interfyl, 1 mg

Q4173 PalinGen or PalinGen XPlus, per sq cm

Q4174 PalinGen or ProMatrX, 0.36 mg per 0.25 cc

Q4175 Miroderm, per sq cm

Q4176 NeoPatch or therion, per sq cm

Q4177 FlowerAmnioFlo, 0.1 cc

Q4178 FlowerAmnioPatch, per sq cm

Q4179 FlowerDerm, per sq cm

Q4180 Revita, per sq cm

Q4181 Amnio Wound, per sq cm

Q4182 Transcyte, per sq cm

Q4183 SurgiGRAFT, per square centimeter

Q4184 Cellesta, per square centimeter

Q4185 Cellesta flowable amnion (25 mg per cc); per 0.5 cc

Q4186 Epifix, per square centimeter

Q4187 Epicord, per square centimeter

Q4188 Amnioarmor, per square centimeter

Q4189 Artacent AC, 1 mg

Q4190 Artacent AC, per square centimeter

Q4191 Restorigin, per square centimeter

Q4192 Restorigin, 1 cc

Q4193 Coll-e-Derm, per square centimeter

Q4194 Novachor, per square centimeter

Q4195 PuraPly, per square centimeter

Q4196 PuraPly AM, per square centimeter

Q4197 PuraPly XT, per square centimeter

Q4198 Genesis amniotic membrane, per square centimeter

Q4199 Cygnus matrix, per square centimeter











Q4200 Skin TE, per square centimeter

Q4201 Matrion, per square centimeter

Q4202 Keroxx (2.5g/cc), 1cc

Q4203 Derma-Gide, per square centimeter

Q4204 XWRAP, per square centimeter

Q4205 Membrane Graft or Membrane Wrap, per square centimeter

Q4206 Fluid Flow or Fluid GF, 1 cc

Q4208 Novafix, per square cenitmeter

Q4209 SurGraft, per square centimeter

Q4210 Axolotl Graft or Axolotl DualGraft, per square centimeter

Q4211 Amnion bio or AxoBioMembrane, per square centimeter

Q4212 Allogen, per cc

Q4213 Ascent, 0.5 mg

Q4214 Cellesta Cord, per square centimeter

Q4215 Axolotl Ambient or Axolotl Cryo, 0.1 mg

Q4216 Artacent Cord, per square centimeter

Q4217 Woundfix, BioWound, Woundfix Plus, BioWound Plus, Woundfix Xplus or BioWound

Xplus, per square centimeter

Q4218 SurgiCORD, per square centimeter

Q4219 SurgiGRAFT-DUAL, per square centimeter

Q4220 BellaCell HD or SureDerm, per square centimeter

Q4221 AmnioWrap2, per square centimeter

Q4222 ProgenaMatrix, per square centimeter

Q4226 MyOwn Skin, includes harvesting and preparation procedures, per square centimeter

Q4227 Amniocore, per square centimeter

Q4229 Cogenex amniotic membrane, per square centimeter

Q4230 Cogenex flowable amnion, per 0.5 cc

Q4231 Corplex P, per cc

Q4232 Corplex, per square centimeter

Q4233 Surfactor or NuDYN, per 0.5 cc

Q4234 Xcellerate, per square centimeter

Q4235 Amniorepair or AltiPly, per square centimeter

Q4237 Cryo-Cord, per square centimeter

Q4238 Derm-Maxx, per square centimeter

Q4239 Amnio-Maxx orAmnio-Maxx Lite, per square centimeter











Q4240 Corecyte, for topical use only, per 0.5 cc

Q4241 Polycyte, for topical use only, per 0.5 cc

Q4242 Amniocyte Plus, per 0.5 cc

Q4244 Procenta, per 200 mg

Q4245 Amniotext, per cc

Q4246 Coretext or Protext, per cc

Q4247 Amniotext patch, per square centimeter

Q4248 Dermacyte amniotic membrane allograft, per square centimeter

Q4249 Amniply, for topical use only, per square centimeter

Q4250 AmnioAMP-MP, per square centimeter

Q4251 Vim, per square centimeter

Q4252 Vendaje, per square centimeter

Q4253 Zenith amniotic membrane, per square centimeter

Q4254 Novafix DL, per square centimeter

Q4255 REGUaRD, for topical use only, per square centimeter

Q5101 Injection, filgrastim-sndz, biosimilar, (Zarxio), 1 mcg

Q5103 Injection, infliximab-dyyb, biosimilar, (Inflectra), 10 mg

Q5104 Injection, infliximab-abda, biosimilar, (Renflexis), 10 mg

Q5105 Injection, epoetin alfa, biosimilar, (Retacrit) (for ESRD on dialysis), 100 units

Q5107 Injection, bevacizumab-awwb, biosimilar (Mvasi),10 mg

Q5108 Injection, pegfilgrastim-jmdb, biosimilar, (Fulphila), 0.5 mg

Q5110 Injection, filgrastim-aafi, biosimilar, (Nivestym), 1 microgram

Q5111 Injection, pegfilgrastim-cbqv, biosimilar, (Udenyca), 0.5 mg

Q5112 Injection, trastuzumab-dttb, biosimilar, (Ontruzant), 10 mg

Q5113 Injection, trastuzumab-pkrb, biosimilar, (Herzuma), 10 mg

Q5114 Injection, trastuzumab-dkst, biosimilar, (Ogivri), 10 mg

Q5115 Injection, rituximab-abbs, biosimilar, (Truxima), 10 mg

Q5116 Injection, trastuzumab-qyyp, biosimilar, (Trazimera), 10 mg

Q5117 Injection, trastuzumab-anns, biosimilar, (Kanjinti), 10 mg

Q5118 Injection, bevacizumab-bvzr, biosimilar, (Zirabev), 10 mg

Q5119 Injection, rituximab-pvvr, biosimilar, (Ruxience), 10 mg

Q5120 Injection, pegfilgrastim-bmez, biosimilar, (Ziextenzo), 0.5 mg

Q5121 Injection, infliximab-axxq, biosimilar, (Avsola), 10 mg

Q5122 Injection, pegfilgrastim-apgf, biosimilar, (Nyvepria), 0.5 mg

Q5123 Injection, rituximab-arrx, biosimilar, (Riabni), 10 mg











Q9991 Injection, buprenorphine extended-release (Sublocade), less than or equal to 100 mg

Q9992 Injection, buprenorphine extended-release (Sublocade), greater than 100 mg

S0013 Esketamine, nasal spray, 1 mg

S0145 Injection, pegylated interferon alfa-2a, 180 mcg per ml

S0148 Injection, pegylated interferon alfa-2B, 10 mcg

S0190 Mifepristone, oral, 200 mg



Added (effective January 1, 2022): A2001–A2010, C9085–C9087, J0172, J2506, J9021, J9061, J9272,

Q2055, Q4199

Removed (effective January 1, 2022): C9081– C9083, J2505


Added (effective December 10, 2021): S0145, S0190

November 16, 2021, update:

Added (effective October 29, 2021): 91307





Added (effective October 22, 2021): C9047


Added (effective October 1, 2021): C9081–C9084, J0699, J0741, J1305, J1426, J1448, J2406, J7294, J7295,

J9247, J9318, J9319, Q2054, Q4251–Q4253

Removed (effective October 1, 2021): C9065, C9075–C9080, J0693, J7303, J9315, Q4228, Q4236

Added (effective July 30, 2021): M0240, M0241, Q0240

August 17, 2021, update:

Added (effective June 24, 2021): M0249, M0250, Q0249


Added (effective July 1, 2021): C9075– C9080, C9077, J1951, J7168, J9348, J9353, Q5123

Removed (effective July 1, 2021): C9132

Added (effective June 8, 2021): M0201

Added (effective June 3, 2021): Q0244

Added (effective May 26, 2021): M0247, M0248, Q0247


Added (effective May 6, 2021): M0244, M0246

May 11, 2021, update:

Removed (effective April 16, 2021): Q0239, M0239


Added (effective April 1, 2021): J1427, J1554, J7402, J9037, J9349, Q2053

Removed (effective April 1, 2021): C9069, C9070, C9072, C9073, C9122

March 30, 2021, update:

Added (effective February 27, 2021): 91303

Added (effective February 9, 2021): M0245, Q0245






Added (effective August 1, 2020): J0221


Added (effective January 1, 2021): 90377, C9069, C9070, C9072, C9073, J0693, J1823, J7212, J9144,

J9223, J9281, J9316, J9317, M0239, M0243, Q0239, Q0243, Q5122, S0013

Removed (effective January 1, 2021): C9062, C9064, C9066


Added (effective December 18, 2020): 91301

Added (effective December 11, 2020): 91300


Added (effective December 10, 2020): J9118


Added (effective October 8, 2020): Q5121


Added (effective October 1, 2020): C9062, C9064–C9066, J0121, J1632, J1738, J3032, J3241, J7351,

J9227, Q4249, Q4250, Q4254, Q4255

Removed (effective October 1, 2020): C9055, C9061, C9063


Added (effective July 16, 2020): Q5112, Q5113


Added (effective July 1, 2020): C9061, C9063, C9122, J0223, J0691, J0791, J0896, J1429, J1558, J3399,

J7169, J7204, J9177, J9198, J9246, J9358, Q4227–Q4242, Q4244–Q4248, Q5119, Q5120

Removed (effective July 1, 2020): C9041, C9053, C9054, C9056, C9058

Revised description (effective July 1, 2020): J7321, J9245, Q4176


Added (effective May 1, 2020): Q5116


Added (effective April 24, 2020): Q5118


Added (effective April 1, 2020): C9053, C9056, C9058


Removed (effective August 19, 2019): J0221


Added (effective February 21, 2020): Q5114, Q5115


Added (effective January 1, 2020): C9054, C9055, J0179, J9199, J9309


Added (effective December 13, 2019): Q5107


Added (effective November 29, 2019): J1095


Added (effective October 1, 2019): J1096




Added (effective October 1, 2019): J0222, J0291, J0593, J1097, J1303, J1943, J1944, J2798, J3031, J3111,

J7314, J9119, J9204, J9210, J9269, J9313, Q4205, Q4206, Q4208–Q4222, Q4226, Q5117

Removed (effective October 1, 2019): C9035–C9040, C9043–C9045, C9049, C9050, C9052, C9447, J1942

Added (effective October 18, 2018): 90585, 90586, 90670, 90710, J0350, J0395, J0600, J0800, J1212,

J1430, J1438, J1560, J1830, J1945, J2504, J2760, J2993, J3305, J7296, J7297, J7298, J7300, J7301,

J7310, J7327, J7330, J7501, J7504, J7505, J7511, J7513, J7525, J9216

Omitted (applicable for table from October 18, 2018, through December 31, 2018): C9497





Added (effective August 16, 2019): Q5111


Added (effective July 11, 2019): C9037, J0714, J0875, J1110, J1452, J1573, J1640, J1730, J2062, J2407,

J2515, J2547, J2730, J2995, J3070, J3090, J3145, J3243, J3304, J9212, Q5101


Added (effective July 1, 2019): C9049, C9050, C9052, J1444, J7208, J7677, J9030, J9036, J9356

Removed (effective July 1, 2019): C9141, J9031


Added (effective April 1, 2019): C9040, C9043–C9046, C9141


Added (effective January 1, 2019): A9513, C9035, C9036, C9038, C9039, J0185, J0517, J0567, J0584,

J0599, J0841, J1301, J1454, J1628, J1746, J2186, J2797, J3245, J3316, J3397, J3398, J7170, J7177,

J7203, J9044, J9057, J9153, J9173, J9229, J9311, J9312, Q2042, Q4183, Q4184, Q4185, Q4186,

Q4187–Q4198, Q4200–Q4204

Removed (effective January 1, 2019): C9014–C9016, C9024, C9028–C9033, C9463–C9468, C9493, J0833,

J9310, Q2040, Q4131, Q4172, Q9995


Added (effective October 1, 2018): C9033, Q5108, Q5110

September 21, 2018, update:

Added (effective September 21, 2018): A9527, C1716, C1717, C1719, C2616, C2634–C2645, C2698,

C2699, J9320

Added (effective September 7, 2018): 90750

Added (effective January 1, 2018): Q4176–Q4182

Added (effective February 2, 2017): J2860, J7503

Added (effective January 1, 2017): J2724


Added (effective August 31, 2018): 90644, 90698, C9257, C9358, C9360, J0215, J0220, J0348, J0364,

J0594, J0740, J1324, J1595, J1655, J1743, J2170, J3465, J7303, J7304, J7306–J7308, J7321,

J7323–J7326, J9261



Added (effective July 1, 2018): C9030, C9031, C9032, Q5105, Q9991, Q9992, Q9995




Added (effective June 1, 2018): J7186


Added (effective April 1, 2018): C9462–C9468, Q2041, Q5103, Q5104

Removed (effective April 1, 2018): Q5102


Removed (effective March 6, 2018): J0606

Added for retroactive coverage (effective October 1, 2017): C9494

Removed (effective December 31, 2017): C9494


Added (effective February 16, 2018): Q2043


Added (effective February 2, 2018): J0887, J0888


Added (effective January 1, 2018): C9014–C9016, C9024, C9028, C9029, J0565, J0606, J1428, J1555,

J1627, J1726, J2326, J2350, J3358, J7210, J7211, J9022, J9023, J9203, J9285, Q2040

Removed (effective January 1, 2018): C9140, C9483–C9486, C9489, C9491, J9300, Q9986, Q9989




Updated description (effective January 1, 2018): 90620, 90621, 90651, Q4132, Q4133, Q4148, Q4156,

Q4158, Q4162, Q4163




Added (effective October 1, 2017): C9491, C9493


Added (effective July 1, 2017): Q9986, Q9989

Removed (effective July 1, 2017): C9487


Added (effective May 11, 2017): J8565, Q4112–Q4114, Q4117, Q4122, Q4123, Q4125–Q4128,

Q4130–Q4136, Q4145, Q4150–Q4175

Added (effective July 1, 2016): J9225, J9226

Table 4 – Procedure Code Linked to Revenue Code 724 – Labor Room/Delivery – Birthing Center

Reviewed/Updated: July 1, 2020

Note: The procedure code on this table is the only code allowable for reimbursement with revenue

code 724. No other procedure codes will be reimbursed when billed with revenue code 724.

See the Obstetrical and Gynecological Services module for more information.


S4005 Interim labor facility global (labor occurring but not resulting in delivery)







90867 Transcranial magnetic stimulation treatment (stimulates nerve cells in brain to improve

symptoms of depression) [initial, including cortical mapping, motor threshold determination,

delivery and management]


symptoms of depression), per session [subsequent delivery and management per session]


symptoms of depression) [subsequent motor threshold redetermination with delivery and

management]

92542 Positional nystagmus test, minimum of 4 positions, with recording

92546 Sinusoidal vertical axis rotational testing

92548 Computerized dynamic posturography

92549 Computerized dynamic assessment of balance and postural instability with motor control and

adaptation test

93886 Transcranial Doppler study of the intracranial arteries; complete study

https://www.in.gov/medicaid/providers/files/obstetrical-and-gynecological-services.pdf









93888 Transcranial Doppler study of the intracranial arteries; limited study

93890 Transcranial Doppler study of the intracranial arteries; vasoreactivity study

93892 Transcranial Doppler study of the intracranial arteries; emboli detection without intravenous

microbubble injection

93893 Transcranial Doppler study of the intraranial arteries; emboli detection with intravenous


93998 Unlisted noninvasive vascular diagnostic study

95249 Continuous monitoring of glucose in tissue fluid using sensor under skin

95250 Ambulatory continuous glucose (sugar) monitoring for a minimum of 72 hours

95782 Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters

of sleep, attended by a technologist


of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation,

attended by a technologist

95808 Sleep monitoring of patient in sleep lab

95810 Sleep monitoring of patient (6 years or older) in sleep lab

95811 Sleep monitoring of patient (6 years or older) in sleep lab with continued pressured respiratory

assistance by mask or breathing tube

95857 Cholinesterase inhibitor challenge test for myasthenia gravis

95933 Orbicularis oculi (blink) reflex, by electrodiagnostic testing

95970 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse

amplitude, pulse duration, configuration of wave form, battery status, electrode selectability,

output modulation, cycling, impedance and patient compliance measurements







95976 Electronic analysis of implanted brain, spinal cord or peripheral stimulation device with

simple cranial nerve stimulator programming


complex cranial nerve stimulator programming


amplitude and duration, configuration of wave form, battery status, electrode selectability,

output modulation, cycling, impedance and patient measurements) gastric neurostimulator

pulse generator/transmitter; subsequent, without reprogramming




pulse generator/transmitter; subsequent, with reprogramming









95983 Electronic analysis of implanted brain, spinal cord or peripheral stimulation device with brain

stimulator programming, first 15 minutes face-to-face time with qualified health care

professional

96000 Comprehensive computer-based motion analysis by video-taping and 3D kinematics

96001 Comprehensive computer-based motion analysis by video-taping and 3D kinematics; with

dynamic plantar pressure measurements during walking

99172 Visual function screening, automated or semi-automated bilateral quantitative determination

of visual acuity, ocular alignment, color vision by pseudoisochromatic plates, and field of

vision (may include all or some screening of the determination(s) for contrast sensitivity,

vision under glare

99173 Screening test of visual acuity, quantitative, bilateral

99174 Instrument-based ocular screening (eg, photoscreening, automated-refraction), bilateral; with

remote analysis and report

99177 Instrument based ocular screening (eg, photoscreening, automated-refraction), bilateral; with

on-site analysis

0589T Electronic analysis with simple programming of nerve-stimulating device in posterior tibial

nerve

0590T Electronic analysis with complex programming of nerve-stimulating device in posterior tibial

nerve

0608T Data analysis and report transmission to health care professional for remote monitoring of

lung fluid monitoring system

0615T Eye-movement analysis with interpretation and report



Added (effective January 1, 2020): 92459


Added (effective July 1, 2020): 0608T, 0615T

Added (effective January 1, 2020): 0589T, 0590T


Added (effective April 23, 2019): 95976, 95977, 95983


Added (effective March 21, 2019): 90867, 90868, 90869




Removed (effective January 1, 2019): 95974, 95978



Added (correction): 99173, 99174


Updated description (effective January 1, 2018): 95250









92542 Positional nystagmus test, minimum of 4 positions, with recording

92543 Assessment and recording of balance system during irrigation of both ears

92546 Sinusoidal vertical axis rotational testing

92548 Computerized dynamic posturography

93886 Transcranial Doppler study of the intracranial arteries; complete study

93888 Transcranial Doppler study of the intracranial arteries; limited study

93890 Transcranial Doppler study of the intracranial arteries; vasoreactivity study

93892 Transcranial Doppler study of the intracranial arteries; emboli detection without intravenous


93893 Transcranial Doppler study of the intracranial arteries; emboli detection with intravenous


93930 Duplex scan of upper extremity arteries or arterial bypass grafts; complete bilateral study

93970 Duplex scan of extremity veins including responses to compression and other maneuvers;

complete bilateral study

93971 Duplex scan of extremity veins including responses to compression and other maneuvers;

unilateral or limited study

93975 Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents

and/or retroperitoneal organs; complete study

93998 Unlisted noninvasive vascular diagnostic study

95249 Continuous monitoring of glucose in tissue fluid using sensor under skin

95250 Ambulatory continuous glucose (sugar) monitoring for a minimum of 72 hours


of sleep, attended by a technologist


of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation,

attended by a technologist

95808 Sleep monitoring of patient in sleep lab

95810 Sleep monitoring of patient (6 years or older) in sleep lab

95811 Sleep monitoring of patient (6 years or older) in sleep lab with continued pressured respiratory

assistance by mask or breathing tube

95857 Cholinesterase inhibitor challenge test for myasthenia gravis

95933 Orbicularis oculi (blink) reflex, by electrodiagnostic testing



















simple cranial nerve stimulator programming


complex cranial nerve stimulator programming




pulse generator/transmitter; subsequent, without reprogramming




pulse generator/transmitter; subsequent, with reprogramming

95983 Electronic analysis of implanted brain, spinal cord or peripheral stimulation device with brain

stimulator programming, first 15 minutes face-to-face time with qualified health care

professional

96000 Comprehensive computer-based motion analysis by video-taping and 3D kinematics;

96001 Comprehensive computer-based motion analysis by video-taping and 3D kinematics; with

dynamic plantar pressure measurements during walking

0589T Electronic analysis with simple programming of nerve-stimulating device in posterior tibial

nerve

0590T Electronic analysis with complex programming of nerve-stimulating device in posterior tibial

nerve



Added (effective January 1, 2020): 0589T, 0590T


Added (correction): 92543


Added (effective April 23, 2019): 95976, 95977, 95983




Removed (effective January 1, 2019): 95974, 95978




Updated description (effective January 1, 2018): 95250



Table 7 – Procedure Codes Linked to Revenue Code 940 – Other Therapeutic Services – General






0474T Insertion of anterior segment aqueous drainage device, with creation of intraocular reservoir,

internal approach, into the supraciliary space


symptoms of depression), per session [subsequent delivery and management per session]


symptoms of depression) [subsequent motor threshold redetermination with delivery and

management]

96900 Application of ultraviolet light to skin

96910 Skin application of tar and ultraviolet B or petrolatum and ultraviolet B

96912 Application of chemical agents activated by ultraviolet light to skin

96913 Application of chemical agents activated by ultraviolet light to skin at least 4-8 hours

96999 Unlisted special dermatological service or procedure

97610 Low frequency, non-contact, non-thermal ultrasound, including topical application(s), when

performed, wound assessment, and instruction(s) for ongoing care, per day

98943 Chiropractic manipulative treatment to 1 or more regions other than spine

99195 Phlebotomy, therapeutic (separate procedure)



Added (effective January 1, 2020): 96900, 96910, 96912, 96913, 98943


Added (effective March 21, 2019): 90868, 90869


Added (effective February 13, 2017): 99195


Added (effective July 1, 2017): 0474T



Table 8 – Procedure Codes Linked to Revenue Codes for Managed Care Billing Only

Reviewed/Updated: July 1, 2020

Note: For managed care entities (MCEs) only, the procedure codes in this table may be separately

reimbursed in the outpatient setting when billed with the revenue codes indicated. No other procedure

codes will be reimbursed when billed with the revenue codes indicated, and the revenue codes

indicated will not be reimbursed when billed without the procedure codes listed. All revenue codes on

this table remain noncovered for fee-for-service (FFS) claims.

Revenue Code 912 –

Behavioral Health Treatments/Services – Partial Hospitalization – Less Intensive


H0035 Mental health partial hospitalization, treatment, less than 24 hours


Behavioral Health Treatments/Services – Partial Hospitalization – Intensive


H0035 Mental health partial hospitalization, treatment, less than 24 hours


Professional Fees (see also 097X and 098X) – General


99354 TH Notification of Pregnancy



Removed (effective July 1, 2019): Revenue codes 905 and 906


Added (effective July 1, 2016): Revenue codes 912 and 913 linked with procedure code H0035

Added (correction): Revenue code 960 linked with procedure code 99354 TH

revenue codes with special procedure code linkages

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