west virginia department of health and … fee...cms and cigna 2012 1st quarter wv dmepos fee...

WEST VIRGINIA DEPARTMENT OF HEALTH AND HUMAN RESOURCES

2012 DMEPOS FEE SCHEDULE

Source: BMS FEE SCHEDULE

CMS and Cigna 2012 1st Quarter WV DMEPOS Fee Schedule

Procedure

Code Modifier Description Methodology 2012 Pricing

A4206 Syringe w/needle sterile 1cc or less Purchased 0.27

A4207 Enteral nutrition infusion pump Purchased 0.31

A4208 Syringe w/needle sterile 3cc Purchased 0.30

A4209 Syringe w/needle sterile 5cc or greater Purchased 0.30

A4213 Syringe sterile 20 cc or greater Purchased 4.32

A4215 Syringe sterile any size Purchased 0.24

A4216 Sterile water/saline, 10 ml Purchased 0.37

A4217 Sterile water/saline, 500 ml Purchased 2.70

A4221 Maint drug infus cath per wk Purchased 19.46

A4222 Infusion Supplies with pump Purchased 38.62

A4223 Infusion supplies not used with pump Purchased 21.51

A4230 Infusion set for ext insulin pump Purchased 14.00

A4231 Infusion set for ext insulin pump Purchased 14.00

A4232 Syringe w needle for ext insulin pump Purchased 2.62

A4233 Alkalin batt for glucose mon Purchased 0.69

A4234 J-Cell batt for glucose mon Purchased 3.12

A4235 Lithium batt for glucose mon Purchased 2.02

A4236 Silvr oxide batt glucose Purchased 1.44

A4244 Alcohol or peroxide, per pint Purchased 0.94

A4245 Alcohol wipes, per box Purchased 1.00

A4246 Betadine or phisohex solution Purchased 11.43

A4247 Betadine or iodine swabs Purchased 11.00

A4250 Urine test or reagent strips Purchased 29.00

A4253 Blood glucose/reagent strips Purchased 35.71

A4253 KS Blood glucose/reagent strips Purchased 35.71

A4253 KX Blood glucose/reagent strips Purchased 35.71

A4256 Calibrator solution/chips Purchased 9.83

A4258 Lancet device each Purchased 17.44

A4259 Lancets per box Purchased 11.10

A4259 KS Lancets per box Purchased 11.10

A4259 KX Lancets per box Purchased 11.10

A4310 Insert tray w/o bag/cath Purchased 6.63

A4311 Catheter w/o bag 2-way latex Purchased 12.74

A4312 Cath w/o bag 2-way silicone Purchased 15.50





Procedure


A4313 Catheter w/bag 3-way Purchased 15.92

A4314 Cath w/drainage 2-way latex Purchased 21.73

A4315 Cath w/drainage 2-way silcne Purchased 22.67

A4316 Cath w/drainage 3-way Purchased 24.40

A4320 Irrigation tray Purchased 4.09

A4322 Irrigation syringe Purchased 2.50

A4326 Male external catheter Purchased 8.91

A4327 Fem urinary collect dev cup Purchased 36.32

A4328 Fem urinary collect pouch Purchased 8.70

A4330 Stool collection pouch Purchased 5.22

A4331 Extension drainage tubing Purchased 2.74

A4332 Lube sterile packet Purchased 0.10

A4333 Urinary cath anchor device Purchased 1.90

A4334 Urinary cath leg strap Purchased 4.23

A4338 Indwelling catheter latex Purchased 10.54

A4340 Indwelling catheter special Purchased 23.19

A4344 Cath indw foley 2 way silicn Purchased 13.76

A4346 Cath indw foley 3 way Purchased 16.83

A4349 Disposable male external cat Purchased 1.74

A4351 Straight tip urine catheter Purchased 1.47

A4352 Coude tip urinary catheter Purchased 4.69

A4353 Intermittent urinary cath Purchased 6.01

A4354 Cath insertion tray w/bag Purchased 10.14

A4355 Bladder irrigation tubing Purchased 7.54

A4356 Ext ureth clmp or compr dvc Purchased 39.21

A4357 Bedside drainage bag Purchased 8.34

A4358 Urinary leg or abdomen bag Purchased 5.70

A4361 Ostomy face plate Purchased 15.78

A4362 Solid skin barrier Purchased 2.91

A4364 Adhesive, liquid or equal Purchased 2.14

A4366 Ostomy vent Purchased 1.12

A4367 Ostomy belt Purchased 6.32

A4368 Ostomy filter Purchased 0.22

A4369 Skin barrier liquid per oz Purchased 2.08





Procedure


A4371 Skin barrier powder per oz Purchased 3.14

A4372 Skin barrier solid 4x4 equiv Purchased 3.60

A4373 Skin barrier with flange Purchased 5.39

A4375 Drainable plastic pch w fcpl Purchased 14.76

A4376 Drainable rubber pch w fcplt Purchased 40.89

A4377 Drainable plstic pch w/o fp Purchased 3.69

A4378 Drainable rubber pch w/o fp Purchased 26.42

A4379 Urinary plastic pouch w fcpl Purchased 12.90

A4380 Urinary rubber pouch w fcplt Purchased 32.08

A4381 Urinary plastic pouch w/o fp Purchased 3.97

A4382 Urinary hvy plstc pch w/o fp Purchased 21.15

A4383 Urinary rubber pouch w/o fp Purchased 24.22

A4384 Ostomy faceplt/silicone ring Purchased 8.26

A4385 Ost skn barrier sld ext wear Purchased 4.38

A4387 Ost clsd pouch w att st barr Purchased 3.18

A4388 Drainable pch w ex wear barr Purchased 3.75

A4389 Drainable pch w st wear barr Purchased 5.34

A4390 Drainable pch ex wear convex Purchased 8.26

A4391 Urinary pouch w ex wear barr Purchased 6.07

A4392 Urinary pouch w st wear barr Purchased 7.03

A4393 Urine pch w ex wear bar conv Purchased 7.77

A4394 Ostomy pouch liq deodorant Purchased 2.22

A4395 Ostomy pouch solid deodorant Purchased 0.04

A4396 Peristomal hernia supprt blt Purchased 34.78

A4397 Irrigation supply sleeve Purchased 4.11

A4398 Ostomy irrigation bag Purchased 11.87

A4399 Ostomy irrig cone/cath w brs Purchased 8.95

A4400 Ostomy irrigation set Purchased 41.99

A4402 Lubricant per ounce Purchased 1.38

A4404 Ostomy ring each Purchased 1.33

A4405 Nonpectin based ostomy paste Purchased 2.93

A4406 Pectin based ostomy paste Purchased 4.93

A4407 Ext wear ost skn barr <=4sq" Purchased 7.53

A4408 Ext wear ost skn barr >4sq" Purchased 8.48





Procedure


A4409 Ost skn barr convex <=4 sq i Purchased 5.34

A4410 Ost skn barr extnd >4 sq Purchased 7.77

A4411 Ost skn barr extnd =4sq Purchased 4.38

A4412 Ost pouch drain high output Purchased 2.33

A4413 2 pc drainable ost pouch Purchased 4.73

A4414 Ost sknbar w/o conv<=4 sq in Purchased 4.23

A4415 Ost skn barr w/o conv >4 sqi Purchased 5.15

A4416 Ost pch clsd w barrier/filtr Purchased 2.37

A4417 Ost pch w bar/bltinconv/fltr Purchased 3.20

A4418 Ost pch clsd w/o bar w filtr Purchased 1.56

A4419 Ost pch for bar w flange/flt Purchased 1.50

A4422 Ost pouch absorbent material Purchased 0.10

A4423 Ost pch for bar w lk fl/fltr Purchased 1.60

A4424 Ost pch drain w bar & filter Purchased 4.09

A4425 Ost pch drain for barrier fl Purchased 3.08

A4426 Ost pch drain 2 piece system Purchased 2.35

A4427 Ost pch drain/barr lk flng/f Purchased 2.39

A4428 Urine ost pouch w faucet/tap Purchased 5.59

A4429 Urine ost pouch w bltinconv Purchased 7.09

A4430 Ost urine pch w b/bltin conv Purchased 7.32

A4431 Ost pch urine w barrier/tapv Purchased 5.34

A4432 Os pch urine w bar/fange/tap Purchased 3.09

A4433 Urine ost pch bar w lock fln Purchased 2.87

A4434 Ost pch urine w lock flng/ft Purchased 3.23

A4450 Non-waterproof tape Purchased 0.10

A4450 AW Non-waterproof tape Purchased 0.10

A4452 Waterproof tape Purchased 0.34

A4452 AW Waterproof tape Purchased 0.34

A4455 Adhesive remover per ounce Purchased 1.23

A4456 Adhesive remover, wipes Purchased 0.22

A4461 Surgicl dress hold non-reuse Purchased 2.82

A4463 Surgical dress holder reuse Purchased 11.45

A4481 Tracheostoma filter Purchased 0.32

A4490 Surgical stocking above the knee Purchased 29.70





Procedure


A4495 Surgical stocking thigh length Purchased 29.70

A4500 Surgical stocking below the knee Purchased 31.50

A4510 Surgical stocking full lenth Purchased 84.15

A4520 Incont garment any type Purchased 0.75

A4554 Disposable underpants Purchased 0.31

A4556 Electrodes, pair Purchased 8.87

A4557 Lead wires, pair Purchased 15.42

A4561 Pessary rubber, any type Purchased 17.14

A4562 Pessary, non rubber,any type Purchased 42.69

A4565 Slings Purchased 5.85

A4570 Splint Purchased 67.50

A4595 TENS suppl 2 lead per month Purchased 24.76

A4601 Lithium Ion Battery for non-proth Purchased 26.00

A4604 Tubing with heating element Purchased 49.48

A4605 Trach suction cath close sys Purchased 14.09

A4606 Oxygen probe for use w/oximeter Purchased 100.00

A4614 Hand-held PEFR meter Purchased 20.44

A4619 Face tent Purchased 1.59

A4623 Tracheostomy inner cannula Purchased 4.78

A4624 Tracheal suction tube Purchased 2.26

A4625 Trach care kit for new trach Purchased 5.95

A4627 Tracheostomy cleaning brush Purchased 20.61 Corrected 08/04/14

A4628 Oropharyngeal suction cath Purchased 3.22

A4629 Tracheostomy care kit Purchased 3.98

A4635 Underarm crutch pad Purchased 4.40

A4636 Handgrip for cane etc Purchased 1.94

A4637 Repl tip cane/crutch/walker Purchased 1.58

A4640 Alternating pressure pad Purchased 46.61

A4927 Gloves, non-sterile, per 100 Purchased 42.71

A5051 Pouch clsd w barr attached Purchased 1.78

A5052 Clsd ostomy pouch w/o barr Purchased 1.28

A5053 Clsd ostomy pouch faceplate Purchased 1.50

A5054 Clsd ostomy pouch w/flange Purchased 1.54

A5055 Stoma cap Purchased 1.14





Procedure


A5056 Ostomy, tracheostomy & urological Supplies 4.01

A5057 Ostomy, tracheostomy & urological Supplies 8.26

A5061 Pouch drainable w barrier at Purchased 3.03

A5062 Drnble ostomy pouch w/o barr Purchased 1.79

A5063 Drain ostomy pouch w/flange Purchased 2.33

A5071 Urinary pouch w/barrier Purchased 5.16

A5072 Urinary pouch w/o barrier Purchased 3.03

A5073 Urinary pouch on barr w/flng Purchased 2.69

A5081 Continent stoma plug Purchased 2.84

A5082 Continent stoma catheter Purchased 10.22

A5093 Ostomy accessory convex inse Purchased 1.43

A5102 Bedside drain btl w/wo tube Purchased 19.26

A5105 Urinary suspensory Purchased 35.03

A5112 Urinary leg bag Purchased 27.07

A5113 Latex leg strap Purchased 3.44

A5114 Foam/fabric leg strap Purchased 6.54

A5120 Skin barrier, wipe or swab Purchased 0.19

A5121 Solid skin barrier 6x6 Purchased 6.13

A5122 Solid skin barrier 8x8 Purchased 11.04

A5126 Disk/foam pad +or- adhesive Purchased 0.97

A5131 Appliance cleaner Purchased 11.58

A5500 Diab shoe for density insert Purchased 54.63

A5501 Diabetic custom molded shoe Purchased 163.88

A5503 Diabetic shoe w/roller/rockr Purchased 26.82

A5504 Diabetic shoe with wedge Purchased 26.82

A5505 Diab shoe w/metatarsal bar Purchased 26.82

A5506 Diabetic shoe w/off set heel Purchased 26.82

A5507 Modification diabetic shoe Purchased 26.82

A5512 Multi den insert direct form Purchased 22.29

A5513 Multi den insert custom mold Purchased 33.26

A6154 Wound pouch each Purchased 11.98

A6196 Alginate dressing <=16 sq in Purchased 6.32

A6197 Alginate drsg >16 <=48 sq in Purchased 14.12

A6198 Alginate or fiber gelling dressing Purchased 14.12





Procedure


A6199 Alginate drsg wound filler Purchased 4.54

A6203 Composite drsg <= 16 sq in Purchased 2.88

A6204 Composite drsg >16<=48 sq in Purchased 5.35

A6205 Composite drsg >48 sq in Purchased 5.35

A6206 Contact layer < 16 Purchased 5.35

A6207 Contact layer >16<= 48 sq in Purchased 6.30

A6208 Contact layer >48 sq in Purchased 6.30

A6209 Foam drsg <=16 sq in w/o bdr Purchased 6.42

A6210 Foam drg >16<=48 sq in w/o b Purchased 17.12

A6211 Foam drg > 48 sq in w/o brdr Purchased 25.24

A6212 Foam drg <=16 sq in w/border Purchased 8.34

A6213 Foam drg wound cover Purchased 8.34

A6214 Foam drg > 48 sq in w/border Purchased 8.84

A6216 Non-sterile gauze<=16 sq in Purchased 0.04

A6217 Non-sterile gauze>16<=48 sq Purchased 0.32

A6218 Gauze >48 sq in w/bordr Purchased 0.54

A6219 Gauze <= 16 sq in w/border Purchased 0.82

A6220 Gauze >16 <=48 sq in w/bordr Purchased 2.22

A6221 Gauze >48 sq in w/bordr Purchased 1.93

A6222 Gauze <=16 in no w/sal w/o b Purchased 1.83

A6223 Gauze >16<=48 no w/sal w/o b Purchased 2.08

A6224 Gauze > 48 in no w/sal w/o b Purchased 3.10

A6229 Gauze >16<=48 sq in watr/sal Purchased 3.10

A6231 Hydrogel dsg<=16 sq in Purchased 4.01

A6232 Hydrogel dsg>16<=48 sq in Purchased 5.90

A6233 Hydrogel dressing >48 sq in Purchased 16.49

A6234 Hydrocolld drg <=16 w/o bdr Purchased 5.62

A6235 Hydrocolld drg >16<=48 w/o b Purchased 14.45

A6236 Hydrocolld drg > 48 in w/o b Purchased 23.42

A6237 Hydrocolld drg <=16 in w/bdr Purchased 6.80

A6238 Hydrocolld drg >16<=48 w/bdr Purchased 19.58

A6239 Hydrocolld drg >48 w/bdr Purchased 15.84

A6240 Hydrocolld drg filler paste Purchased 10.52

A6241 Hydrocolloid drg filler dry Purchased 2.21





Procedure


A6242 Hydrogel drg <=16 in w/o bdr Purchased 5.21

A6243 Hydrogel drg >16<=48 w/o bdr Purchased 10.58

A6244 Hydrogel drg >48 in w/o bdr Purchased 33.75

A6245 Hydrogel drg <= 16 in w/bdr Purchased 6.24

A6246 Hydrogel drg >16<=48 in w/b Purchased 8.53

A6247 Hydrogel drg > 48 sq in w/b Purchased 20.44

A6248 Hydrogel drsg gel filler Purchased 13.95

A6250 Skin sealants, protectants Purchased 15.00

A6251 Absorpt drg <=16 sq in w/o b Purchased 1.71

A6252 Absorpt drg >16 <=48 w/o bdr Purchased 2.79

A6253 Absorpt drg > 48 sq in w/o b Purchased 5.45

A6254 Absorpt drg <=16 sq in w/bdr Purchased 1.04

A6255 Absorpt drg >16<=48 in w/bdr Purchased 2.61

A6256 Specialty absorptive dressing Purchased 2.61

A6257 Transparent film <= 16 sq in Purchased 1.32

A6258 Transparent film >16<=48 in Purchased 3.70

A6259 Transparent film > 48 sq in Purchased 9.41

A6260 Wound cleanser any type or size Purchased 18.00

A6266 Impreg gauze no h20/sal/yard Purchased 1.66

A6402 Sterile gauze <= 16 sq in Purchased 0.10

A6403 Sterile gauze>16 <= 48 sq in Purchased 0.37

A6404 Gauze, nonimpregnated, sterile Purchased 2.16

A6407 Packing strips, non-impreg Purchased 1.62

A6441 Pad band w>=3" <5"/yd Purchased 0.58

A6442 Conform band n/s w<3"/yd Purchased 0.14

A6443 Conform band n/s w>=3"<5"/yd Purchased 0.25

A6444 Conform band n/s w>=5"/yd Purchased 0.48

A6445 Conform band s w <3"/yd Purchased 0.28

A6446 Conform band s w>=3" <5"/yd Purchased 0.35

A6447 Conform band s w >=5"/yd Purchased 0.58

A6448 Lt compres band <3"/yd Purchased 1.00

A6449 Lt compres band >=3" <5"/yd Purchased 1.50

A6452 High compres band w>=3"<5"yd Purchased 5.08

A6453 Self-adher band w <3"/yd Purchased 0.53





Procedure


A6454 Self-adher band w>=3" <5"/yd Purchased 0.66

A6455 Self-adher band >=5"/yd Purchased 1.20

A6456 Zinc paste band w >=3"<5"/yd Purchased 1.10

A6530 Gradient Compress stocking below knee Purchased 25.20

A6531 Compression stocking BK30-40 Purchased 37.18

A6532 Compression stocking BK40-50 Purchased 52.38

A6533 Gradient Compress stocking thigh length Purchased 29.70



A6536 Gradient Compress stocking full length Purchased 29.70

A6537 Gradient Compress stocking full length Purchased 29.70

A6539 Gradient Compress stocking waist length Purchased 84.15

A6544 Gradient Compress stocking garter belt Purchased 13.50

A6550 Neg pres wound ther drsg set Purchased 20.32

A7000 Disposable canister for pump Purchased 6.30

A7002 Tubing used w suction pump Purchased 3.30

A7003 Nebulizer administration set Purchased 2.01

A7004 Disposable nebulizer sml vol Purchased 1.55

A7005 Nondisposable nebulizer set Purchased 26.50

A7006 Filtered nebulizer admin set Purchased 8.20

A7007 Large volume nebulizer, disposable Purchased 3.97

A7012 Nebulizer water collec devic Purchased 2.77

A7013 Disposable compressor filter Purchased 0.71

A7015 Aerosol mask used w nebulize Purchased 1.41

A7030 CPAP full face mask Purchased 139.71

A7031 Replacement facemask interfa Purchased 51.67

A7032 Replacement nasal cushion Purchased 30.02

A7033 Replacement nasal pillows Purchased 21.04

A7034 Nasal application device Purchased 87.12

A7035 Pos airway press headgear Purchased 29.43

A7036 Pos airway press chinstrap Purchased 11.45

A7037 Pos airway pressure tubing Purchased 30.27

A7038 Pos airway pressure filter Purchased 3.40

A7039 Filter, non disposable w pap Purchased 10.36





Procedure


A7045 Repl exhalation port for PAP Purchased 14.42

A7046 Repl water chamber, PAP dev Purchased 14.45

A7507 Integrated filter & holder Purchased 2.14

A7508 Housing & Integrated Adhesiv Purchased 2.46

A7509 Heat & moisture exchange sys Purchased 1.22

A7520 Trach/laryn tube non-cuffed Purchased 40.80

A7521 Trach/laryn tube cuffed Purchased 40.42

A7522 Trach/laryn tube stainless Purchased 38.81

A7524 Tracheostoma stent/stud/bttn Purchased 66.51

A7525 Tracheostomy mask Purchased 1.78

A7526 Tracheostomy tube collar Purchased 2.90

A7527 Trach/laryn tube plug/stop Purchased 3.08

A8000 Soft protect helmet prefab Purchased 131.78

A8001 Hard protect helmet prefab Purchased 131.78

A8002 Soft protect helmet custom Purchased 375.35

A8003 Hard protect helmet custom Purchased 375.35

B4034 Enteral feeding supply kit, syringe fed Purchased 4.85 Priced per Cigna Fee Schedule - CY2012 1st Qtr

B4035 Enteral feeding supply kit, pump fed Purchased 9.25 Priced per Cigna Fee Schedule - CY2012 1st Qtr

B4036 Enteral feeding supply kit, gravity fed Purchased 6.35 Priced per Cigna Fee Schedule - CY2012 1st Qtr

B4081 Nasogastic tubing with stylet Purchased 17.15 Priced per Cigna Fee Schedule - CY2012 1st Qtr

B4082 Nasogastic tubing with stylet Purchased 12.75 Priced per Cigna Fee Schedule - CY2012 1st Qtr

B4083 Stomach tube Purchased 1.96 Priced per Cigna Fee Schedule - CY2012 1st Qtr

B4087 Gastrostomy/jejunostomy tube Purchased 28.31 Priced per Cigna Fee Schedule - CY2012 1st Qtr

B4088 Gastrostomy/jejunostomy tube Purchased 28.31 Priced per Cigna Fee Schedule - CY2012 1st Qtr

B4164 Paretneral nut solution - carbohydrate Purchased 15.16 Priced per Cigna Fee Schedule - CY2012 1st Qtr

B4168 Paretneral nut solution - amino acid Purchased 22.10 Priced per Cigna Fee Schedule - CY2012 1st Qtr

B4172 Parenteral nut solution - amino acid Purchased 30.50



B4180 Paretneral nut solution - carbohydrate Purchased 21.76 Priced per Cigna Fee Schedule - CY2012 1st Qtr

B4185 Paretneral nut solution - lipid Purchased 10.02 Priced per Cigna Fee Schedule - CY2012 1st Qtr








Procedure



B4216 Paretneral nut solution - additives Purchased 6.89 Priced per Cigna Fee Schedule - CY2012 1st Qtr

B4220 Paretneral nut solution - supply kit Purchased 7.14 Priced per Cigna Fee Schedule - CY2012 1st Qtr

B4222 Paretneral nut solution - supply kit Purchased 8.81 Priced per Cigna Fee Schedule - CY2012 1st Qtr

B4224 Paretneral nut solution - administration kit Purchased 22.31 Priced per Cigna Fee Schedule - CY2012 1st Qtr




B9000 Enteral nutrition infusion pump CAP Rental 89.39 From Cigna fee schedule modifier RR




E0100 Cane adjust/fixed with tip Purchased 16.78

E0105 Cane adjust/fixed quad/3 pro Purchased 39.02

E0110 Crutch forearm pair Purchased 56.67

E0111 Crutch forearm each Purchased 41.61

E0112 Crutch underarm pair wood Purchased 28.83

E0113 Crutch underarm each wood Purchased 15.44

E0114 Crutch underarm pair no wood Purchased 34.47

E0116 Crutch underarm each no wood Purchased 20.26

E0130 Walker rigid adjust/fixed ht Purchased 52.02

E0135 Walker folding adjust/fixed Purchased 56.64

E0140 Walker w trunk support Purchased 267.15

E0141 Rigid wheeled walker adj/fix Purchased 72.58

E0143 Walker folding wheeled w/o s Purchased 75.69

E0147 Walker variable wheel resist Purchased 425.72

E0148 Heavyduty walker no wheels Purchased 94.10

E0149 Heavy duty wheeled walker Purchased 165.31

E0153 Forearm crutch platform atta Purchased 50.68

E0154 Walker platform attachment Purchased 44.39

E0155 Walker wheel attachment,pair Purchased 23.37

E0156 Walker seat attachment Purchased 16.64

E0157 Walker crutch attachment Purchased 51.58

E0158 Walker leg extenders set of4 Purchased 23.83





Procedure


E0159 Brake for wheeled walker Purchased 13.23

E0160 Sitz type bath or equipment Purchased 24.14

E0161 Sitz bath/equipment w/faucet Purchased 22.54

E0162 Sitz bath chair Purchased 120.22

E0163 Commode chair with fixed arm Purchased 91.41

E0165 Commode chair with detacharm Purchased 135.76 Multiplied by 10

E0167 Commode chair pail or pan Purchased 10.31

E0168 Heavyduty/wide commode chair Purchased 129.69

E0181 Press pad alternating w/ pum Purchased 223.92 Multiplied by 10

E0182 Replace pump, alt press pad Purchased 191.20 Multiplied by 10

E0184 Dry pressure mattress Purchased 142.22

E0185 Gel pressure mattress pad Purchased 233.62

E0186 Air pressure mattress Purchased 174.48 Multiplied by 10

E0187 Water pressure mattress Purchased 199.44 Multiplied by 10

E0188 Synthetic sheepskin pad Purchased 22.71

E0189 Lambswool sheepskin pad Purchased 44.66

E0190 Positioning cushion pillow Purchased 14.98

E0191 Protector heel or elbow Purchased 8.54

E0196 Gel pressure mattress Purchased 271.30 Price corrected 03/01/12; s/h/b Multiplied by 10

E0197 Air pressure pad for mattres Purchased 190.41

E0198 Water pressure pad for mattr Purchased 190.41

E0199 Dry pressure pad for mattres Purchased 23.42

E0202 Phototherapy light w/ photom CAP Rental 53.80

E0241 Bathtub wall rail Purchased 63.00

E0243 Toilet rail Purchased 28.35

E0244 Raised toilet seat Purchased 81.00

E0245 Tub stool or bench Purchased 141.75

E0250 Hosp bed fixed ht w/ mattres CAP Rental 72.40

E0255 Hospital bed var ht w/ mattr CAP Rental 87.01

E0260 Hosp bed semi-electr w/ matt CAP Rental 104.03

E0271 Mattress innerspring Purchased 139.78

E0272 Mattress foam rubber Purchased 141.18

E0275 Bed pan standard Purchased 13.16

E0276 Bed pan fracture Purchased 11.44





Procedure


E0277 Powered pres-redu air mattrs CAP Rental 520.99

E0300 Enclosed ped crib hosp grade CAP Rental 210.24 Divided by 10

E0303 Hosp bed hvy dty xtra wide CAP Rental 217.97

E0304 Hosp bed xtra hvy dty x wide CAP Rental 570.78

E0305 Rails bed side half length Purchased 112.00 Multiplied by 10

E0310 Rails bed side full length Purchased 136.95

E0325 Urinal male jug-type Purchased 7.38

E0326 Urinal female jug-type Purchased 9.02

E0371 Nonpower mattress overlay CAP Rental 318.07

E0424 Stationary compressed gas 02 Rental 140.85

E0431 Portable gaseous 02 Rental 23.54

E0434 Portable liquid 02 Rental 23.54

E0439 Stationary liquid 02 Rental 140.85

E0441 Stationary O2 contents, gas Rental 61.96

E0443 Portable 02 contents, gas Rental 61.96

E0445 Oximeter device Rental 250.00

E0450 Vol control vent invasiv int Rental 820.22

E0460 Neg press vent portabl/statn Rental 630.36

E0463 Press supp vent invasive int Rental 1,208.50

E0464 Press supp vent noninv int Rental 1,208.50

E0464 RR Press supp vent noninv int Rental 1,208.50

E0470 RAD w/o backup non-inv intfc CAP Rental 190.05

E0470 RR RAD w/o backup non-inv intfc CAP Rental 190.05

E0471 RAD w/backup non inv intrfc Rental 475.61

E0471 RR RAD w/backup non inv intrfc Rental 475.61

E0472 RAD w backup invasive intrfc Rental 475.61

E0472 RR RAD w backup invasive intrfc Rental 475.61

E0480 Percussor elect/pneum home m CAP Rental 34.63

E0482 Cough stimulating device CAP Rental 357.02

E0483 Chest compression gen system CAP Rental 913.54

E0484 Non-elec oscillatory pep dvc Purchased 31.73

E0561 Humidifier nonheated w PAP Purchased 79.25

E0562 Humidifier heated used w PAP Purchased 223.10

E0565 Compressor air power source CAP Rental 44.57





Procedure


E0570 Nebulizer with compression Purchased 138.40 Multiplied by 10

E0600 Suction pump portab hom modl Purchased 393.44 Multiplied by 10

E0601 Cont airway pressure device CAP Rental 80.34

E0602 Manual breast pump Purchased 25.37

E0603 Breast Pump Purchased 55.00

E0605 Vaporizer room type Purchased 21.50

E0606 Drainage board postural Purchased 197.20 Multiplied by 10

E0607 Blood glucose monitor home Purchased 57.42

E0619 Apnea monitor w recorder CAP Rental 323.00

E0621 Patient lift sling or seat Purchased 70.11

E0630 Patient lift hydraulic CAP Rental 84.47

E0650 Pneuma compresor non-segment CAP Rental 56.69 Divided by 10

E0651 Pneum compressor segmental CAP Rental 67.08 Divided by 10

E0652 Pneum compres w/cal pressure CAP Rental 450.24 Divided by 10

E0655 Pneumatic appliance half arm Purchased 92.74

E0660 Pneumatic appliance full leg Purchased 137.27

E0665 Pneumatic appliance full arm Purchased 100.06

E0666 Pneumatic appliance half leg Purchased 118.66

E0667 Seg pneumatic appl full leg Purchased 278.21

E0668 Seg pneumatic appl full arm Purchased 322.75

E0669 Seg pneumatic appli half leg Purchased 149.56

E0671 Pressure pneum appl full leg Purchased 356.91

E0672 Pressure pneum appl full arm Purchased 277.32

E0673 Pressure pneum appl half leg Purchased 230.44

E0705 Transfer device Purchased 40.26

E0720 Tens two lead Purchased 315.86

E0730 Tens four lead Purchased 315.74

E0747 Elec osteogen stim not spine Purchased 3,365.08

E0748 Elec osteogen stim spinal Purchased 3,343.28

E0760 Osteogen ultrasound stimltor Purchased 2,778.21

E0781 External ambulatory infus pu CAP Rental 214.02

E0784 Ext amb infusn pump insulin CAP Rental 358.74

E0860 Tract equip cervical tract Purchased 31.97

E0910 Trapeze bar attached to bed Purchased 136.80 Multiplied by 10





Procedure


E0911 HD trapeze bar attach to bed Purchased 369.10 Multiplied by 10

E0912 HD trapeze bar free standing Purchased 847.80 Multiplied by 10

E0935 Cont pas motion exercise dev CAP Rental 19.54

E0940 Trapeze bar free standing Purchased 218.88 Multiplied by 10

E0942 Cervical head harness/halter Purchased 15.18

E0950 Tray Purchased 65.44

E0951 Loop heel Purchased 11.94

E0952 Toe loop/holder, each Purchased 11.86

E0955 Cushioned headrest Purchased 149.74

E0956 W/c lateral trunk/hip suppor Purchased 73.01

E0957 W/c medial thigh support Purchased 102.16

E0958 Whlchr att- conv 1 arm drive Purchased 374.88 Multiplied by 10

E0959 Amputee adapter Purchased 32.29

E0960 W/c shoulder harness/straps Purchased 67.38

E0961 Wheelchair brake extension Purchased 25.56

E0966 Wheelchair head rest extensi Purchased 53.22

E0967 Manual wc hand rim w project Purchased 56.44

E0968 Wheelchair commode seat Purchased 154.08 Multiplied by 10

E0969 Wheelchair narrowing device Purchased 127.74

E0971 Wheelchair anti-tipping devi Purchased 37.28

E0973 W/Ch access det adj armrest Purchased 72.38

E0974 W/Ch access anti-rollback Purchased 67.38

E0978 W/C acc,saf belt pelv strap Purchased 31.09

E0980 Wheelchair safety vest Purchased 27.46

E0981 Seat upholstery, replacement Purchased 29.68

E0982 Back upholstery, replacement Purchased 32.44

E0983 Add pwr joystick Purchased 2,079.44 Multiplied by 10

E0984 Add pwr tiller Purchased 1,453.42

E0988 Lever Activated wheel drive Purchased 257.23 New code

E0990 Wheelchair elevating leg res Purchased 73.92

E0992 Wheelchair solid seat insert Purchased 69.50

E1002 Pwr seat tilt Purchased 3,001.95

E1003 Pwr seat recline Purchased 3,252.35

E1004 Pwr seat recline mech Purchased 3,606.18





Procedure


E1005 Pwr seat recline pwr Purchased 3,903.42

E1006 Pwr seat combo w/o shear Purchased 4,781.32

E1007 Pwr seat combo w/shear Purchased 6,474.09

E1008 Pwr seat combo pwr shear Purchased 6,474.67

E1010 Add pwr leg elevation Purchased 847.13

E1014 Reclining back add ped w/c Purchased 313.77

E1015 Shock absorber for man w/c Purchased 98.57

E1016 Shock absorber for power w/c Purchased 97.26

E1020 Residual limb support system Purchased 180.28

E1028 W/c manual swingaway Purchased 152.97

E1029 W/c vent tray fixed Purchased 273.70

E1030 W/c vent tray gimbaled Purchased 863.04

E1031 Rollabout chair with casters CAP Rental 43.41

E1161 Manual adult wc w tiltinspac Purchased 2,033.18

E1225 Manual semi-reclining back Purchased 388.40 Multiplied by 10

E1226 Manual fully reclining back Purchased 454.21

E1231 Rigid ped w/c tilt-in-space Purchased 1,710.73

E1232 Folding ped wc tilt-in-space Purchased 1,837.53

E1233 Rig ped wc tltnspc w/o seat Purchased 1,903.98

E1234 Fld ped wc tltnspc w/o seat Purchased 1,657.54

E1235 Rigid ped wc adjustable Purchased 1,596.09

E1236 Folding ped wc adjustable Purchased 1,408.16

E1237 Rgd ped wc adjstabl w/o seat Purchased 1,420.46

E1238 Fld ped wc adjstabl w/o seat Purchased 1,408.16

E1372 Immersion external heater for nebulizer Purchased 119.07

E1390 Oxygen concentrator Rental 140.85

E2100 Bld glucose monitor w voice Purchased 552.69

E2201 Man w/ch acc seat w>=20÷<24÷ Purchased 320.61

E2202 Seat width 24-27 in Purchased 407.29

E2203 Frame depth less than 22 in Purchased 411.65

E2204 Frame depth 22 to 25 in Purchased 698.96

E2205 Manual wc accessory, handrim Purchased 28.07

E2206 Complete wheel lock assembly Purchased 34.95

E2207 Crutch and cane holder Purchased 37.25





Procedure


E2208 Cylinder tank carrier Purchased 87.98

E2209 Arm trough each Purchased 79.37

E2210 Wheelchair bearings Purchased 4.85

E2211 Pneumatic propulsion tire Purchased 29.89

E2212 Pneumatic prop tire tube Purchased 5.05

E2213 Pneumatic prop tire insert Purchased 26.14

E2214 Pneumatic caster tire each Purchased 26.30

E2215 Pneumatic caster tire tube Purchased 8.25

E2219 Foam caster tire any size ea Purchased 35.96

E2220 Solid propulsion tire each Purchased 22.14

E2221 Solid caster tire each Purchased 21.95

E2222 Solid caster integrated whl Purchased 18.10

E2224 Propulsion whl excludes tire Purchased 71.62

E2225 Caster wheel excludes tire Purchased 14.95

E2226 Caster fork replacement only Purchased 32.61

E2228 Mwc acc, wheelchair brake Purchased 804.53

E2231 Manual wheelchair accessory, solid seat Purchased 132.06

E2310 Electro connect btw control Purchased 866.72

E2311 Electro connect btw 2 sys Purchased 1,754.72

E2312 Mini-prop remote joystick Purchased 1,732.96

E2313 PWC harness, expand control Purchased 275.19

E2321 Hand interface joystick Purchased 1,176.94

E2322 Mult mech switches Purchased 1,044.56

E2323 Special joystick handle Purchased 51.22

E2324 Chin cup interface Purchased 32.46

E2325 Sip and puff interface Purchased 997.50

E2326 Breath tube kit Purchased 257.10

E2327 Head control interface mech Purchased 1,934.82

E2328 Head/extremity control inter Purchased 3,670.08

E2329 Head control nonproportional Purchased 1,308.06

E2330 Head control proximity switc Purchased 2,534.51

E2340 W/c wdth 20-23 in seat frame Purchased 307.94

E2341 W/c wdth 24-27 in seat frame Purchased 461.94

E2342 W/c dpth 20-21 in seat frame Purchased 384.95





Procedure


E2343 W/c dpth 22-25 in seat frame Purchased 615.93

E2351 Electronic SGD interface Purchased 517.43

E2360 22nf nonsealed leadacid Purchased 96.54

E2361 22nf sealed leadacid battery Purchased 103.30

E2362 Gr24 nonsealed leadacid Purchased 79.04

E2363 Gr24 sealed leadacid battery Purchased 137.76

E2364 U1nonsealed leadacid battery Purchased 96.54

E2365 U1 sealed leadacid battery Purchased 96.38

E2366 Battery charger, single mode Purchased 195.25

E2368 Power wc motor replacement Purchased 382.59

E2369 Pwr wc gear box replacement Purchased 333.24

E2370 Pwr wc motor/gear box combo Purchased 594.61

E2371 Gr27 sealed leadacid battery Purchased 111.64

E2373 Hand/chin ctrl spec joystick Purchased 604.07

E2374 Hand/chin ctrl std joystick Purchased 395.52

E2375 Non-expandable controller Purchased 634.40

E2376 Expandable controller, repl Purchased 994.13

E2377 Expandable controller, initl Purchased 359.74

E2381 Pneum drive wheel tire Purchased 56.42

E2382 Tube, pneum wheel drive tire Purchased 15.38

E2383 Insert, pneum wheel drive Purchased 112.49

E2384 Pneumatic caster tire Purchased 59.93

E2385 Tube, pneumatic caster tire Purchased 36.66

E2386 Foam filled drive wheel tire Purchased 111.47

E2387 Foam filled caster tire Purchased 48.09

E2388 Foam drive wheel tire Purchased 37.31

E2389 Foam caster tire Purchased 20.26

E2390 Solid drive wheel tire Purchased 31.69

E2391 Solid caster tire Purchased 15.18

E2392 Solid caster tire, integrate Purchased 39.90

E2394 Drive wheel excludes tire Purchased 56.85

E2395 Caster wheel excludes tire Purchased 40.40

E2396 Caster fork Purchased 45.73

E2397 Power wc accessory, lithium battery, eacy Purchased 355.87





Procedure


E2402 Neg press wound therapy pump CAP Rental 1,271.27

E2500 SGD digitized pre-rec <=8min Purchased 336.03

E2502 SGD prerec msg >8min <=20min Purchased 1,027.54

E2508 SGD spelling phys contact Purchased 3,073.38

E2510 SGD w multi methods msg/accs Purchased 5,815.95

E2601 Gen w/c cushion wdth < 22 in Purchased 45.30

E2602 Gen w/c cushion wdth >=22 in Purchased 88.43

E2603 Skin protect wc cus wd <22in Purchased 112.27

E2604 Skin protect wc cus wd>=22in Purchased 139.54

E2605 Position wc cush wdth <22 in Purchased 199.36

E2606 Position wc cush wdth>=22 in Purchased 311.02

E2607 Skin pro/pos wc cus wd <22in Purchased 214.67

E2608 Skin pro/pos wc cus wd>=22in Purchased 257.80

E2611 Gen use back cush wdth <22in Purchased 231.34

E2612 Gen use back cush wdth>=22in Purchased 312.95

E2613 Position back cush wd <22in Purchased 291.10

E2614 Position back cush wd>=22in Purchased 402.86

E2615 Pos back post/lat wdth <22in Purchased 335.00

E2616 Pos back post/lat wdth>=22in Purchased 450.74

E2619 Replace cover w/c seat cush Purchased 38.00

E2620 WC planar back cush wd <22in Purchased 405.64

E2621 WC planar back cush wd>=22in Purchased 425.69

E2626 Seo mobile are support attachment to wheel chair Purchased 526.33 Replaces L3964

E2627 Arm support attachment to wheel chair rancho type Purchased 723.91 Replaces L3965

E2628 Mobile arm supports reclining Purchased 545.35 Replaces L3966

E2629 Friction dampening arm support Purchased 811.92 Replaces L3968

E2630 Monosuspension arm/hand support Purchased 482.61 Replaces L3969

E2631 Elevated proximal arm support Purchased 193.06 Replaces L3970

E2632 Offset/lat rocker arm w/elevation Purchased 122.75 Replaces L3972

E2633 Mobile arm supports supinator Purchased 104.12 Replaces L3974

K0001 Standard wheelchair CAP Rental 45.77

K0002 Stnd hemi (low seat) whlchr CAP Rental 60.00

K0003 Lightweight wheelchair CAP Rental 76.99

K0004 High strength ltwt whlchr CAP Rental 105.77





Procedure


K0005 Ultralightweight wheelchair CAP Rental 158.86 Divided by 10

K0006 Heavy duty wheelchair CAP Rental 91.60

K0007 Extra heavy duty wheelchair CAP Rental 150.24

K0015 Detach non-adjus hght armrst Purchased 117.10

K0017 Detach adjust armrest base Purchased 37.85

K0018 Detach adjust armrst upper Purchased 21.14

K0019 Arm pad each Purchased 12.11

K0020 Fixed adjust armrest pair Purchased 34.42

K0037 High mount flip-up footrest Purchased 30.31

K0038 Leg strap each Purchased 17.98

K0039 Leg strap h style each Purchased 39.90

K0040 Adjustable angle footplate Purchased 55.30

K0041 Large size footplate each Purchased 39.19

K0042 Standard size footplate each Purchased 26.98

K0043 Ftrst lower extension tube Purchased 14.46

K0044 Ftrst upper hanger bracket Purchased 12.32

K0045 Footrest complete assembly Purchased 41.94

K0046 Elevat legrst low extension Purchased 14.46

K0047 Elevat legrst up hangr brack Purchased 56.64

K0050 Ratchet assembly Purchased 24.07

K0051 Cam relese assem ftrst/lgrst Purchased 38.96

K0052 Swingaway detach footrest Purchased 68.47

K0053 Elevate footrest articulate Purchased 75.55

K0056 Seat ht <17 or >=21 ltwt wc Purchased 81.72

K0065 Spoke protectors Purchased 38.20

K0069 Rear whl complete solid tire Purchased 85.87

K0070 Rear whl compl pneum tire Purchased 157.39

K0071 Front castr compl pneum tire Purchased 93.88

K0072 Frnt cstr cmpl sem-pneum tir Purchased 56.51

K0073 Caster pin lock each Purchased 28.75

K0077 Front caster assem complete Purchased 50.57

K0098 Drive belt power wheelchair Purchased 2.28

K0105 Iv hanger Purchased 85.44

K0195 Elevating whlchair leg rests Purchased 154.08 Multiplied by 10





Procedure


K0606 AED garment w elec analysis CAP Rental 2,163.95

K0730 Ctrl dose inh drug deliv sys Purchased 1,481.45

K0739 Repair for eq. other than Oxygen eq. Purchased 11.24 Priced per CMS Change Request 7635, Attachment A

K0740 Repair for Oxygen eq. Purchased 6.30 Not priced - Using fee BMS developed for the closed repair code E1340

K0800 POV group 1 std up to 300lbs CAP Rental 95.75 Divided by 10

K0801 POV group 1 hd 301-450 lbs CAP Rental 154.36 Divided by 10

K0802 POV group 1 vhd 451-600 lbs CAP Rental 174.69 Divided by 10

K0806 POV group 2 std up to 300lbs CAP Rental 115.83 Divided by 10

K0807 POV group 2 hd 301-450 lbs CAP Rental 175.76 Divided by 10

K0808 POV group 2 vhd 451-600 lbs CAP Rental 271.93 Divided by 10

K0813 PWC gp 1 std port seat/back CAP Rental 268.00

K0814 PWC gp 1 std port cap chair CAP Rental 343.07

K0815 PWC gp 1 std seat/back CAP Rental 390.62

K0816 PWC gp 1 std cap chair CAP Rental 374.11

K0820 PWC gp 2 std port seat/back CAP Rental 286.26

K0821 PWC gp 2 std port cap chair CAP Rental 367.47



K0824 PWC gp 2 hd seat/back CAP Rental 537.99

K0825 PWC gp 2 hd cap chair CAP Rental 492.53

K0826 PWC gp 2 vhd seat/back CAP Rental 696.50

K0827 PWC gp vhd cap chair CAP Rental 592.23

K0828 PWC gp 2 xtra hd seat/back CAP Rental 767.47

K0829 PWC gp 2 xtra hd cap chair CAP Rental 704.77



K0835 PWC gp2 std sing pow opt s/b CAP Rental 450.76

K0836 PWC gp2 std sing pow opt cap CAP Rental 467.46

K0837 PWC gp 2 hd sing pow opt s/b CAP Rental 537.99

K0838 PWC gp 2 hd sing pow opt cap CAP Rental 481.29

K0839 PWC gp2 vhd sing pow opt s/b CAP Rental 696.50

K0840 PWC gp2 xhd sing pow opt s/b CAP Rental 1,055.19

K0841 PWC gp2 std mult pow opt s/b CAP Rental 479.78

K0842 PWC gp2 std mult pow opt cap CAP Rental 479.78





Procedure


K0843 PWC gp2 hd mult pow opt s/b CAP Rental 577.65



K0850 PWC gp 3 hd seat/back CAP Rental 680.98


K0852 PWC gp 3 vhd seat/back CAP Rental 786.83

K0853 PWC gp 3 vhd cap chair CAP Rental 808.28

K0854 PWC gp 3 xhd seat/back CAP Rental 1,070.78

K0855 PWC gp 3 xhd cap chair CAP Rental 1,011.51

K0856 PWC gp3 std sing pow opt s/b CAP Rental 630.16

K0857 PWC gp3 std sing pow opt cap CAP Rental 642.78

K0858 PWC gp3 hd sing pow opt s/b CAP Rental 781.85

K0859 PWC gp3 hd sing pow opt cap CAP Rental 745.63

K0860 PWC gp3 vhd sing pow opt s/b CAP Rental 1,116.96

K0861 PWC gp3 std mult pow opt s/b CAP Rental 631.17

K0862 PWC gp3 hd mult pow opt s/b CAP Rental 781.85

K0863 PWC gp3 vhd mult pow opt s/b CAP Rental 1,116.96

K0884 PWC gp3 xhd mult pow opt s/b Purchased Cost Inv + 40%

L0112 Cranial cervical orthosis Purchased 1,012.28

L0113 Cranial cervical orthosis Purchased 206.25

L0120 Cerv flexible non-adjustable Purchased 19.38

L0130 Flex thermoplastic collar mo Purchased 136.95

L0140 Cervical semi-rigid adjustab Purchased 45.29

L0150 Cerv semi-rig adj molded chn Purchased 83.08

L0160 Cerv semi-rig wire occ/mand Purchased 108.52

L0170 Cervical collar molded to pt Purchased 446.84

L0172 Cerv col thermplas foam 2 pi Purchased 96.89

L0174 Cerv col foam 2 piece w thor Purchased 190.34

L0180 Cer post col occ/man sup adj Purchased 263.93

L0190 Cerv collar supp adj cerv ba Purchased 343.22

L0200 Cerv col supp adj bar & thor Purchased 357.80

L0220 Thor rib belt custom fabrica Purchased 97.71

L0430 Dewall posture protector Purchased 997.34

L0450 TLSO flex prefab thoracic Purchased 122.68





Procedure


L0452 tlso flex custom fab thoraci Purchased 198.51

L0454 TLSO flex prefab sacrococ-T9 Purchased 250.84

L0456 TLSO flex prefab Purchased 719.34

L0466 TLSO rigid frame pre soft ap Purchased 261.30

L0468 TLSO rigid frame prefab pelv Purchased 346.18

L0470 TLSO rigid frame pre subclav Purchased 441.74

L0472 TLSO rigid frame hyperex pre Purchased 280.16

L0480 TLSO rigid plastic custom fa Purchased 986.61

L0482 TLSO rigid lined custom fab Purchased 1,145.98

L0484 TLSO rigid plastic cust fab Purchased 1,231.33

L0486 TLSO rigidlined cust fab two Purchased 1,306.37

L0488 TLSO rigid lined pre one pie Purchased 726.00

L0490 TLSO rigid plastic pre one Purchased 204.60

L0491 TLSO 2 piece rigid shell Purchased 555.46

L0492 TLSO 3 piece rigid shell Purchased 365.31

L0621 SIO flex pelvisacral prefab Purchased 63.90

L0622 SIO flex pelvisacral custom Purchased 209.27

L0623 SIO panel prefab Purchased 336.26

L0625 LO flexibl L1-below L5 pre Purchased 39.83

L0626 LO sag stays/panels pre-fab Purchased 56.37

L0627 LO sagitt rigid panel prefab Purchased 297.30

L0628 LO flex w/o rigid stays pre Purchased 60.68

L0630 LSO post rigid panel pre Purchased 117.14

L0631 LSO sag-coro rigid frame pre Purchased 742.47

L0633 LSO flexion control prefab Purchased 207.40

L0635 LSO sagit rigid panel prefab Purchased 663.22

L0636 LSO sagittal rigid panel cus Purchased 981.80

L0637 LSO sag-coronal panel prefab Purchased 776.98

L0638 LSO sag-coronal panel custom Purchased 953.90

L0639 LSO s/c shell/panel prefab Purchased 776.98

L0640 LSO s/c shell/panel custom Purchased 756.81

L0700 Ctlso a-p-l control molded Purchased 1,416.43

L0710 Ctlso a-p-l control w/ inter Purchased 1,447.07

L0810 Halo cervical into jckt vest Purchased 1,809.74





Procedure


L0820 Halo cervical into body jack Purchased 1,624.36

L0830 Halo procedure, innto Milwaukee type brace Purchased 2,289.20

L0859 Addition to halo procedures, MRI system Purchased 954.01

L0861 Halo repl liner/interface Purchased 155.89

L0970 Tlso corset front Purchased 93.17

L0972 Lso corset front Purchased 83.68

L0974 Tlso full corset Purchased 124.26

L0976 Lso full corset Purchased 110.79

L0978 Axillary crutch extension Purchased 146.25

L0980 Peroneal straps pair Purchased 15.97

L0982 Stocking supp grips set of f Purchased 11.28

L0984 Protective body sock each Purchased 46.84

L1000 Ctlso milwauke initial model Purchased 1,421.10

L1010 Ctlso axilla sling Purchased 46.50

L1020 Kyphosis pad Purchased 59.89

L1025 Kyphosis pad floating Purchased 114.32

L1030 Lumbar bolster pad Purchased 44.07

L1040 Lumbar or lumbar rib pad Purchased 57.67

L1050 Sternal pad Purchased 69.53

L1060 Thoracic pad Purchased 83.40

L1070 Trapezius sling Purchased 81.44

L1080 Outrigger Purchased 45.82

L1085 Outrigger bil w/ vert extens Purchased 123.92

L1090 Lumbar sling Purchased 81.98

L1100 Ring flange plastic/leather Purchased 130.92

L1110 Ring flange plas/leather mol Purchased 176.96

L1120 Covers for upright each Purchased 29.92

L1200 Furnsh initial orthosis only Purchased 1,085.62

L1210 Lateral thoracic extension Purchased 181.30

L1220 Anterior thoracic extension Purchased 173.18

L1230 Milwaukee type superstructur Purchased 443.94

L1240 Lumbar derotation pad Purchased 60.01

L1250 Anterior asis pad Purchased 60.01

L1260 Anterior thoracic derotation Purchased 61.28





Procedure


L1270 Abdominal pad Purchased 62.25

L1280 Rib gusset (elastic) each Purchased 71.60

L1290 Lateral trochanteric pad Purchased 56.68

L1300 Body jacket mold to patient Purchased 1,276.23

L1310 Post-operative body jacket Purchased 1,311.34

L1500 Thkao mobility frame Purchased 1,311.34

L1510 Thkao standing frame Purchased 1,311.34

L1520 Thkao swivel walker Purchased 1,311.34

L1600 Abduct hip flex frejka w cvr Purchased 89.29

L1610 Abduct hip flex frejka covr Purchased 39.40

L1620 Abduct hip flex pavlik harne Purchased 111.59

L1630 Abduct control hip semi-flex Purchased 117.41

L1640 Pelv band/spread bar thigh c Purchased 357.40

L1650 HO abduction hip adjustable Purchased 180.85

L1660 HO abduction static plastic Purchased 118.58

L1680 Pelvic & hip control thigh c Purchased 844.22

L1685 Post-op hip abduct custom fa Purchased 861.55

L1686 HO post-op hip abduction Purchased 795.54

L1690 Combination bilateral HO Purchased 1,398.58

L1700 Leg perthes orth toronto typ Purchased 1,058.10

L1710 Legg perthes orth newington Purchased 1,238.62

L1720 Legg perthes orthosis trilat Purchased 913.01

L1730 Legg perthes orth scottish r Purchased 784.19

L1755 Legg perthes patten bottom t Purchased 1,244.46

L1810 Ko elastic with joints Purchased 68.23

L1820 Ko elas w/ condyle pads & jo Purchased 105.72

L1830 Ko immobilizer canvas longit Purchased 64.28

L1831 Knee orth pos locking joint Purchased 212.86

L1832 KO adj jnt pos rigid support Purchased 490.03

L1834 Ko w/0 joint rigid molded to Purchased 537.85

L1836 Rigid KO wo joints Purchased 96.50

L1840 Ko derot ant cruciate custom Purchased 716.43

L1843 KO single upright custom fit Purchased 648.94

L1844 Ko w/adj jt rot cntrl molded Purchased 1,124.82





Procedure


L1845 Ko w/ adj flex/ext rotat cus Purchased 673.42

L1846 Ko w adj flex/ext rotat mold Purchased 825.68

L1847 KO adjustable w air chambers Purchased 415.99

L1850 Ko swedish type Purchased 210.62

L1860 Ko supracondylar socket mold Purchased 743.49

L1900 Afo sprng wir drsflx calf bd Purchased 186.92

L1902 Afo ankle gauntlet Purchased 64.59

L1904 Afo molded ankle gauntlet Purchased 388.43

L1906 Afo multiligamentus ankle su Purchased 83.33

L1907 AFO supramalleolar custom Purchased 406.96

L1910 Afo sing bar clasp attach sh Purchased 189.25

L1920 Afo sing upright w/ adjust s Purchased 242.22

L1930 Afo plastic Purchased 163.91

L1932 Afo rig ant tib prefab TCF/= Purchased 645.40

L1940 Afo molded to patient plasti Purchased 342.66

L1945 Afo molded plas rig ant tib Purchased 819.23

L1950 Afo spiral molded to pt plas Purchased 543.20

L1951 AFO spiral prefabricated Purchased 607.42

L1960 Afo pos solid ank plastic mo Purchased 409.69

L1970 Afo plastic molded w/ankle j Purchased 493.02

L1971 AFO w/ankle joint, prefab Purchased 339.01

L1980 Afo sing solid stirrup calf Purchased 254.29

L1990 Afo doub solid stirrup calf Purchased 308.85

L2000 Kafo sing fre stirr thi/calf Purchased 731.71

L2005 KAFO sng/dbl mechanical act Purchased 2,963.68

L2010 Kafo sng solid stirrup w/o j Purchased 682.58

L2020 Kafo dbl solid stirrup band/ Purchased 859.46

L2030 Kafo dbl solid stirrup w/o j Purchased 780.20

L2034 KAFO pla sin up w/wo k/a cus Purchased 1,473.62

L2035 KAFO plastic pediatric size Purchased 126.55

L2036 Kafo plas doub free knee mol Purchased 1,332.15

L2037 Kafo plas sing free knee mol Purchased 1,242.83

L2038 Kafo w/o joint multi-axis an Purchased 1,262.52

L2040 Hkafo torsion bil rot straps Purchased 153.12





Procedure


L2050 Hkafo torsion cable hip pelv Purchased 330.06

L2060 Hkafo torsion ball bearing j Purchased 402.28

L2070 Hkafo torsion unilat rot str Purchased 103.30

L2080 Hkafo unilat torsion cable Purchased 249.22

L2090 Hkafo unilat torsion ball br Purchased 303.82

L2106 Afo tib fx cast plaster mold Purchased 471.10

L2108 Afo tib fx cast molded to pt Purchased 820.26

L2112 Afo tibial fracture soft Purchased 377.28

L2114 Afo tib fx semi-rigid Purchased 473.22

L2116 Afo tibial fracture rigid Purchased 544.48

L2126 Kafo fem fx cast thermoplas Purchased 910.81

L2128 Kafo fem fx cast molded to p Purchased 1,289.76

L2132 Kafo femoral fx cast soft Purchased 699.26

L2134 Kafo fem fx cast semi-rigid Purchased 746.18

L2136 Kafo femoral fx cast rigid Purchased 890.60

L2180 Plas shoe insert w ank joint Purchased 83.12

L2182 Drop lock knee Purchased 68.87

L2184 Limited motion knee joint Purchased 94.14

L2186 Adj motion knee jnt lerman t Purchased 130.58

L2188 Quadrilateral brim Purchased 250.06

L2190 Waist belt Purchased 64.62

L2192 Pelvic band & belt thigh fla Purchased 283.72

L2200 Limited ankle motion ea jnt Purchased 32.94

L2210 Dorsiflexion assist each joi Purchased 47.68

L2220 Dorsi & plantar flex ass/res Purchased 56.74

L2230 Split flat caliper stirr & p Purchased 53.17

L2232 Rocker bottom, contact AFO Purchased 71.98

L2240 Round caliper and plate atta Purchased 65.80

L2250 Foot plate molded stirrup at Purchased 266.78

L2260 Reinforced solid stirrup Purchased 138.90

L2265 Long tongue stirrup Purchased 81.60

L2270 Varus/valgus strap padded/li Purchased 38.26

L2275 Plastic mod low ext pad/line Purchased 90.20

L2280 Molded inner boot Purchased 315.42





Procedure


L2300 Addition to lower extremity Purchased 197.77

L2310 Abduction bar-straight Purchased 99.04

L2320 Non-molded lacer Purchased 142.56

L2330 Lacer molded to patient mode Purchased 298.42

L2335 Addition to lower extrmity, anterior Purchased 184.24

L2340 Pre-tibial shell molded to p Purchased 398.86

L2350 Prosthetic type socket molde Purchased 688.87

L2360 Extended steel shank Purchased 35.85

L2370 Patten bottom Purchased 232.30

L2375 Torsion ank & half solid sti Purchased 98.12

L2380 Torsion straight knee joint Purchased 85.30

L2385 Straight knee joint heavy du Purchased 92.81

L2387 Add LE poly knee custom KAFO Purchased 133.71

L2390 Offset knee joint each Purchased 77.70

L2395 Offset knee joint heavy duty Purchased 108.41

L2397 Suspension sleeve lower ext Purchased 84.47

L2405 Knee joint drop lock ea jnt Purchased 63.06

L2415 Knee joint cam lock each joi Purchased 87.83

L2425 Knee disc/dial lock/adj flex Purchased 103.67

L2430 Knee jnt ratchet lock ea jnt Purchased 103.67

L2492 Knee lift loop drop lock rin Purchased 94.12

L2500 Thi/glut/ischia wgt bearing Purchased 225.18

L2510 Th/wght bear quad-lat brim m Purchased 505.23

L2520 Th/wght bear quad-lat brim c Purchased 333.28

L2525 Th/wght bear nar m-l brim mo Purchased 899.19

L2526 Th/wght bear nar m-l brim cu Purchased 513.12

L2530 Thigh/wght bear lacer non-mo Purchased 162.80

L2540 Thigh/wght bear lacer molded Purchased 292.94

L2550 Thigh/wght bear high roll cu Purchased 198.99

L2570 Hip clevis type 2 posit jnt Purchased 330.02

L2580 Pelvic control pelvic sling Purchased 321.57

L2600 Hip clevis/thrust bearing fr Purchased 176.09

L2610 Hip clevis/thrust bearing lo Purchased 186.50

L2620 Pelvic control hip heavy dut Purchased 209.71





Procedure


L2622 Hip joint adjustable flexion Purchased 237.75

L2624 Hip adj flex ext abduct cont Purchased 229.44

L2627 Plastic mold recipro hip & c Purchased 1,251.98

L2628 Metal frame recipro hip & ca Purchased 1,231.51

L2630 Pelvic control band & belt u Purchased 171.57

L2640 Pelvic control band & belt b Purchased 232.84

L2650 Pelv & thor control gluteal Purchased 99.14

L2660 Thoracic control thoracic ba Purchased 129.14

L2670 Thorac cont paraspinal uprig Purchased 125.24

L2680 Thorac cont lat support upri Purchased 116.02

L2750 Plating chrome/nickel pr bar Purchased 57.91

L2755 Carbon graphite lamination Purchased 94.49

L2760 Extension per extension per Purchased 42.10

L2780 Non-corrosive finish Purchased 46.90

L2785 Drop lock retainer each Purchased 22.05

L2795 Knee control full kneecap Purchased 59.81

L2800 Knee cap medial or lateral p Purchased 91.91

L2810 Knee control condylar pad Purchased 72.15

L2820 Soft interface below knee se Purchased 60.17

L2830 Soft interface above knee se Purchased 65.10

L2840 Tibial length sock fx or equ Purchased 38.49

L2850 Femoral lgth sock fx or equa Purchased 42.90

L3000 Ft insert ucb berkeley shell Purchased 227.19

L3001 Foot insert remov molded spe Purchased 95.66

L3002 Foot insert plastazote or eq Purchased 116.81

L3003 Foot insert silicone gel eac Purchased 126.03

L3010 Foot longitudinal arch suppo Purchased 126.03

L3020 Foot longitud/metatarsal sup Purchased 143.50

L3030 Foot arch support remov prem Purchased 55.20

L3040 Ft arch suprt premold longit Purchased 34.03

L3050 Foot arch supp premold metat Purchased 34.03

L3060 Foot arch supp longitud/meta Purchased 53.34

L3070 Arch suprt att to sho longit Purchased 22.97

L3080 Arch supp att to shoe metata Purchased 22.97





Procedure


L3090 Arch supp att to shoe long/m Purchased 29.44

L3100 Hallus-valgus nght dynamic s Purchased 31.27

L3140 Abduction rotation bar shoe Purchased 64.40

L3150 Abduct rotation bar w/o shoe Purchased 58.87

L3170 Foot plastic heel stabilizer Purchased 36.82

L3201 Orthopedic shoe Purchased 36.00






L3208 Surgical boot Purchased 17.10



L3212 Benesch boot Purchased 41.40



L3215 Orthopedic footwear Purchased 80.38






L3224 Woman's shoe oxford brace Purchased 46.09

L3225 Man's shoe oxford brace Purchased 47.33



L3252 Foot, shoe molded Purchased 81.00

L3253 Foot, shoe molded Purchased 55.89

L3254 Nonstandard size or width Purchased 12.96

L3255 Nonstandard size or width Purchased 12.96



L3265 Plastazote sandal Purchased 40.50





Procedure


L3300 Sho lift taper to metatarsal Purchased 37.70

L3310 Shoe lift elev heel/sole neo Purchased 58.87

L3320 Shoe lift elev heel/sole neo Purchased 103.68

L3330 Lifts elevation metal extens Purchased 409.32

L3332 Shoe lifts tapered to one-ha Purchased 53.34

L3334 Shoe lifts elevation heel /i Purchased 27.60

L3340 Shoe wedge sach Purchased 61.64

L3350 Shoe heel wedge Purchased 16.57

L3360 Shoe sole wedge outside sole Purchased 25.75

L3370 Shoe sole wedge between sole Purchased 35.86

L3380 Shoe clubfoot wedge Purchased 35.86

L3390 Shoe outflare wedge Purchased 35.86

L3400 Shoe metatarsal bar wedge ro Purchased 29.44

L3410 Shoe metatarsal bar between Purchased 67.14

L3420 Full sole/heel wedge btween Purchased 39.55

L3430 Sho heel count plast reinfor Purchased 115.90

L3440 Heel leather reinforced Purchased 55.20

L3450 Shoe heel sach cushion type Purchased 76.35

L3455 Shoe heel new leather standa Purchased 29.44

L3460 Shoe heel new rubber standar Purchased 24.82

L3465 Shoe heel thomas with wedge Purchased 42.32

L3470 Shoe heel thomas extend to b Purchased 45.06

L3480 Shoe heel pad & depress for Purchased 45.06

L3485 Heel pad Purchased 13.77

L3500 Ortho shoe add leather insol Purchased 21.15

L3510 Orthopedic shoe add rub insl Purchased 21.15

L3520 O shoe add felt w leath insl Purchased 22.97

L3530 Ortho shoe add half sole Purchased 22.97

L3540 Ortho shoe add full sole Purchased 36.82

L3550 O shoe add standard toe tap Purchased 6.42

L3560 O shoe add horseshoe toe tap Purchased 16.57

L3570 O shoe add instep extension Purchased 61.64

L3580 O shoe add instep velcro clo Purchased 46.90

L3590 O shoe convert to sof counte Purchased 38.62





Procedure


L3595 Ortho shoe add march bar Purchased 30.35

L3600 Trans shoe calip plate exist Purchased 55.20

L3610 Trans shoe caliper plate new Purchased 72.66

L3620 Trans shoe solid stirrup exi Purchased 55.20

L3630 Trans shoe solid stirrup new Purchased 72.66

L3640 Shoe dennis browne splint bo Purchased 31.27

L3650 Shlder fig 8 abduct restrain Purchased 46.07

L3660 Abduct restrainer canvas&web Purchased 69.69

L3670 Acromio/clavicular canvas&we Purchased 92.10

L3671 SO cap design w/o jnts CF Purchased 593.12

L3672 SO airplane w/o jnts CF Purchased 593.12

L3673 SO airplane w/joint CF Purchased 593.12

L3702 EO w/o joints CF Purchased 190.06

L3710 Elbow elastic with metal joi Purchased 105.95

L3720 Forearm/arm cuffs free motio Purchased 472.75

L3730 Forearm/arm cuffs ext/flex a Purchased 611.19

L3740 Cuffs adj lock w/ active con Purchased 724.62

L3763 EWHO rigid w/o jnts CF Purchased 462.04

L3764 EWHO w/joint(s) CF Purchased 603.07

L3765 EWHFO rigid w/o jnts CF Purchased 844.00

L3766 EWHFO w/joint(s) CF Purchased 893.73

L3806 WHFO w/joint(s) custom fab Purchased 298.99

L3807 WHFO,no joint, prefabricated Purchased 164.59

L3808 WHFO, rigid w/o joints Purchased 246.14

L3900 Hinge extension/flex wrist/f Purchased 959.76

L3901 Hinge ext/flex wrist finger Purchased 1,089.92

L3904 Whfo electric custom fitted Purchased 1,985.52

L3905 WHO w/nontorsion jnt(s) CF Purchased 652.77

L3906 WHO w/o joints CF Purchased 289.83

L3908 Wrist cock-up non-molded Purchased 45.62

L3912 Flex glove w/elastic finger Purchased 79.01

L3913 HFO w/o joints CF Purchased 178.27

L3915 WHO w nontor jnt(s) prefab Purchased 349.88

L3917 Prefab metacarpl fx orthosis Purchased 69.54





Procedure


L3919 HO w/o joints CF Purchased 178.27

L3921 HFO w/joint(s) CF Purchased 211.43

L3923 HFO w/o joints PF Purchased 63.53

L3925 FO pip/dip with joint/spring Purchased 34.07

L3929 HFO nontorsion joint, prefab Purchased 60.38

L3931 WHFO nontorsion joint prefab Purchased 123.63

L3933 FO w/o joints CF Purchased 140.44

L3935 FO nontorsion joint CF Purchased 145.41

L3960 Sewho airplan desig abdu pos Purchased 498.74

L3961 Sewho shoulder cap desig custom Purchased 1,105.89

L3962 Sewho Erb's palsy design Purchased 486.47

L3964 SEO mobile arm support attached to w/c Purchased 486.47 E2626

L3965 SEO, mobile arm support, Rancho type Purchased 486.47 E2627 No longer Covering

L3966 SEO mobile arm support, reclining Purchased 486.47 E2628 No longer Covering

L3967 SEWHO airplan design, custom Purchased 1,305.68

L3968 SEO mobile arm support,prefabricated Purchased 1,305.68 E2629 No longer Covering

L3969 SEO mobile arm support, monosuspension Purchased 1,305.68 E2630 No longer Covering

L3970 SEO, addition to mobile arm support Purchased 1,305.68 E2631 No longer Covering

L3971 Sewho shoulder cap desig custom Purchased 1,239.40

L3972 SEO, addition to mobile arm support Purchased 1,239.40 E2632 No longer Covering

L3973 SEWHO abduction position, airplane design Purchased 1,305.68

L3974 SEO, addition to mobile arm support supinator Purchased 1,305.68 E2633 No longer Covering

L3975 SEWHO, shoulder cap design Purchased 1,105.89



L3978 SEWHO, airplane design Purchased 1,305.68

L3980 Upp ext fx orthosis humeral Purchased 217.10

L3982 Upper ext fx orthosis rad/ul Purchased 253.11

L3984 Upper ext fx orthosis wrist Purchased 233.37

L3995 Sock fracture or equal each Purchased 24.18

L4000 Repl girdle milwaukee orth Purchased 953.81

L4002 Replace strap, any orthosis Purchased 11.52

L4010 Replace trilateral socket br Purchased 465.00

L4020 Replace quadlat socket brim Purchased 650.32





Procedure


L4030 Replace socket brim cust fit Purchased 349.82

L4040 Replace molded thigh lacer Purchased 285.46

L4045 Replace non-molded thigh lac Purchased 227.28

L4050 Replace molded calf lacer Purchased 286.05

L4055 Replace non-molded calf lace Purchased 185.22

L4060 Replace high roll cuff Purchased 220.19

L4070 Replace prox & dist upright Purchased 194.99

L4080 Repl met band kafo-afo prox Purchased 79.98

L4090 Repl met band kafo-afo calf/ Purchased 63.11

L4100 Repl leath cuff kafo prox th Purchased 82.87

L4110 Repl leath cuff kafo-afo cal Purchased 62.43

L4130 Replace pretibial shell Purchased 350.08

L4205 Repair of orthotic device Purchased 15.98 Priced per CMS Change Request 7635, Attachment A

L4350 Ankle control orthosi prefab Purchased 69.36

L4360 Pneumati walking boot prefab Purchased 213.20

L4370 Pneumatic full leg splint Purchased 140.99

L4380 Pneumatic knee splint Purchased 140.99

L4386 Non-pneum walk boot prefab Purchased 114.67

L4392 Replace AFO soft interface Purchased 17.02

L4394 Replace foot drop spint Purchased 12.41

L4396 Static AFO Purchased 121.36

L4398 Foot drop splint recumbent Purchased 55.88

L5000 Sho insert w arch toe filler Purchased 411.44

L5010 Mold socket ank hgt w/ toe f Purchased 898.68

L5020 Tibial tubercle hgt w/ toe f Purchased 1,462.87

L5050 Ank symes mold sckt sach ft Purchased 1,694.07

L5060 Symes met fr leath socket ar Purchased 2,038.83

L5100 Molded socket shin sach foot Purchased 1,764.77

L5105 Plast socket jts/thgh lacer Purchased 2,801.06

L5150 Mold sckt ext knee shin sach Purchased 2,592.22

L5160 Mold socket bent knee shin s Purchased 2,819.51

L5200 Kne sing axis fric shin sach Purchased 2,456.03

L5210 No knee/ankle joints w/ ft b Purchased 1,791.23

L5220 No knee joint with artic ali Purchased 2,036.06





Procedure


L5230 Fem focal defic constant fri Purchased 2,808.13

L5250 Hip canad sing axi cons fric Purchased 3,830.03

L5270 Tilt table locking hip sing Purchased 3,796.48

L5280 Hemipelvect canad sing axis Purchased 3,758.52

L5301 BK mold socket SACH ft endo Purchased 1,694.86

L5311 Knee disart, SACH ft, endo Purchased -

L5312 Prosthetics and Orthotics 2,434.85 Replaces code L5311

L5321 AK open end SACH Purchased 2,426.15

L5331 Hip disart canadian SACH ft Purchased 3,433.09

L5341 Hemipelvectomy canadian SACH Purchased 3,730.69

L5400 Postop dress & 1 cast chg bk Purchased 888.42

L5410 Postop dsg bk ea add cast ch Purchased 389.24

L5420 Postop dsg & 1 cast chg ak/d Purchased 1,122.03

L5430 Postop dsg ak ea add cast ch Purchased 495.27

L5450 Postop app non-wgt bear dsg Purchased 316.84

L5460 Postop app non-wgt bear dsg Purchased 466.99

L5500 Init bk ptb plaster direct Purchased 948.06

L5505 Init ak ischal plstr direct Purchased 1,283.91

L5510 Prep BK ptb plaster molded Purchased 1,074.68

L5520 Perp BK ptb thermopls direct Purchased 1,061.53

L5530 Prep BK ptb thermopls molded Purchased 1,343.67

L5535 Prep BK ptb open end socket Purchased 1,324.18

L5540 Prep BK ptb laminated socket Purchased 1,398.28

L5560 Prep AK ischial plast molded Purchased 1,434.70

L5570 Prep AK ischial direct form Purchased 1,491.58

L5580 Prep AK ischial thermo mold Purchased 1,741.31

L5585 Prep AK ischial open end Purchased 1,888.66

L5590 Prep AK ischial laminated Purchased 1,774.51

L5595 Hip disartic sach thermopls Purchased 3,119.13

L5600 Hip disart sach laminat mold Purchased 3,402.10

L5610 Above knee hydracadence Purchased 1,528.30

L5611 Ak 4 bar link w/fric swing Purchased 1,189.32

L5613 Ak 4 bar ling w/hydraul swig Purchased 1,809.03

L5614 4-bar link above knee w/swng Purchased 1,222.83





Procedure


L5616 Ak univ multiplex sys frict Purchased 1,002.55

L5617 AK/BK self-aligning unit ea Purchased 405.45

L5618 Test socket symes Purchased 233.57

L5620 Test socket below knee Purchased 205.22

L5622 Test socket knee disarticula Purchased 313.42

L5624 Test socket above knee Purchased 299.02

L5626 Test socket hip disarticulat Purchased 420.33

L5628 Test socket hemipelvectomy Purchased 398.11

L5629 Below knee acrylic socket Purchased 304.02

L5630 Syme typ expandabl wall sckt Purchased 331.29

L5631 Ak/knee disartic acrylic soc Purchased 396.17

L5632 Symes type ptb brim design s Purchased 163.90

L5634 Symes type poster opening so Purchased 224.54

L5636 Symes type medial opening so Purchased 188.09

L5637 Below knee total contact Purchased 251.24

L5638 Below knee leather socket Purchased 359.24

L5639 Below knee wood socket Purchased 842.74

L5640 Knee disarticulat leather so Purchased 513.10

L5642 Above knee leather socket Purchased 459.35

L5643 Hip flex inner socket ext fr Purchased 1,148.92

L5644 Above knee wood socket Purchased 435.99

L5645 Bk flex inner socket ext fra Purchased 588.98

L5646 Below knee cushion socket Purchased 404.45

L5647 Below knee suction socket Purchased 587.18

L5648 Above knee cushion socket Purchased 485.99

L5649 Isch containmt/narrow m-l so Purchased 1,475.41

L5650 Tot contact ak/knee disart s Purchased 360.36

L5651 Ak flex inner socket ext fra Purchased 886.48

L5652 Suction susp ak/knee disart Purchased 321.82

L5653 Knee disart expand wall sock Purchased 429.61

L5654 Socket insert symes Purchased 244.81

L5655 Socket insert below knee Purchased 207.28

L5656 Socket insert knee articulat Purchased 291.98

L5658 Socket insert above knee Purchased 284.35





Procedure


L5661 Multi-durometer symes Purchased 494.14

L5665 Multi-durometer below knee Purchased 377.96

L5666 Below knee cuff suspension Purchased 56.16

L5668 Socket insert w/o lock lower Purchased 74.99

L5670 Bk molded supracondylar susp Purchased 228.28

L5671 BK/AK locking mechanism Purchased 367.18

L5672 Bk removable medial brim sus Purchased 278.94

L5673 Socket insert w lock mech Purchased 518.62

L5676 Bk knee joints single axis p Purchased 267.50

L5677 Bk knee joints polycentric p Purchased 363.96

L5678 Bk joint covers pair Purchased 29.31

L5679 Socket insert w/o lock mech Purchased 432.16

L5680 Bk thigh lacer non-molded Purchased 255.66

L5681 Intl custm cong/latyp insert Purchased 953.21

L5682 Bk thigh lacer glut/ischia m Purchased 461.64

L5683 Initial custom socket insert Purchased 953.21

L5684 Bk fork strap Purchased 35.53

L5685 Below knee sus/seal sleeve Purchased 92.82

L5686 Bk back check Purchased 47.93

L5688 Bk waist belt webbing Purchased 45.09

L5690 Bk waist belt padded and lin Purchased 87.31

L5692 Ak pelvic control belt light Purchased 101.35

L5694 Ak pelvic control belt pad/l Purchased 133.91

L5695 Ak sleeve susp neoprene/equa Purchased 140.49

L5696 Ak/knee disartic pelvic join Purchased 153.52

L5697 Ak/knee disartic pelvic band Purchased 62.36

L5698 Ak/knee disartic silesian ba Purchased 77.54

L5699 Shoulder harness Purchased 137.63

L5700 Replace socket below knee Purchased 2,126.61

L5701 Replace socket above knee Purchased 2,638.26

L5702 Replace socket hip Purchased 3,325.13

L5703 Symes ankle w/o (SACH) foot Purchased 1,544.15

L5704 Custom shape cover BK Purchased 433.61

L5705 Custom shape cover AK Purchased 794.97





Procedure


L5706 Custom shape cvr knee disart Purchased 775.40

L5707 Custom shape cvr hip disart Purchased 1,041.72

L5710 Kne-shin exo sng axi mnl loc Purchased 265.49

L5711 Knee-shin exo mnl lock ultra Purchased 402.74

L5712 Knee-shin exo frict swg & st Purchased 318.07

L5714 Knee-shin exo variable frict Purchased 328.02

L5716 Knee-shin exo mech stance ph Purchased 538.01

L5718 Knee-shin exo frct swg & sta Purchased 672.46

L5722 Knee-shin pneum swg frct exo Purchased 701.73

L5724 Knee-shin exo fluid swing ph Purchased 1,114.20

L5726 Knee-shin ext jnts fld swg e Purchased 1,463.07

L5728 Knee-shin fluid swg & stance Purchased 1,822.78

L5780 Knee-shin pneum/hydra pneum Purchased 878.86

L5785 Exoskeletal bk ultralt mater Purchased 383.52

L5790 Exoskeletal ak ultra-light m Purchased 530.76

L5795 Exoskel hip ultra-light mate Purchased 792.57

L5810 Endoskel knee-shin mnl lock Purchased 368.70

L5811 Endo knee-shin mnl lck ultra Purchased 538.36

L5812 Endo knee-shin frct swg & st Purchased 417.29

L5814 Endo knee-shin hydral swg ph Purchased 2,691.29

L5816 Endo knee-shin polyc mch sta Purchased 627.78

L5818 Endo knee-shin frct swg & st Purchased 708.88

L5822 Endo knee-shin pneum swg frc Purchased 1,375.30

L5824 Endo knee-shin fluid swing p Purchased 1,132.03

L5826 Miniature knee joint Purchased 2,285.68

L5828 Endo knee-shin fluid swg/sta Purchased 2,157.90

L5830 Endo knee-shin pneum/swg pha Purchased 1,533.27

L5840 Multi-axial knee/shin system Purchased 2,703.74

L5845 Knee-shin sys stance flexion Purchased 1,298.86

L5850 Endo ak/hip knee extens assi Purchased 98.05

L5855 Mech hip extension assist Purchased 227.97

L5910 Endo below knee alignable sy Purchased 269.25

L5920 Endo ak/hip alignable system Purchased 391.66

L5925 Above knee manual lock Purchased 248.03





Procedure


L5930 High activity knee frame Purchased 2,439.15

L5940 Endo bk ultra-light material Purchased 370.27

L5950 Endo ak ultra-light material Purchased 625.53

L5960 Endo hip ultra-light materia Purchased 749.27

L5962 Below knee flex cover system Purchased 433.89

L5964 Above knee flex cover system Purchased 777.20

L5966 Hip flexible cover system Purchased 1,001.14

L5970 Foot external keel sach foot Purchased 162.06

L5971 SACH foot, replacement Purchased 162.06

L5972 Flexible keel foot Purchased 260.15

L5974 Foot single axis ankle/foot Purchased 219.49

L5975 Combo ankle/foot prosthesis Purchased 335.94

L5976 Energy storing foot Purchased 413.39

L5978 Ft prosth multiaxial ankl/ft Purchased 215.42

L5979 Multi-axial ankle/ft prosth Purchased 1,728.59

L5980 Flex foot system Purchased 2,736.92

L5981 Flex-walk sys low ext prosth Purchased 2,365.70

L5982 Exoskeletal axial rotation u Purchased 426.74

L5984 Endoskeletal axial rotation Purchased 422.96

L5985 Lwr ext dynamic prosth pylon Purchased 204.64

L5986 Multi-axial rotation unit Purchased 470.25

L5987 Shank ft w vert load pylon Purchased 5,213.01

L5988 Vertical shock reducing pylo Purchased 1,447.66

L5990 User adjustable heel height Purchased 1,314.69

L6000 Par hand robin-aids thum rem Purchased 980.80

L6010 Hand robin-aids little/ring Purchased 1,091.47

L6020 Part hand robin-aids no fing Purchased 1,017.62

L6050 Wrst MLd sck flx hng tri pad Purchased 1,402.24

L6055 Wrst mold sock w/exp interfa Purchased 2,228.93

L6100 Elb mold sock flex hinge pad Purchased 1,420.69

L6110 Elbow mold sock suspension t Purchased 1,506.88

L6120 Elbow mold doub splt soc ste Purchased 1,756.06

L6130 Elbow stump activated lock h Purchased 1,910.91

L6200 Elbow mold outsid lock hinge Purchased 2,013.79





Procedure


L6205 Elbow molded w/ expand inter Purchased 3,355.77

L6250 Elbow inter loc elbow forarm Purchased 1,982.24

L6300 Shlder disart int lock elbow Purchased 2,750.14

L6310 Shoulder passive restor comp Purchased 2,261.64

L6320 Shoulder passive restor cap Purchased 1,261.49

L6350 Thoracic intern lock elbow Purchased 2,891.36

L6360 Thoracic passive restor comp Purchased 2,373.63

L6370 Thoracic passive restor cap Purchased 1,786.98

L6380 Postop dsg cast chg wrst/elb Purchased 965.14

L6382 Postop dsg cast chg elb dis/ Purchased 1,154.91

L6384 Postop dsg cast chg shlder/t Purchased 1,409.31

L6386 Postop ea cast chg & realign Purchased 337.97

L6388 Postop applicat rigid dsg on Purchased 324.51

L6400 Below elbow prosth tiss shap Purchased 1,716.46

L6450 Elb disart prosth tiss shap Purchased 2,275.84

L6500 Above elbow prosth tiss shap Purchased 2,277.70

L6550 Shldr disar prosth tiss shap Purchased 2,814.83

L6570 Scap thorac prosth tiss shap Purchased 3,415.35

L6580 Wrist/elbow bowden cable mol Purchased 1,192.18

L6582 Wrist/elbow bowden cbl dir f Purchased 1,015.95

L6584 Elbow fair lead cable molded Purchased 1,645.66

L6586 Elbow fair lead cable dir fo Purchased 1,439.61

L6588 Shdr fair lead cable molded Purchased 2,376.47

L6590 Shdr fair lead cable direct Purchased 2,173.79

L6600 Polycentric hinge pair Purchased 146.67

L6605 Single pivot hinge pair Purchased 136.92

L6610 Flexible metal hinge pair Purchased 122.90

L6611 Additional switch, ext power Purchased 298.37

L6615 Disconnect locking wrist uni Purchased 151.54

L6616 Disconnect insert locking wr Purchased 63.84

L6620 Flexion/extension wrist unit Purchased 237.84

L6621 Flex/ext wrist w/wo friction Purchased 1,657.52

L6623 Spring-ass rot wrst w/ latch Purchased 544.41

L6624 Flex/ext/rotation wrist unit Purchased 2,729.15





Procedure


L6625 Rotation wrst w/ cable lock Purchased 396.15

L6628 Quick disconn hook adapter o Purchased 404.82

L6629 Lamination collar w/ couplin Purchased 108.00

L6630 Stainless steel any wrist Purchased 159.09

L6632 Latex suspension sleeve each Purchased 53.06

L6635 Lift assist for elbow Purchased 147.35

L6637 Nudge control elbow lock Purchased 305.88

L6638 Elec lock on manual pw elbow Purchased 1,812.19

L6640 Shoulder abduction joint pai Purchased 208.74

L6641 Excursion amplifier pulley t Purchased 138.73

L6642 Excursion amplifier lever ty Purchased 197.52

L6645 Shoulder flexion-abduction j Purchased 239.87

L6650 Shoulder universal joint Purchased 249.86

L6655 Standard control cable extra Purchased 55.45

L6660 Heavy duty control cable Purchased 67.76

L6665 Teflon or equal cable lining Purchased 38.73

L6670 Hook to hand cable adapter Purchased 36.73

L6672 Harness chest/shlder saddle Purchased 124.47

L6675 Harness figure of 8 sing con Purchased 88.65

L6676 Harness figure of 8 dual con Purchased 89.52

L6677 UE triple control harness Purchased 214.97

L6680 Test sock wrist disart/bel e Purchased 171.26

L6682 Test sock elbw disart/above Purchased 191.94

L6684 Test socket shldr disart/tho Purchased 257.30

L6686 Suction socket Purchased 478.50

L6687 Frame typ socket bel elbow/w Purchased 425.78

L6688 Frame typ sock above elb/dis Purchased 411.87

L6689 Frame typ socket shoulder di Purchased 497.38

L6690 Frame typ sock interscap-tho Purchased 538.62

L6691 Removable insert each Purchased 322.13

L6692 Silicone gel insert or equal Purchased 412.81

L6693 Lockingelbow forearm cntrbal Purchased 2,057.32

L6694 Elbow socket ins use w/lock Purchased 518.62

L6695 Elbow socket ins use w/o lck Purchased 432.16





Procedure


L6696 Cus elbo skt in for con/atyp Purchased 953.21

L6697 Cus elbo skt in not con/atyp Purchased 953.21

L6698 Below/above elbow lock mech Purchased 367.18

L6703 Term dev, passive hand mitt Purchased 261.06

L6706 Term dev mech hook vol open Purchased 257.57

L6707 Term dev mech hook vol close Purchased 1,085.51

L6708 Term dev mech hand vol open Purchased 617.46

L6709 Term dev mech hand vol close Purchased 999.32

L6711 Term device mech, open pediatric Purchased 487.18

L6712 Term device mech, closing,pediatric Purchased 897.02

L6713 Term device, hand, opening, pediatric Purchased 1,132.15

L6714 Term device, hand, closing, pediatric Purchased 958.91

L6721 Term device hook or hand, opening Purchased 1,704.38

L6722 Term device hook or hand, closing Purchased 1,469.30

L6805 Term dev modifier wrist unit Purchased 265.71

L6810 Term dev precision pinch dev Purchased 144.84

L6883 Replc sockt below e/w disa Purchased 1,171.39

L6884 Replc sockt above elbow disa Purchased 1,647.98

L6885 Replc sockt shldr dis/interc Purchased 2,373.63

L6890 Prefab glove for term device Purchased 125.55

L6895 Custom glove for term device Purchased 456.97

L6900 Hand restorat thumb/1 finger Purchased 1,185.98

L6905 Hand restoration multiple fi Purchased 1,164.30

L6910 Hand restoration no fingers Purchased 1,195.23

L6915 Hand restoration replacmnt g Purchased 462.11

L6920 Wrist disarticul switch ctrl Purchased 5,689.99

L6925 Wrist disart myoelectronic c Purchased 6,237.88

L6930 Below elbow switch control Purchased 5,382.87

L6935 Below elbow myoelectronic ct Purchased 6,369.70

L6940 Elbow disarticulation switch Purchased 7,017.54

L6945 Elbow disart myoelectronic c Purchased 7,848.99

L6950 Above elbow switch control Purchased 7,437.10

L6955 Above elbow myoelectronic ct Purchased 9,044.95

L6960 Shldr disartic switch contro Purchased 9,602.61





Procedure


L6965 Shldr disartic myoelectronic Purchased 10,999.74

L6970 Interscap-thor myoelectronic Purchased 11,822.53

L6975 Interscap-thor myoelectronic Purchased 13,052.24

L7007 Adult electric hand Purchased 2,677.37

L7008 Pediatric electric hand Purchased 4,523.06

L7009 Adult electric hook Purchased 2,737.92

L7040 Prehensile actuator Purchased 2,147.37

L7045 Pediatric electric hook Purchased 1,193.13

L7170 Electronic elbow hosmer swit Purchased 4,328.27

L7180 Electronic elbow sequential Purchased 25,773.70

L7185 Electron elbow adolescent sw Purchased 4,431.43

L7186 Electron elbow child switch Purchased 6,767.15

L7190 Elbow adolescent myoelectron Purchased 5,769.54

L7191 Elbow child myoelectronic ct Purchased 7,288.78

L7260 Electron wrist rotator otto Purchased 1,876.94

L7261 Electron wrist rotator utah Purchased 3,456.12

L7266 Servo control steeper or equ Purchased 3,456.12

L7272 Analogue control unb or equa Purchased 3,456.12

L7274 Proportional ctl 12 volt uta Purchased 3,456.12

L7360 Six volt bat otto bock/eq ea Purchased 220.56

L7362 Battery chrgr six volt otto Purchased 198.70

L7364 Twelve volt battery utah/equ Purchased 367.30

L7366 Battery chrgr 12 volt utah/e Purchased 494.82

L7400 Add UE prost be/wd, ultlite Purchased 222.10

L7401 Add UE prost a/e ultlite mat Purchased 248.64

L7402 Add UE prost s/d ultlite mat Purchased 268.51

L7403 Add UE prost b/e acrylic Purchased 266.86

L7404 Add UE prost a/e acrylic Purchased 402.78

L7405 Add UE prost s/d acrylic Purchased 526.78

L7500 Repair prothetic device Purchased 46.80

L7510 Repair prothetic device Purchased 46.80

L7520 Repair prothetic device Purchased 21.71 Priced per CMS Change Request 7635, Attachment A

L8000 Mastectomy bra Purchased 26.95

L8001 Breast prosthesis bra & form Purchased 90.89





Procedure


L8002 Brst prsth bra & bilat form Purchased 119.54

L8010 Mastectomy sleeve Purchased 39.03

L8015 Ext breastprosthesis garment Purchased 43.44

L8020 Mastectomy form Purchased 184.67

L8030 Breast prosthes w/o adhesive Purchased 239.02

L8031 Breast prosthesis with adhesive Purchased 239.02

L8035 Custom breast prosthesis Purchased 2,654.90

L8300 Truss single w/ standard pad Purchased 62.26

L8310 Truss double w/ standard pad Purchased 98.31

L8320 Truss addition to std pad wa Purchased 44.07

L8330 Truss add to std pad scrotal Purchased 36.45

L8400 Sheath below knee Purchased 12.82

L8410 Sheath above knee Purchased 17.12

L8415 Sheath upper limb Purchased 16.84

L8417 Pros sheath/sock w gel cushn Purchased 54.45

L8420 Prosthetic sock multi ply BK Purchased 15.12

L8430 Prosthetic sock multi ply AK Purchased 16.34

L8435 Pros sock multi ply upper lm Purchased 15.52

L8440 Shrinker below knee Purchased 30.87

L8460 Shrinker above knee Purchased 49.20

L8465 Shrinker upper limb Purchased 43.55

L8470 Pros sock single ply BK Purchased 4.93

L8480 Pros sock single ply AK Purchased 6.79

L8485 Pros sock single ply upper l Purchased 8.53

L8500 Artificial larynx Purchased 649.55

L8501 Tracheostomy speaking valve Purchased 89.17

L8505 Artificial larynx Purchased 49.40

L8510 Voice amplifier Purchased 183.10

L8614 Cochlear device Purchased 14,394.27

L8617 Coch implant trans coil repl Purchased 66.49

L8619 Coch imp ext proc/contr rplc Purchased 6,179.36

L8621 Repl zinc air battery Purchased 0.45

L8623 Lith ion batt CID,non-earlvl Purchased 46.87

L8624 Lith ion batt CID, ear level Purchased 116.86





Procedure


S1040 Cranial remolding orthosis Purchased 1,200.00

S8490 KX Insulin syringes Purchased 27.00

V5030 Body worn hearing aid Purchased Cost Inv + 40%

V5040 Body worn hearing aid Purchased Cost Inv + 40%

V5050 Hearing aid monaural in ear Purchased Cost Inv + 40%

V5060 Behind ear hearing aid Purchased Cost Inv + 40%

V5120 Body worn binaur hearing aid Purchased Cost Inv + 40%

V5130 In ear binaural hearing aid Purchased Cost Inv + 40%

V5140 Behind ear binaur hearing aid Purchased Cost Inv + 40%

V5170 Within ear cros hearing aid Purchased Cost Inv + 40%

V5180 Behind ear cros hearing aid Purchased Cost Inv + 40%

V5210 In ear bicros hearing aid Purchased Cost Inv + 40%

V5220 Behind ear bicros hearing aid Purchased Cost Inv + 40%

V5230 Hearing aid bicros, glasses Purchased Cost Inv + 40%

V5246 Hearing aid, prog, mon, ite Purchased Cost Inv + 40%

V5247 Hearing aid, prog, mon, bte Purchased Cost Inv + 40%

V5252 Hearing aid, prog, bin, ite Purchased Cost Inv + 40%

V5253 Hearing aid, prog, bin bte Purchased Cost Inv + 40%

V5256 Hearing aid, digit, mon, ite Purchased Cost Inv + 40%

V5257 Hearing aid, digit, mon, bte Purchased Cost Inv + 40%

V5260 Hearing aid, digit, bin, ite Purchased Cost Inv + 40%

V5261 Hearing aid, digit, bin, bte Purchased Cost Inv + 40%

V5264 Ear mold insert Purchased 34.75

V5266 Battery for use in hearing device Purchased 2.25

V5275 Ear impression Purchased 32.27

V5298 Hearing aid noc Purchased Cost Inv + 40%

west virginia department of health and … fee...cms and cigna 2012 1st quarter wv dmepos fee...

Documents