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Provider Manual
Section 5.0
Utilization Management
Table of Contents
5.1 Utilization Management
5.2 Review Criteria/Standards for Review
5.3 Authorization Requirements
5.4 Online Authorization
5.5 Inpatient Admissions and Observation
5.6 Outpatient Services
5.7 High Cost Medication
5.8 Prior Authorization for Members with Original Medicare
5.9 Retrospective Authorization
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5.0 Utilization Management
5.1 Utilization Management
Utilization Management (UM) is the process of influencing the continuum of care by evaluating the
necessity and efficiency of health care services and affecting patient care decisions through assessments
of the appropriateness of care. The UM department helps to assure prompt delivery of
medically-appropriate health care services to Passport Health Plan members and subsequently monitors the
quality of care. Medically Necessary or Medical Necessity means Covered Services which are medically
necessary as defined under 907 KAR 3:130 or other applicable Kentucky law or regulation, and
provided in accordance with 42 CFR §440.230, including children’s services pursuant to 42 U.S.C.
1396d(r).
All Passport Health Plan participating providers are required to obtain prior authorization from the
Plan’s UM department for inpatient services and specified outpatient services listed in Section 5.3,
―Authorization Requirements.‖
Failure to submit an authorization or failure to submit an authorization in a timely manner may result in
a denial of services. An authorization is not a guarantee of benefits. Member eligibility should be
verified for every request of service.
The UM department is available Monday through Friday from 8:00 a.m. to 5:30 p.m. EST, except
holidays. All requests for authorization of services may be received during these hours of operation by
calling or faxing:
Department
Phone Number
Fax Number
General Number (800) 578-0636 (502) 585-7989 Concurrent Review (502) 585-2023 (502) 585-7989 Retrospective Review (502) 585-7972 (502) 585-8207 Home Health (502) 585-7320 (502) 585-8204 DME (502) 585-7310 (502) 585-7990 Therapies/Pain Management (502) 585-6055 (502) 585-8205 Cosmetics (502) 585-7069
Request can be sent via confidential email to: PassportUMCosmetics
@Passporthealthplan.com
Appeals (502) 585- 7307 (502) 585-8461
High Dollar Radiology Administered by MedSolutions
1-877-791-4099 1-888-693-3210 or on-line authorization at www.Medsolutionsonline.com
After business hours or on holidays, a provider can leave a message and a representative will return the
call the next business day.
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Director, to ask questions about a utilization management issue, or to seek information from the nurse
reviewer about the Utilization Management process and the authorization of care by calling Utilization
Management at (800) 578-0636.
Because of frequent changes in member eligibility for Medicaid coverage, providers should verify
continued eligibility via the Plan’s web site, www.passporthealthplan.com, or by calling the IVR or
Provider Services at (800) 578-0775.
5.2 Review Criteria/Standards for Review
Passport Health Plan’s Utilization Management (UM) department is charged with ensuring that the
Plan’s members use their benefits appropriately. Passport’s UM Department uses InterQual® Criteria
during the review process. In the event InterQual® Criteria is not available for a specific request, the
reviewer may use internal medical policies which are reviewed and approved by actively practicing
practitioners in the community.
The Partnership Council approves both the use of InterQual Criteria® and Medical Polices. Criteria are
only made available to participating and non-participating providers as allowed under copyright
limitations and trademark considerations.
At the request of the practitioner, the Passport UM Department, or the Chief Medical Officer, will
provide a copy of up to three (3) InterQual® Criteria guidelines. If the guidelines are not available for
distribution, or the number of guidelines exceeds the copyright limit, the practitioner has the option to
request the guideline be read over the telephone, or review the guideline at Passport Health Plan.
Internal Medical policies are communicated to providers via the Provider Newsletter or the Passport
Health Plan web site, www.passporthealthplan.com. Providers may request a copy of a policy at any
time from the Passport UM Department or the Chief Medical Officer.
Durable medical equipment is reviewed utilizing Medicaid and Medicare guidelines as well as any
applicable Passport Health Plan internal medical policies. Medicare and Medicaid criteria/guidelines are
shared with providers upon request. These requests may be made by contacting the UM Department or
the Chief Medical Officer. Criteria are distributed to providers who have Medicare/Medicaid
practitioner numbers issued by state and federal entities.
5.3 Authorization Requirements
The Passport UM department hours of operation are 8 a.m. to 5:30 p.m., Monday through Friday. The
general UM department phone number is: (800) 578-0636. The general UM department fax number is
(502) 585-7989.
The following table lists procedures and/or services that require authorization from Passport Health
Plan’s Utilization Management (UM) department.
Page 4 of 39 All Inpatient Admissions /
Hospitalizations
Maternity
Code Range: 644.XX through 665.XX ---
•If stay is less than or equal to 3 days with the above codes, no authorization is required
AUTHORIZATION IS REQUIRED FOR: All Cesarean Sections
All Scheduled inductions
All Non-par providers, regardless of delivery type Rehabilitation 23 Hour Observation greater than one (1) overnight stay Pain Management (i.e. Epidural
Blocks – Trigger Point Injections)
Home Hospice
Stem Cell/Progenitor Cell Retrieval Investigational/Experimental Procedures
Cosmetic Procedures Ocular Photodynamic Therapy/with Verteporfin (Visudyne) Neuropsychological Testing Diabetic Education
Therapy Services Chiropractic Services
No authorization for the first 12 visits in a calendar year Services beyond 12 visits require authorization
Benefit limit = total of 26 chiropractic visits within a calendar period
Specified Outpatient Surgical Procedures:
Adenoidectomy - Cardiac Catheterization - EGD
PET Scan / MRI / MRA / CT / CTA / Select Cardiac Imaging – Authorization administered by MSI
DME > $500 – rental or purchase All DME with E1399 Codes Enteral Products Select Orthotics / Prosthetics
Ostomy Supplies Home Health / Skilled Nursing / Private Duty Nursing Home Infusion – IV Therapy (IVT)
Authorization for IVT will be administered by PBM
High Cost Medication > $400
Synagis Injections – Synagis Injections – Authorizations administered by PBM
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Select EPSDT Special Services Family Planning – Terminations
To determine if a service or supply, such as cosmetic procedures, is considered benefit exclusion, please
contact the Passport Utilization Management (UM) department.
The assigned authorization number must be submitted on the claim form.
Policy for Newborns:
An infant born by Normal Vaginal Delivery (NVD) does not require authorization until day four (4). If
an infant born via NVD stays <= 3 days, authorization is not required.
An infant born by Section does not require authorization until day six (6). If an infant born via
C-Section stays <= 5 days, authorization is not required.
Benefit inclusions/exclusions must be considered in determining eligibility for coverage for individual
cases.
To determine if a service or supply, such as cosmetic procedures, is considered a benefit exclusion,
please contact the Passport Utilization Management (UM) department.
The assigned authorization number must be submitted on the claim form.
5.4 Online Authorization
Passport Health Plan’s Utilization Management Department utilizes an online authorization system via
NaviNet. The online authorization system is a web-based auto-review system for providers to obtain
authorization for services.
For questions regarding the online authorization, contact NaviNet or your Provider Network Account
Manager.
The online authorization system also allows you, the provider, to search for authorizations by member,
authorization number, date of service and/or physician. View the following information online for each
authorization:
•
Member identification number, coverage dates, and PCP
•
Authorization number
•
Service requested
•
Primary diagnosis
•
Treatment dates
•
Status of the authorization
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5.5 Inpatient Admissions
UM reviews all requests for inpatient admissions utilizing InterQual® criteria and internal medical
policies. For those requests meeting the established medical necessity criteria, an inpatient will be
authorized.
Requests not meeting the established medical necessity criteria will be referred to Passport’s Medical
Director for further review and evaluation.
When requesting a review, at a minimum, documentation must include:
• The member’s name and Passport Health Plan ID number.
• The diagnosis for which the treatment or testing procedure is being sought.
• Other treatment or testing methods that have been tried, their duration, and any outcomes.
• Additional clinical information as applicable to the requested service.
• Applicable sections of the medical record.
Some authorization requests may require a physician’s letter of medical necessity or a copy of the
medical records. These should be directed to the Utilization Management nurse who is coordinating the
specific case.
To receive authorization for an admission, contact Passport Health Plan’s Utilization Management
department at (800) 578-0636 or fax request to (502) 585-7989, Monday through Friday, between the
hours of 8 a.m. and 5:30 p.m.
5.5.1 Inpatient Admissions and Observation Requirements
All inpatient admissions require an authorization.
If a member is discharged from an inpatient level of care and subsequently re-admitted to the same
hospital within 24 hours, the UM Department continues the member's inpatient stay under the same
case reference number.
Requests for prior authorization of elective inpatient services should be received prior to the date the
requested service will be performed. Passport Health Plan will accept the hospital’s or the attending
physician’s request for prior authorization of elective hospital admissions; however, neither party
should assume that the other has obtained prior authorization.
For an urgent or emergent admission, the facility must notify the plan within one business day of the
admission.
For weekend admissions to a hospital or for services delivered on the weekend or after normal
business hours, authorization must be obtained within one business day of the admission or service
being provided.
If the member’s condition or results of evaluation and testing meet inpatient criteria after the 23-hour
observation period, the stay will be converted to inpatient beginning with the observation stay
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inpatient.
To receive authorization for an inpatient admission, contact Passport Health Plan’s Utilization
Management department at (800) 578-0636 or fax the request to (502) 585-7989, Monday through
Friday, between the hours of 8 a.m. and 5:30 p.m. EST.
To receive authorization for an inpatient admission, contact Passport Health Plan’s Utilization
Management department at (800) 578-0636 or fax request to (502) 585-7989, Monday through Friday,
between the hours of 8 a.m. and 5:30 p.m. EST.
Failure to obtain authorization of an admission will result in an administrative denial of the admission
(see Section 2.11).
Denied authorization requests may be appealed (see Section 2.11).
Inpatient Only Codes:
In accordance with the Centers for Medicare and Medicaid Services (CMS) billing requirements, select
surgical procedures must be performed in the inpatient setting.
A detailed list of codes may be obtained at the following CMS website:
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/downloads/cms-1427-p_addE.pdf
If a provider performs one of the listed procedures in an outpatient setting and the claim is denied,
they may submit supporting medical records documentation for review through the claims appeals
process.
5.5.2 Inpatient Admissions to Non-Participating Facilities
Requests for admission to non-participating facilities should be submitted to the Passport Health Plan
UM department for review.
To receive authorization for admission to a non-participating facility, contact Passport Health Plan’s
Utilization Management department at (800) 578-0636 or fax the request to (502) 585-7989, Monday
through Friday, between the hours of 8 a.m. and 5:30 p.m. EST.
5.5.3 Elective Participating-Hospital Transfer Policy
Elective participating facility transfers must be prior authorized by Passport Health Plan. Patient
clinical information will be required to complete the authorization process, approve the transfer, and
determine prospective length of stay.
Either the transferring or receiving facility may initiate the prior authorization; however, the
transferring facility will be able to provide the most accurate required clinical information. If a hospital
transfer request is made by another Passport Health Plan facility, the receiving facility may request that
the transferring facility obtain the authorization before the case will be accepted at the receiving facility.
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The receiving facility should contact Passport Health Plan to confirm the authorization.
In cases deemed emergent, notification of the admission is required within one business day after the
transfer.
To assist with transfers, contact Passport Health Plan’s Utilization Management department at (800)
578-0636 or fax the request to (502) 585-7989, Monday through Friday, between the hours of 8 a.m.
and 5:30 p.m.
5.5.4 Inpatient Rehabilitation Admissions
If a member requires an inpatient rehabilitation admission, the rehabilitation hospital will contact the
on-site review nurse at the acute-care facility where the member is currently an inpatient. If there is not
an on-site review nurse at the acute-care facility, the rehab hospital can contact Passport Health Plan’s
Utilization Management via phone (800) 578-0636 or fax (502) 585-7989.
Inpatient rehabilitation includes Acute Inpatient Rehab, Inpatient Cardiac Rehab and Inpatient
Pulmonary Rehab.
If the member is to be directly admitted from home or any other sub-acute facility, contact Passport
Health Plan’s Case Management department at (800) 578-0636 ext. 2024.
5.5.5 Inpatient Skilled-Nursing Facility
Passport Health Plan is not responsible for, nor does it reimburse nursing facility costs, for members at
skilled-nursing facilities. Those services are covered by the Kentucky Medicaid Program. Passport
Health Plan is responsible for costs of professional services, such as physician or therapist services that
are not part of the routine facility service. After a member is in a nursing facility for 31 days, the
disenrollment process begins for that member. Passport Health Plan’s responsibility for those
non-facility services continues for any of its members while they are still enrolled with the Plan. After the
Kentucky Medicaid Program completes the managed care disenrollment process and reinstates the
member in the fee-for-service Medicaid program, the Plan no longer has financial responsibility for any
services for that Medicaid recipient. To obtain skilled-nursing facility authorization, please call the
DMS-contracted review entity
.5.6 Outpatient Services
For authorization of select outpatient services listed in Section 5.3, ―Authorization Requirements,‖ the
PCP/specialist notifies Passport Health Plan via the online authorization system, telephonically or by
fax. Prior authorization is mandatory for select outpatient procedures / diagnostics to qualify for
payment.
When requesting a review, at a minimum, documentation submitted must include:
• The member’s name and Passport Health Plan ID number.
• The diagnosis for which the treatment or testing procedure is being sought.
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• Additional clinical information as applicable to the requested service.
• Applicable sections of the medical record.
Some authorization requests may require a physician’s letter of medical necessity or a copy of the
medical records. These should be directed to the Utilization Management nurse who is coordinating the
specific case.
Requests for prior authorization of elective services should be received prior to the date the requested
service will be performed.
Requests for authorization of urgent and emergent services must be submitted to UM within one
business day of the procedure being performed.
Passport Health Plan will accept the hospital’s or the attending physician’s request for prior
authorization of elective hospital admissions; however, neither party should assume that the other has
obtained prior authorization.
Failure to obtain prior authorization for an elective procedure / service or failure to request
authorization of an urgent or emergent procedure / service within one business day of the procedure/
service being performed or rendered will result in an administrative denial of the service (see Section
5.10.2). Denied requests may be appealed (see Section 2.11).
The assigned prior-authorization number must be on the claim form. If practitioners wish to confirm
authorization, they may verify online via the online authorization system.
5.6.1 Outpatient Procedures / Diagnostics / Services
Providers are required to obtain prior authorization for select outpatient procedures / diagnostics from
the Plan’s Utilization Management Department
.
See Table in section 5.3 for outpatient list.
For authorization of select outpatient services listed in Section 5.3, ―Authorization Requirements,‖ the
provider notifies Passport Health Plan via the online authorization system, telephonically or by fax.
The general UM department phone number is: (800) 578-0636. The general UM department fax
number is (502) 585-7989.
For Outpatient Imaging Services requiring authorization, see section 5.6.2.
5.6.2 Outpatient Radiology Services
Providers are required to obtain authorization for select radiological services through the high dollar
radiology program for advanced diagnostic imaging services. This program is administered in
partnership with MedSolutions (MSI).
Authorizations are required for select diagnostic imaging services performed in an outpatient setting.
Advanced diagnostic imaging includes:
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•
Computed Tomography (CT); Computed Tomographic Angiogram (CTA)
•
Magnetic Resonance Imaging (MRI); Magnetic Resonance Angiogram (MRA)
•
Positron Emissions Tomography (PET)
•
Nuclear Cardiac Imaging (NCM)
Authorizations are performed at MSI using their own internal criteria and medical management system.
MSI performs initial review, retrospective review, denials and 1st level appeals. Authorization is
required for advanced diagnostic imaging services performed in any outpatient setting.
Authorization is NOT required if the imaging service is performed in:
•
Emergency rooms
•
Inpatient settings
•
23-hour observations – Service performed in observation do not require an authorization.
There are three (3) ways to request an authorization:
1. Internet:
www.medsolutionsonline.com -
Available 24/7
2. Phone: (877) 791-4099
Available 8 a.m. - 9 p.m. EST, Monday through Friday
Toll free
3. Fax: 1-888-693-3210
Forms available at
www.medsolutionsonline.com
or by calling MedSolutions Customer
Service at (877) 791-4099
Only MedSolutions fax forms are accepted
Available 24/7
See Appendix A for a list of codes that require an authorization.
5.6.3 Durable Medical Equipment
The Department for Medicaid Services (DMS) requires that an updated Certificate of Medical
Necessity (CMN) be signed by the provider for all supplies and equipment and kept on file by the
supplier for a period of five (5) years. The only exception is oxygen for which Passport Health Plan
follows Medicare guidelines.
DME PURCHASE
DME items with billable charges greater than $500 require an authorization. Requests for authorization
of purchase MUST be received PRIOR to the end of the rental period.
DME RENTAL
Authorization requirements of rentals are determined by the billable price of the item being rented.
Rental charges will be applied to purchase price.
If the billable price of the rental is $500 or less, no authorization is required. If the billable price of the
rental is greater than $500, authorization is required.
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All mini-nebulizers will be a purchase only item and do not require prior authorization.
Authorization requirements for DME purchases are based on total monthly cost or monthly quantity
of items purchased. The following is a list of purchases with authorization requirements by quantity:
Item m
Quantity Limitations
Name Brand Diapers Regardless of quantity, all requests for name
brand diapers require authorization Generic Diapers 180 per month require authorization
Underpads (Chux) 180 per month require authorization
Ostomy Supplies 2 boxes per month require authorization
Bedside Drainage Bags 4 per month require authorization
Syringes 100 per month require authorization
G-Tube
Compression Stockings
1 per month requires authorization
6 pair per year require authorization
* Maintenance, repair, or replacement in excess of $500 must have prior authorization from the UM department.*
Enteral Products
• Enteral products with allowable amounts greater than $500 for a month’s supply require an
authorization.
These services should be billed according to the fee schedule in your Provider Contract (Allowable
Charges).
For authorization of DME, the provider notifies Passport Health Plan via the online authorization
system, telephonically or by fax. The DME phone number is: (502) 585-7310. The DME fax number
is: (502) 585-7990.
For a list of Orthotics and Prosthetics that require an Authorization, see Appendix A.
For a list of Ostomy supplies that require an Authorization, see Appendix B.
5.6.4 Home Health Services
When medically appropriate, home health, private duty nursing, or home infusion may be a good
alternative to hospitalization.
Prior authorization of all home health / private duty nursing / hospice / home infusion services is
required. If the member is an inpatient and the facility has a Passport Health Plan on-site nurse
reviewer, the request may be given directly to the on-site review nurse.
Private duty nursing is limited to 2,000 hours per calendar year. Additional hours for children may be
obtained under EPSDT Special Services.
A request for prior authorization must be received prior to the delivery of the service for a non-urgent
request and within one business day of the service being performed for an urgent or emergent service.
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For authorization of Home Health Services, including home health care, private duty nursing and home
hospice, the provider notifies Passport Health Plan through the online authorization system,
telephonically or by fax. The Home Health phone number is: (502) 585-7320. The Home Health fax
number is: (502) 585-8204.
For authorization of home infusion, the provider should submit the infusion therapy authorization
form to Magellan via fax at (800) 229-3928. The authorization form can be found at
http://www.passporthealthplan.com/pharmacy
.
5.6.5 Therapy, Chiropractic Services and Outpatient Rehab Services
Providers are required to obtain prior authorization for physical, occupational, aquatic and speech
therapy for acute and chronic conditions and chiropractic services.
•
Therapy
Authorization of outpatient therapy services (physical, occupational, aquatic and speech) is required.
If the member is an inpatient and the facility has a Passport Health Plan onsite nurse reviewer, the
request may be given directly to the onsite review nurse. Review is required for the initial therapy
visit and all subsequent visits.
Requests for continuation of a service that is ongoing should be sent to the therapy department
seven days prior to the end of the authorization period. Please fax request together with progress
notes and current plan of care to (502) 585-8204.
For authorization of therapy requests, providers must notify Passport Health Plan through the online
authorization system, telephonically or by fax. The therapy phone number is: (502) 585-6055. The
therapy fax number is (502) 585-8205.
•
Chiropractic ServicesAuthorization requests for chiropractic services are required after the 12th visit. No authorization is
required for the first 12 visits in a calendar year. The benefit limit equals the total of 26 chiropractic
visits within a 12-month calendar period.
•
Outpatient Rehab ServicesAuthorization requests for outpatient rehab services (cardiac rehab and pulmonary rehab) are
required. If the member is an inpatient and the facility has a Passport Health Plan onsite nurse
reviewer, the request may be given directly to the onsite review nurse. For authorization of
chiropractic or outpatient rehab services, providers must notify Passport Health Plan telephonically
at (502) 585-6055 or via fax at (502) 585-8205.
5.7 High-Cost Medications
Providers are required to obtain prior authorization for High-Cost Medications greater than $400
billable amount per dose from the Utilization Management Department
.
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does not apply to the pharmacy benefit. See Section 14 for prior authorizations related to pharmacy.
Authorizations for Synagis must be requested from Passport’s Pharmacy Benefits Manager. See section
14 for prior authorizations related to pharmacy.
For requests of high cost medications, providers may contact the UM Department at (800) 578-0636 or
fax the request to (502) 585-7989.
5.8 Prior Authorization for Members with Medicare
Prior authorization is not required for services listed on the prior authorization list when the member
has Medicare as the primary payer and benefits under Medicare have not been exhausted. This applies
to both inpatient and outpatient services. When benefits are exhausted, or if the service is not a benefit
covered under Medicare, and Passport Health Plan becomes the primary payer, prior authorization
requirements apply for both outpatient and inpatient services.
For those members who have exhausted their Medicare Part A inpatient lifetime reserve days, prior
authorization of inpatient services must be obtained. If a member’s lifetime reserve days are exhausted
during an inpatient hospitalization, notification to Passport Health Plan must be made within one
business day of the notification to the facility of the exhaustion of benefits by Medicare.
5.9 Retrospective Authorization
Retrospective review of inpatient services is performed when the patient was not a member of Passport
Health Plan prior to or at the time of the service. Outpatient services do not require retrospective
review by Utilization Management for members whose eligibility is determined retrospectively.
Providers have 60 days from the notification of eligibility on retrospectively enrolled members to submit
medical records for review and utilization management authorization request. If the practitioner does
not provide documentation, the card issue date, segment date, and claims history are used. A decision
and written notification is provided within ten (10) business days of receipt of the medical information
for the retrospective review request. An administrative denial is issued for retrospective requests when
the provider fails to request a utilization management review of the medical record within the timeframe
specified.
The provider is notified of all decisions regarding retrospective reviews. In cases of denial, a written
notification is provided.
Requests received beyond 60 days from the card issue date or from the provider’s documentation of the
date when they were aware of the member’s eligibility will be administratively denied.
Send requests for retrospective review to:
Utilization Management Retrospective Review
5100 Commerce Crossings Drive
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The phone number for retrospective review is: (502) 585-7972 or fax to: (502) 585-8207 (for large chart
review, please send records via mail).
5.10 Denials
An authorization request for a service may be denied for failure to meet guidelines, protocols, medical
policies, or failure to follow administrative procedures outlined in the Provider Contract or this
Provider
Manual
.
Members may not be billed by participating providers for deductibles, copays, and coinsurance except
those allowed by DMS. If pre-authorization criteria are not met resulting in a denied claim, members
must be held harmless for denied services.
To speak with the Medical Director or to the nurse reviewer regarding a denial, please contact
Utilization Management at (800) 578-0636.
5.10.1 Medical Necessity Denials
Utilization Management utilizes InterQual® Guidelines, medical policies and protocols to render
review decisions. Requests not meeting the guidelines, protocols, or policies are referred to a Medical
Director for clinical review.
A Passport Health Plan Medical Director renders all medical necessity denial decisions. Whenever a
denial is issued, Utilization Management provides the name, telephone number, title, and office hours
of the Medical Director who rendered the decision. The Passport Health Plan Medical Director is
available to discuss any decision rendered with the attending practitioner.
5.10.2 Administrative Denials
An administrative denial is issued for those services for which the provider has not followed the
requirements set forth in the Provider Contract or this
Provider Manual
. For example, an administrative
denial may be issued for failure to prior authorize an elective service, procedure, or admission. It may
also be issued for failure to notify Utilization Management within one business day of an emergency
service, procedure, or admission.
A provider may appeal an administrative denial by submitting the appeal request in writing to:
Clinical Appeals Department
5100 Commerce Crossings Drive
Louisville, KY 40229
Appendix A: Radiology Codes
The codes on the list below require authorization through MedSolutions
CPT® Category
CPT®
Code DescriptionCPT®
MRI TMJ 70336 MRI Temporomandibular Joint (s)
Page 15 of 39 CPT ® Category CPT® Code DescriptionCPT®
CT 70460 CT Head with contrast
CT 70470 CT Head with & without contrast CT 70480 CT Orbit, et al without contrast CT 70481 CT Orbit, et al with contrast CT 70482 CT Orbit, et al W & W/O
CT 70486 CT Maxillofacial area, (sinus) without contrast CT 70487 CT Maxillofacial area, (sinus) with contrast CT 70488 CT Maxillofacial area, (sinus) W & W/O CT 70490 CT Soft-tissue Neck without contrast CT 70491 CT Soft-tissue Neck with contrast
CT 70492 CT Soft-tissue Neck with & without contrast W & W/O CT Angiography (CTA) 70496 CTA HEAD, with contrast, including noncontrast images, if
performed, & image post-processing
CT Angiography (CTA) 70498 CTA NECK, with contrast, including noncontrast images, if performed, & image post-processing
MRI 70540 MRI Orbit, Face and/or Neck without contrast MRI 70542 MRI Orbit, Face and/or Neck with contrast MRI 70543 MRI Orbit, Face and/or Neck W & W/O MRA 70544 MR Angiography (MRA) Head without contrast MRA 70545 MR Angiography (MRA) Head with contrast
MRA 70546 MR Angiography (MRA) Head with and without contrast W & W/O
MRA 70547 MR Angiography (MRA) Neck without contrast MRA 70548 MR Angiography (MRA) Neck with contrast
MRA 70549 MR Angiography (MRA) Neck with and without contrast W & W/O
MRI 70551 MRI Brain (Head) without contrast MRI 70552 MRI Brain (Head) with contrast
MRI 70553 MRI Brain (Head) with and without contrast W & W/O Functional MRI (fMRI) 70554 MRI Brain, functional MRI; including test selection and
administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration Functional MRI (fMRI) 70555 MRI, Brain, functional MRI; requiring physician or psychologist
administration of entire neurofunctional testing
CT 71250 CT Chest without contrast
CT 71260 CT Chest with contrast
CT 71270 CT Chest with and without contrast W & W/O
CT Angiography (CTA) 71275 CTA CHEST, (non-coronary), with contrast, including noncontrast images, if performed, & image post-processing
MRI 71550 MRI Chest without contrast
MRI 71551 MRI Chest with contrast
MRI 71552 MRI Chest with and without contrast W & W/O
MRA 71555 MR Angiography (MRA) Chest (excluding myocardium)- W or W/O
CT 72125 CT Cervical Spine without contrast CT 72126 CT Cervical Spine with contrast
Page 16 of 39 CPT ® Category CPT® Code DescriptionCPT®
CT 72127 CT Cervical Spine with and without contrast W & W/O CT 72128 CT Thoracic Spine without contrast
CT 72129 CT Thoracic Spine with contrast
CT 72130 CT Thoracic Spine with and without contrast W & W/O
CT 72131 CT Lumbar Spine without contrast
CT 72132 CT Lumbar Spine with contrast
CT 72133 CT Lumbar Spine with and without out contrast W & W/O MRI 72141 MRI Cervical Spine without contrast
MRI 72142 MRI Cervical Spine with contrast MRI 72146 MRI Thoracic Spine without contrast MRI 72147 MRI Thoracic Spine with contrast MRI 72148 MRI Lumbar Spine without contrast MRI 72149 MRI Lumbar Spine with contrast
MRI 72156 MRI Cervical Spine with and without contrast W & W/O MRI 72157 MRI Thoracic Spine with and without contrast W & W/O MRI 72158 MRI Lumbar Spine with and without contrast W & W/O MRA 72159 MR Angiography (MRA) Spinal Canal and contents -with or w/o
contrast
CT Angiography (CTA) 72191 CTA PELVIS, with contrast, including noncontrast images, if performed, & image post-processing
CT 72192 CT Pelvis without contrast
CT 72193 CT Pelvis with contrast
CT 72194 CT Pelvis with and without contrast W & W/O
MRI 72195 MRI Pelvis without contrast
MRI 72196 MRI Pelvis with contrast
MRI 72197 MRI Pelvis with and without contrast W & W/O
MRA 72198 MR Angiography (MRA) Pelvis -with or without contrast CT 73200 CT Upper Extremity without contrast
CT 73201 CT Upper Extremity with contrast
CT 73202 CT Upper Extremity with and without contrast W & W/O CT Angiography (CTA) 73206 CTA Upper Extremity, with contrast, including noncontrast
images, if performed, & image postprocessing
MRI 73218 MRI Upper Extremity-other than joint-without contrast MRI 73219 MRI Upper Extremity-other than joint-with contrast MRI 73220 MRI Upper Extremity-other than joint-W & W/O MRI 73221 MRI Any Joint of Upper Extremity--without contrast MRI 73222 MRI Any Joint of Upper Extremity--with contrast MRI 73223 MRI Any Joint of Upper Extremity—W & W/O
MRA 73225 MR Angiography (MRA) Upper Extremity -with or without contrast
CT 73700 CT Lower Extremity without contrast CT 73701 CT Lower Extremity with contrast
CT 73702 CT Lower Extremity with and without contrast W & W/O CT Angiography (CTA) 73706 CTA Lower Extremity, with contrast, including noncontrast
images, if performed, & image postprocessing
MRI 73718 MRI Lower Extremity-other than joint-without contrast MRI 73719 MRI Lower Extremity-other than joint-with contrast
Page 17 of 39 CPT ® Category CPT® Code DescriptionCPT®
MRI 73720 MRI Lower Extremity-other than joint- W & W/O MRI 73721 MRI Any Joint of Lower Extremity--without contrast MRI 73722 MRI Any Joint of Lower Extremity--with contrast MRI 73723 MRI Any Joint of Lower Extremity—W & W/O
MRA 73725 MR Angiography (MRA) Lower Extremity-with or without contrast
CT 74150 CT Abdomen without contrast
CT 74160 CT Abdomen with contrast
CT 74170 CT Abdomen with and without contrast W & W/O
CT Angiography (CTA) 74174 Computed tomographic angiography; abdomen and pelvis; with contrast material(s), including noncontrast images, if performed, and image postprocessing
CT Angiography (CTA) 74175 CTA ABDOMEN, with contrast, including noncontrast images, if performed, & image postprocessing
CT 74176 CT Abdomen & Pelvis, without contrast CT 74177 CT Abdomen & Pelvis, with contrast
CT 74178 CT Abdomen & Pelvis, with and without contrast
MRI 74181 MRI Abdomen without contrast
MRI 74182 MRI Abdomen with contrast
MRI 74183 MRI Abdomen with and without contrast W & W/O MRA 74185 MR Angiography (MRA) Abdomen-with or without contrast Diagnostic CT
Colonography (CTC) 74261 Computed tomographic (CT) colonography, diagnostic, including image postprocessing; without contrast material Diagnostic CT
Colonography (CTC)
74262 Computed tomographic (CT) colonography, diagnostic, including image postprocessing; with contrast material(s) including non- contrast images, if performed
CT Colonography (CTC)
for Screening 74263 Computed tomographic (CT) colonography, screening, including image postprocessing Cardiac MRI 75557 Cardiac MRI for morphology and function without contrast Cardiac MRI 75559 Cardiac MRI for morphology and function without contrast
material; with stress imaging
Cardiac MRI 75561 Cardiac MRI for morphology and function without contrast, followed by contrast W & W/O
Cardiac MRI 75563 Cardiac MRI for morphology and function without contrast, followed by contrast; with stress imaging
Cardiac MRI 75565 Cardiac magnetic resonance imaging for velocity flow mapping (List separately in addition to code for primary procedure) Cardiac CT Calcium
Scoring 75571 CT, heart, without contrast with quantitative
Cardiac CT 75572 CT, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3D image post processing, assessment of cardiac function, and evaluation of venous structures, if performed)
Page 18 of 39 CPT ® Category CPT® Code DescriptionCPT®
Cardiac CT 75573 CT, heart, with contrast material, for evaluation of cardiac
structure and morphology in the setting of congenital heart disease (including 3D image post processing, assessment of cardiac LV function, RV structure and function and evaluation of venous structures, if performed)
CT Coronary
Angiography (CTCA) 75574 CT, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image post processing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed)
CT Angiography (CTA) 75635 CTA ABDOMINAL AORTA and bilateral iliofemoral lower extremity runoff, with contrast, including noncontrast images, if performed, and image post-processing
3D Rendering 76376 3D Rendering with interpretation and reporting of CT, 3D Rendering 76377 3D Rendering with interpretation and reporting of CT, CT 76380 CT Limited or Localized follow-up
MR Spectroscopy (MRS) 76390 MR Spectroscopy (MRS)
Unlisted CT 76497 Unlisted CT procedure (eg, diagnostic, interventional) Unlisted MR 76498 Unlisted MR procedure (eg, diagnostic, interventional) CT guidance 77011 CT guidance stereotactic localization
CT guidance 77012 CT guidance needle placement (eg, biopsy, aspiration, injection, localization device)
CT guidance 77013 CT Guidance for, and monitoring of, parenchymal tissue MR Guidance 77021 MR guidance for needle placement (eg, for biopsy, MR Guidance 77022 MR guidance for, and monitoring of, parenchymal tissue Breast MRI 77058 MRI BREAST, without and/or with contrast UNILATERAL Breast MRI 77059 MRI BREAST, without and/or with contrast BILATERAL CT Bone Density 77078 CT BONE MINERAL DENSITY study, 1 or more sites, axial
skeleton
MRI Bone Marrow 77084 MRI Bone Marrow blood supply
Nuclear Cardiac Imaging 78451 Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic)
Nuclear Cardiac Imaging 78452 Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection Nuclear Cardiac Imaging 78453 Myocardial perfusion imaging, planar (including qualitative or
quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic)
Page 19 of 39 CPT ® Category CPT® Code DescriptionCPT®
Nuclear Cardiac Imaging 78454 Myocardial perfusion imaging, planar (including qualitative or
quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection
Cardiac PET 78459 PET Cardiac (myocardial imaging) – metabolic evaluation Nuclear Cardiac Imaging 78466 Myocardial Imaging, infarct avid, planar; qualitative or
quantitative
Nuclear Cardiac Imaging 78468 Myocardial Imaging, infarct avid, planar; w/ EF by first pass technique
Nuclear Cardiac Imaging 78469 Myocardial Imaging, infarct avid, planar; tomographic SPECT Nuclear Cardiac Imaging 78472 Cardiac Blood Pool imaging, gated equilibrium; planar, single
study at rest or stress
Nuclear Cardiac Imaging 78473 Cardiac Blood Pool imaging, gated equilibrium; multiple studies, wall motion plus ejection fraction, at rest and stress
Nuclear Cardiac Imaging 78481 Cardiac Blood Pool imaging, (planar), first pass technique; single study, at rest or with stress, wall motion study plus ejection fraction
Nuclear Cardiac Imaging 78483 Cardiac Blood Pool imaging, (planar), first pass technique; multiple studies at rest and with stress, wall motion study plus ejection fraction
Cardiac PET 78491 PET Cardiac (myocardial imaging), perfusion single study at rest or stress
Cardiac PET 78492 PET Cardiac (myocardial imaging), perfusion multiple studies rest/stress
Nuclear Cardiac Imaging 78494 Cardiac Blood Pool imaging, gated equilibrium, SPECT Nuclear Cardiac Imaging 78496 Cardiac Blood Pool imaging, gated equilibrium, RV EF by first
pass Unlisted Nuclear
Cardiology
78499 Unlisted Nuclear Cardiology diagnostic nuclear Non-Cardiac PET 78608 PET Brain – metabolic evaluation
Non-Cardiac PET 78609 PET Brain – perfusion evaluation
Non-Cardiac PET 78811 PET imaging; limited area (eg, chest, head/neck) Non-Cardiac PET 78812 PET imaging; skull base to mid-thigh
Non-Cardiac PET 78813 PET imaging; whole body
Non-Cardiac PET 78814 PET imaging with concurrently acquired CT for attenuation correction and anatomical localization; limited area (eg, chest, head/neck)
Non-Cardiac PET 78815 PET imaging with concurrently acquired CT for attenuation correction and anatomical localization; skull base to mid-thigh Non-Cardiac PET 78816 PET imaging with concurrently acquired CT for attenuation
correction and anatomical localization; whole body Ceberal Perfusion 0042T Ceberal Perfusion Analysis using CT with contrast Analysis
CAD for Breast MRI 0159T CAD, including computer algorithm analysis, BREAST Magnetic Source
Page 20 of 39 CPT ® Category CPT® Code DescriptionCPT® MRCP S8037 MRCP (Magnetic ResonancE)
MRI Low field S8042 MRI Low field Cardiac CT Calcium
Page 21 of 39
Appendix B – Orthotics and Prosthetics (L codes)
AUTHORIZATION REQUIRED
HCPCS Description HCPC
S
Description L0113 Cranial cervical orthosis, torticollis type,
w/wo joint, w/o soft interface, prefab. Incl. fitting & adj.
L5460 Postop app non-wgt bear dsg L0130 Flex thermoplastic collar molded to
patient L5500 Init bk ptb plaster direct
L0170 Cervical collar molded to pt L5505 Init ak ischal plstr direct L0220 Thor rib belt custom fabrica L5510 Prep BK ptb plaster molded L0430 Spinal orthosis, Dewall posture
protector L5520 Perp BK ptb thermopls direct
L0452 TLSO flexible, provides trunk support,
upper thoracic region, customized L5530 Prep BK ptb thermopls molded L0456 TLSO, flexible thoracic region, prefab L5535 Prep BK ptb open end socket L0460 TLSO, triplanar control prefab L5540 Prep BK ptb laminated socket L0462 TLSO, triplanar control, prefab L5560 Prep AK ischial plast molded L0464 TLSO, triplanar control 4 piece rigid
plastic with interface, prefab L5570 Prep AK ischial direct form L0480 TLSO, triplanar control, one piece rigid
plastic shell L5580 Prep AK ischial thermo mold
L0482 TLSO, triplanor, custom fabricated, one
piece rigid plastic shell, each L5585 Prep AK ischial open end L0484 TLSO, triplanor control, two piece L5590 Prep AK ischial laminated L0486 TLSO, triplanor control 2 piece rigid
plastic with interface, custom L5595 Hip disartic sach thermopls L0488 TLSO triplanor, one piece, prefab L5600 Hip disart sach laminat mold L0491 TLSO 2 rigid plastic shells, pre fab L5610 Above knee hydracadence L0622 Sacroiliac orthosis, flexible, custom L5611 Ak 4 bar link w/fric swing L0623 Sacroiliac orthosis, rigid or semi-rigid,
pre fab
L5613 Ak 4 bar ling w/hydraul swig L0624 Sacroiliac orthosis, rigid or semi-rigid,
custom L5614 4-bar link above knee w/swng
L0629 Lumbar-sacral orthosis, flexible, custom L5616 Ak univ multiplex sys frict L0631 Lumbar-sacral orthosis, sagittal control,
pre fab L5639 Below knee wood socket
L0632 Lumbar-sacral orthosis, sag. Control,
rigid ant./post. Custom L5643 Hip flex inner socket ext fr L0634 Lumbar-sacral orthosis, sag. Control,
Page 22 of 39 L0635 Lumbar-sacral orthosis, sag-coronal
control, prefab L5647 Below knee suction socket L0636 Lumbar-sacral orthosis, sag-coronal
control, custom
L5648 Above knee air cushion socket L0637 Lumbar-sacral orthosis, sag-coronal
control, rigid ant/post., prefab
L5649 Isch containmt/narrow m-l so L0638 Lumbar-sacral orth, sag-coronal control,
rigid ant./post., custom L5651 Ak flex inner socket ext fra L0639 Lumbar-sacral orthosis, sag.-coronal
control, rigid post. Prefab L5670 Bk molded supracondylar susp L0640 Lumbar-sacral orthosis, sag-coronal
control, rigid post., custom
L5673 below knee/above knee socket insert, silicone gel or elastomeric w/locking mech, custom
L0700 Ctlso a-p-l control molded L5679 below knee/above knee socket insert, silicone gel or elastomeric no locking mech, custom
L0710 Ctlso a-p-l control w/ inter L5681 below knee/above knee, custom fab. Socket inset initial only for cong. Or atypical
L0810 Halo cervical into jckt vest L5682 Bk thigh lacer glut/ischia molded L0820 Halo cervical into body jack L5683 below knee/above knee, custom fab,
socket inset, initial only not cong.or atypical
L0830 Halo cerv into milwaukee typ L5700 Replace socket below knee L0999 Addition to spinal orthosis, NOS L5701 Replace socket above knee L1000 Ctlso milwauke initial model L5702 Replace socket hip
L1001 Cervical TLSO, infant, prefab L5704 Custom shape covr below knee L1200 Furnsh initial orthosis only L5705 Custom shape cover above knee L1300 Body jacket mold to patient L5706 Custom shape cvr knee disart L1310 Post-operative body jacket L5707 Custom shape cover hip disart L1499 Spinal orthosis NOS L5716 Knee-shin exo mech stance ph L1500 Thkao mobility frame L5718 Knee-shin exo frct swg & sta L1510 Thkao standing frame L5722 Knee-shin pneum swg frct exo L1520 Thkao swivel walker L5724 Knee-shin exo fluid swing ph L1680 Pelvic & hip control thigh c L5726 Knee-shin ext jnts fld swg e L1685 Post-op hip abduct custom fa L5728 Knee-shin fluid swg & stance L1686 HO post-op hip abduction L5780 Knee-shin pneum/hydra pneum L1690 Combination bilateral LS/hip/femur L5781 Addt. to lower limb prosthesis, vacuum
pump, residual limb volume management and moisture evacuation system
L1700 Legg perthes orth toronto typ L5782 Addt. To lower leg prosth. Vacuum L1710 Legg perthes orth newington L5790 Exoskeletal ak ultra-light m
Page 23 of 39
L1730 Legg perthes orth scottish L5811 Endo knee-shin mnl lck ultra L1755 Legg perthes patten bottom L5814 Endo knee-shin hydral swg ph L1832 KO adj jnt pos rigid support L5816 Endo knee-shin polyc mch sta L1834 KO w/0 joint rigid molded to L5818 Endo knee-shin frct swg & st L1840 KO derot ant cruciate custom L5822 Endo knee-shin pneum swg frc L1843 KO single upright thigh & calf-
prefabricated, each L5824 Endo knee-shin fluid swing p L1844 KO w/adj jt rot cntrl molded L5826 Miniature knee joint
L1845 KO w/ adj flex/ext rotat cus L5828 Endo knee-shin fluid swg/sta L1846 KO w adj flex/ext rotat mold L5830 Endo knee-shin pneum/swg pha L1860 KO supracondylar socket mold L5840 Multi-axial knee/shin system L1904 AFO molded ankle gauntlet L5845 Knee-shin sys stance flexion L1907 supramalleolar w/straps w/wo
interface/pads, custom fabricated L5848 Knee-shin system dampening feature L1932 AFO, rigid anterior tibial section,pre fab,
incl. Fitting & adj. L5856 Addt. To lower ext. prosthesis, knee shin sys.,microprocessor, incl. Sensor, any type
L1940 AFO, plastic or other material custom L5857 Addt. To lower ext. prosth., swing phase only knee shin sys.,micro, incl. Sensor , any type
L1945 AFO molded plas rig ant tib L5858 Addt. To lower ext. prosth, knee shin sys.,micro, incl. Sens , stance phase L1950 AFO spiral molded to pt plas L5930 High activity knee frame
L1951 spiral, IRM type, plastic or other
material prefab, incl. Fitting and adj. L5950 Endo ak ultra-light material L1960 AFO pos solid ank plastic mo; custom L5960 Endo hip ultra-light materia L1970 AFO plastic molded w/ankle j L5964 addt. Endoskeleton above knee,
flexible protective outer surface L1980 AFO sing solid stirrup calf custom L5966 Hip flexible cover system L1990 AFO doub solid stirrup calf; custom L5968 Multiaxial ankle w dorsiflex L2000 KAFO using fre stirr thi/calf; custom L5973 Endoskeletal ankle foot system,
microprocessor, incl. power source L2005 KAFO any material, single or dbl. Upright
includes ankle joint custom fabricated L5976 Energy storing foot L2010 KAFO single upright, free ankle, solid
stirrup L5979 Multi-axial ankle/ft prosth
L2020 KAFO dbl solid stirrup band/ L5980 Flex foot system
L2030 KAFO dbl solid stirrup w/o j L5981 Flex-walk sys low ext prosth L2034 KAFO full plastic, single upright, w/wo
free motion knee,custom fabricated L5987 Shank ft w vert load pylon L2036 KAFO plas doub free knee mol L5988 Vertical shock reducing pylo L2037 KAFO plas sing free knee mol L5990 addt. To lower ext. user adj. ht L2038 KAFO w/o joint multi-axis an L5999 Lower extremity prosthesis, NOC L2050 Hkafo torsion cable hip pelv; custom L6000 Par hand robin-aids thum rem
Page 24 of 39
L2060 Hkafo torsion ball bearing j; custom L6010 Hand robin-aids little/ring L2070 Hkafo torsion unilat rot str; custom L6020 Part hand robin-aids no fing L2080 Hkafo unilat torsion cable, custom L6050 Wrst MLd sck flx hng tri pad L2090 Hkafo unilat torsion ball br, custom L6055 Wrst mold sock w/exp interfa L2106 AFO tib fx cast plaster mold, custom L6100 Elb mold sock flex hinge pad L2108 AFO tib fx cast molded to pt L6110 Elbow mold sock suspension t L2116 Afo tibial fracture rigid L6120 Elbow mold doub splt soc ste L2126 Kafo fem fx cast thermoplas L6130 Elbow stump activated lock h L2128 Kafo fem fx cast molded to p L6200 Elbow mold outsid lock hinge L2132 Kafo femoral fx cast soft L6205 Elbow molded w/ expand inter L2134 Kafo fem fx cast semi-rigid L6250 Elbow inter loc elbow forarm L2136 Kafo femoral fx cast rigid L6300 Shlder disart int lock elbow L2232 Addt. To lower extremity orthosis,
rocker bottom, custom fabricated only L6310 Shoulder passive restor comp L2280 Molded inner boot L6320 Shoulder passive restor cap L2330 Lacer molded to patient, custom L6350 Thoracic intern lock elbow L2340 Pre-tibial shell molded to p L6360 Thoracic passive restor comp L2350 Prosthetic type socket molded L6370 Thoracic passive restor cap L2510 Th/wght bear quad-lat brim m L6380 Postop dsg cast chg wrst/elb L2520 Th/wght bear quad-lat brim custom L6382 Postop dsg cast chg elb dis/ L2525 Th/wght bear m-l brim mo L6384 Postop dsg cast chg shlder/t L2526 Th/wght bear m-l brim cu L6400 Below elbow prosth tiss shap L2540 Thigh/wght bear lacer molded L6450 Elb disart prosth tiss shap L2627 Plastic mold recipro hip & c L6500 Above elbow prosth tiss shap L2628 Metal frame recipro hip & ca L6550 Shldr disar prosth tiss shap L2768 Orthotic side bar, Disconnect device,
each L6570 Scap thorac prosth tiss shap
L2861 addt. to lower ext-joint, knee or ankle,
custom only, each L6580 Wrist/elbow bowden cable mol L2999 Lower extremity orthosis NOS L6582 Wrist/elbow bowden cbl dir f L3060 Foot arch support, removable,
premolded, longitudinal & horizontal, each
L6584 Elbow fair lead cable molded L3201 Oxford w supinator/pronator inf each L6586 Elbow fair lead cable dir fo L3202 Oxford w supinator/pronator child each L6588 Shdr fair lead cable molded L3203 Oxford w supinator/pronator jun each L6590 Shdr fair lead cable direct
L3204 Hightop w supp/pronator infant each L6611 Addt. To upper ext. prosthesis, ext. pwr switch addt.
L3206 Hightop w supp/pronator child each L6623 Spring-asst. rot wrst w/ latch
L3207 Hightop w supp/pronator junior each L6624 Upper ext. addt. Flex. Ext rotation wrist L3208 Surgical boot, each infant L6638 upper ext addt. To prosth. Electric
locking only for use with manually powered elbow
Page 25 of 39
L3209 Surgical boot, each child L6686 Suction socket
L3211 Surgical boot, each junior L6689 Frame typ socket shoulder di L3212 Benesch boot pair infant L6690 Frame typ sock interscap-tho L3213 Benesch boot pair child L6693 Locking elbow forearm cntrbal L3214 Benesch boot pair junior L6694 Add. To upper ext. pros.,for use with
locking mechanism
L3215 Orthopedic ftwear ladies oxf each L6695 Add. To upper ext. pros., not for use with locking mechanism, custom L3216 Orthopedic ftwear ladies depth each L6696 Add. To upper ext. pros., congenital or
atypical traumatic amputees, initial only
L3217 Ladies shoes hightop depth each L6697 Add. To upper ext. pros., other than congenital or traumatic amputees, initial only
L3219 Orthopedic mens shoes oxford each L6707 term dev hook, mech vol closing, any material, any size, lined or unlined L3221 Orthopedic mens shoes dpth each L6708 term dev, hand, mech vol opening, any
material, any size
L3222 Mens shoes hightop depth inl each L6709 term dev hand, mech vol. closing, any material, any size
L3224 Woman's shoe oxford brace each L6712 Terminal device, hook,mechanical vol. closing, any material, any size, lined or unlined, Pediatric, each
L3225 Man's shoe oxford brace each L6713 Terminal device, hand, mechanical, vol. opening, any material, any size,lined or unlined, Pediatric, each
L3230 Custom shoes depth inlay each L6714 Terminal device, mechanical, vol. closing, any material, any size, Pediatric, each
L3250 Custom mold shoe remov prost each L6721 terminal device, hook or hand, hvy, dty., mechanical, vol.opening, any material, any size, lined or unlined, each
L3251 Shoe molded to pt silicone s each L6722 Terminal device, hook or hand, heavy duty, mechanical, vol. closing, any material, any size, lined or unlined, each
L3252 Shoe molded plastazote cust each L6881 Automatic grasp, addt. To upper limb elect. Prosth. Terminal device
L3253 Shoe molded plastazote cust each L6882 Microprocessor control feature, addt. To upper limb prosth. Terminal device L3254 Orth foot non-std size/w L6895 Custom glove
L3255 Orth foot non-std size/w L6900 Hand restorat thumb/1 finger L3257 Orth foot add charge split L6905 Hand restoration multiple fi L3330 Lift elevation, metal extension, (skate)
Page 26 of 39
L3649 orthopedic shoe modification NOS L6915 Hand restoration replacmnt g L3671 Shoulder othosis, cap design w/o joints L6920 Wrist disarticul switch ctrl L3702 elbow orthosis w/o joints, may include
soft interface, straps, custom fabricated incl. fitting & adj.
L6925 Wrist disart myoelectronic c L3720 Forearm/arm cuffs free motio L6930 Below elbow switch control L3730 Forearm/arm cuffs ext/flex a L6935 Below elbow myoelectronic ct L3740 Cuffs adj lock w/ active con L6940 Elbow disarticulation switch L3763 elbow wrist hand orthosis rigid w/o
joints custom fab incl. fitting & adj. L6945 Elbow disart myoelectronic c L3806 WHFO, incl. 1 or more nontorsion joints.
Custom L6950 Above elbow switch control
L3808 WHFO, rigid w/o joints, custom, L6955 Above elbow myoelectronic ct L3891 Addt. to upper ext. joint, wrist, or
elbow, custom fabricated only, each L6960 Shldr disartic switch contro L3900 Hinge extension/flex wrist/f L6965 Shldr disartic myoelectronic L3901 Hinge ext/flex wrist finger L6970 Interscapular-thor switch ct L3904 Whfo electric custom fitted L6975 Interscap-thor myoelectronic L3905 wrist/hand orthosis custom L7007 elect. Hand, myoelectric or switch,
adult
L3906 Wrist hand orthosis, w/o joints, custom L7008 elect. Hand, myoelectric or switch, ped L3907 Whfo wrist gauntlt thmb spica L7009 elect hook, switch or myoelect, adult L3913 Hand finger orthosis, w/o joints, may
include soft interface, straps, custom fabricated, incl fitting & adjustment, each
L7040 Prehensile actuator switch controlled
L3927 Finger orthosis, PIP/DIP, non-torsion w/o joint/spring, ext./flex., pre-fab, incl fitting & adj., each
L7045 Electric hook, switch or myoelectric controlled, pediatric
L3933 Finger orthosis, w/o joints, may include soft interface, custom fabricated, incl. fitting & adjustment, each
L7170 Electronic elbow hosmer swit L3956 addt. Of joint to upper ext orth. any
material, per joint L7180 Electronic elbow utah myoele
L3960 Sewho airplan desig abdu pos L7181 electronic elbow, sim. Control of elbow and terminal device
L3962 Sewho erbs palsey design abd L7185 electronic elbow, sim. Variety Village or equal switch control
L3964 Seo mobile arm sup att to wc L7186 Electron elbow child switch L3965 Arm supp att to wc rancho ty L7190 Elbow adolescent myoelectron L3966 Mobile arm supports reclinin L7191 Elbow child myoelectronic ct L3968 Friction dampening arm supp L7260 Electron wrist rotator otto L3969 Monosuspension arm/hand supp L7261 Electron wrist rotator utah L3971 SEHWO, shoulder cap design, custom
Page 27 of 39 L3999 Upper limb orthosis, not otherwise
specified L7272 Analogue control unb or equa
L4000 Repl girdle milwaukee orth L7274 Proportional ctl 12 volt uta L4002 Replacement strap, any orthosis,
includes all components, any lgth., any type
L7499 Upper extremity prosthesis NOS L4010 Replace trilateral socket brim L7500 Prosthetic dvc repair hourly
L4020 Replace quadlat socket brim L7510 Repair of prosthetic device, minor parts L4030 Replace socket brim cust fit L7520 Repair prosthetic device, labor
component, per 15 min
L4040 Replace molded thigh lacer L7600 Prosthetic donning sleeve, any material L4050 Replace molded calf lacer L7900 Vacuum erection system
L4205 Repair orthotic device per 15 min labor L8000 Mastectomy bra - 5 per year
L4210 repair or replace minor parts L8001 Breast prosthesis , masectomy bra with integrated breast prothesis form, unilateral - 5 per year
L5000 Sho insert w arch toe filler L8002 Breast prosthesis, masectomy bra with integrated breast prothesis form, bilateral - 5 per year
L5010 Mold socket ank hgt w/ toe f L8020 Mastectomy form - 2 per year
L5020 Tibial tubercle hgt w/ toe f L8030 Breast prosthesis silicone/e - 2 per year L5050 Ank symes mold sckt sach ft L8031 Breast prosthesis, silicone or equal,
with intergral adhesive, each L5060 Symes met fr leath socket ar L8035 Custom breast prosthesis L5100 Molded socket shin sach foot L8039 Breast prosthesis, NOS
L5105 Plast socket jts/thgh lacer L8040 Nasal prothesis, provided by a non- physician
L5150 Mold sckt ext knee shin sach L8041 Midfacial prothesis, provided by a non- physician
L5160 Mold socket bent knee shin s L8042 Orbital prothesis, provided by a non- physician
L5200 Knee sing axis fric shin sach L8043 Upper facial prosthesis, provided by a non-physician
L5210 No knee/ankle joints w/ ft b L8044 Hemi-facial prosthesis, provided by a non-physician
L5220 No knee joint with artic ali L8045 Prosthetic External Ear provided by a non-physician
L5230 Fem focal defic constant fri L8046 Partial facial prosthesis, provided by a non-physician
L5250 Hip canadian sing axi cons fric L8047 Nasal septal prosthesis, provided by a non-physician
L5270 Tilt table locking hip sing L8048 Unspecified Maxillofacial Prosthesis, by a non-physician
L5280 Hemipelvect canadian sing axis L8049 Repair or modification of maxillofacial prosthesis, by a non-physician
Page 28 of 39 L5301 Below Knee molded socket, shin each
foot, endosketal system L8499 Unlisted Misc prosthetic service L5311 Knee disarticulation , molded socket,
external knee joints, shin,sach foot endo L8500 artifical larynx L5321 Above Knee, molded socket, open end,
sach foot, endoskelttal system, single axis knee
L8501 Tracheostomy speaking valve L5331 Hip disarticulation, Canadian type,
molded socket endoskeletal system, hip joint, single
L8505 Artificial larynx replacement battery/accessory, any type, each L5341 Hemipelvectomy, Canadian type,
molded socket, endoskeletal hip joint single axis knee
L8619 cochlear implant external speech processor replacement
L5400 Postop dress & 1 cast chg bk L8627 Cochlear implant, external speech processor, component, replacement L5410 Postop dsg bk ea add cast ch L8628 Cochlear implant, external controller
component, replacement
L5420 Postop dsg & 1 cast chg ak/d L8629 Transmitting coil and cable, integrated for use with cochlear implant device, replacement
L5430 Postop dsg ak ea add cast ch L8691 auditory osseointegrated dev, ext. sound replacer, repl only
L5450 Postop app non-wgt bear dsg
AUTHORIZATION NOT REQUIRED
HCPCS Description HCPC
S
Description
L0120 Cerv flexible non-adjustable L3670 Acromio/clavicular canvas&we L0140 Cervical semi-rigid adjustab L3675 Canvas vest SO
L0150 Cerv semi-rig adj molded chn L3710 Elbow elastic with metal joi
L0160 Cerv semi-rig wire occ/mand L3760 Elbow orthosis, adj position locking joints, prefab, inc fitting and adj
L0172 Cerv col thermplas foam 2 piece L3762 Elbow orthosis rigid, w/o joints, prefab, soft interface, incl. Fitting/adj.
L0174 Cerv col foam 2 piece w thor L3807 WHFO w/o joints, prefab includes fitting and adjustments any type L0180 Cer post col occ/man sup adj L3908 Wrist cock-up non-molded L0190 Cerv collar supp adj cerv ba - 1 Per Year
*
L3912 Flex glove w/elastic finger
Page 29 of 39
year * prefab,
L0450 TLSO flexible, provides trunk support,
uper thoracic region, prefab L3917 hand orthosis, metacarpal fracture orthosis, prefab, incl fitting and adj. L0454 TLSO, Flexible, provides trunk support,
sacrococcygeal juntion to T-9, prefab L3923 Hand finger orthosis, without joint, prefab, inc fitting and adj L0466 TLSO Sagittal control, prefab L3925 Finger orthosis, PIP/DIP, non-torsion
joint/spring, ext./flex., pre-fab, incl fitting & adj., each
L0468 TLSO sagittal-coronol control, rigid
posterior frame - 1 per year * L3929 Hand finger orthosis, incl. 1 or more nontorsion joints, turnbuckles, elastic bands/spring, straps, pre-fab, incl. fitting & adj., each
L0470 TLSO triplanar control - 1 per year * L3931 Wrist, hand, finger orthosis, incl. 1 or more nontorsion joints,turnbuckles, elastic bands/springs, straps, pre-fab, incl. fitting & adj., each
L0472 TLSO, triplanar control, hyperextension
prefab - 1 per year * L3970 Elevat proximal arm support L0490 TLSO sagittal coronal control one piece
prefab L3972 Offset/lat rocker arm w/ ela
L0492 TLSO 3 rigid plastic shells, pre fab - 1
per year * L3974 Mobile arm support supinator
L0621 Sacroiliac orthosis, flexible, pre fab L3980 Upp ext fx orthosis humeral L0625 Lumbar orthosis, flexible, pre fab L3982 Upper ext fx orthosis rad/ul L0626 Lumbar orthosis, sagittal control, pre
fab L3984 Upper ext fx orthosis wrist
L0627 Lumbar orthosis, sagittal control with
rigid ant./post. Panels, pre fab L3995 Add. To upper ext. sock, fracture, or equal, each L0628 Lumbar-sacral orthosis, flexible, pre fab L4045 Replace non-molded thigh lac L0630 Lumbar-sacral orthosis, sag. Control,
pre fab L4055 Replace non-molded calf lace
L0633 Lumbar-sacral orthosis, sag. Control,
rigid post., pre fab L4060 Replace high roll cuff L0970 Tlso corset front L4070 Replace prox & dist upright L0972 Lso corset front L4080 Repl met band kafo-afo prox L0974 Tlso full corset L4090 Repl met band kafo-afo calf/ L0976 Lso full corset L4100 Repl leath cuff kafo prox th L0978 Axillary crutch extension L4110 Repl leath cuff kafo-afo cal L0980 Peroneal straps pair L4130 Replace pretibial shell L0982 Stocking supp grips set of 4 L4350 Pneumatic ankle cntrl splint L0984 Protective body sock each L4360 Pneumatic walking splint L1010 Ctlso axilla sling L4370 Pneumatic full leg splint
L1020 Kyphosis pad L4380 Pneumatic knee splint
L1025 Kyphosis pad floating L4386 Non-pneumatic walking boot L1030 Lumbar bolster pad L4394 Replacement Foot Drop Splint
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L1040 Lumbar or lumbar rib pad L4396 Static AFO
L1050 Sternal pad L4398 Foot drop splint recumbent
L1060 Thoracic pad L5617 AK/BK self-aligning unit ea
L1070 Trapezius sling L5618 Test socket symes
L1080 Outrigger L5620 Test socket below knee
L1085 Outrigger bil w/ vert extens L5622 Test socket knee disarticula
L1090 Lumbar sling L5624 Test socket above knee
L1100 Ring flange plastic/leather L5626 Test socket hip disarticulat L1110 Ring flange plas/leather molded to
patient L5628 Test socket hemipelvectomy
L1120 Covers for upright each L5629 Below knee acrylic socket L1210 Lateral thoracic extension L5630 Syme typ expandabl wall sckt L1220 Anterior thoracic extension L5631 Ak/knee disartic acrylic soc L1230 Milwaukee type superstructur L5632 Symes type ptb brim design s L1240 Lumbar derotation pad L5634 Symes type poster opening so L1250 Anterior asis pad L5636 Symes type medial opening so L1260 Anterior thoracic derotation pad L5637 Below knee total contact L1270 Abdominal pad L5638 Below knee leather socket L1280 Rib gusset (elastic) each L5640 Knee disarticulat leather so L1290 Lateral trochanteric pad L5642 Above knee leather socket L1600 Abduct hip flex frejka w cvr L5644 Above knee wood socket L1610 Abduct hip flex frejka covr L5646 Below knee air cushion socket L1620 Abduct hip flex pavlik harne L5650 Tot contact ak/knee disart s L1630 Abduct control hip semi-flex L5652 Suction susp ak/knee disart L1640 Pelv band/spread bar thigh c L5653 Knee disart expand wall sock L1650 HO abduction hip adjustable L5654 Socket insert symes
L1660 HO ab
