CMS Manual System Department of Health & Human Services (DHHS)

Pub 100-20 One-Time Notification Centers for Medicare & Medicaid Services (CMS)

Transmittal 10896 Date: July 21, 2021

Change Request 12282

Transmittal 10801, dated May 20, 2021, is being rescinded and replaced by Transmittal 10896, dated, July 21, 2021 to add business requirements 12282.13, 12282.14, 12282.15, 12282.16 and 12282.17. All other information remains the same. SUBJECT: Additional Payment Edits for DMEPOS Suppliers of Custom Fabricated and Prefabricated (Custom Fitted) Orthotics. Update to Change Request (CR) 3959, CR 8390, and CR 8730 I. SUMMARY OF CHANGES: The purpose of this CR is to communicate the addition of HCPCS codes which require the use of a licensed/certified orthotist or prosthetist for furnishing of orthotics or prosthetics under the following product and service codes:

1. OR01 Orthoses: Custom Fabricated 2. OR02 Orthoses: Prefabricated (Custom Fitted)

EFFECTIVE DATE: October 1, 2021 *Unless otherwise specified, the effective date is the date of service. IMPLEMENTATION DATE: October 4, 2021 Disclaimer for manual changes only: The revision date and transmittal number apply only to red italicized material. Any other material was previously published and remains unchanged. However, if this revision contains a table of contents, you will receive the new/revised information only, and not the entire table of contents. II. CHANGES IN MANUAL INSTRUCTIONS: (N/A if manual is not updated) R=REVISED, N=NEW, D=DELETED-Only One Per Row.

R/N/D CHAPTER / SECTION / SUBSECTION / TITLE

N/A N/A III. FUNDING: For Medicare Administrative Contractors (MACs): The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined in your contract. CMS does not construe this as a change to the MAC Statement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the Contracting Officer. If the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the Contracting Officer, in writing or by e-mail, and request formal directions regarding continued performance requirements.

IV. ATTACHMENTS: One Time Notification

Attachment - One-Time Notification

Pub. 100-20 Transmittal: 10896 Date: July 21, 2021 Change Request: 12282 Transmittal 10801, dated May 20, 2021, is being rescinded and replaced by Transmittal 10896, dated, July 21, 2021 to add business requirements 12282.13, 12282.14, 12282.15, 12282.16 and 12282.17. All other information remains the same. SUBJECT: Additional Payment Edits for DMEPOS Suppliers of Custom Fabricated and Prefabricated (Custom Fitted) Orthotics. Update to Change Request (CR) 3959, CR 8390, and CR 8730 EFFECTIVE DATE: October 1, 2021 *Unless otherwise specified, the effective date is the date of service. IMPLEMENTATION DATE: October 4, 2021 I. GENERAL INFORMATION A. Background: The Centers for Medicare & Medicaid Services (CMS) issued Transmittal 656, Change Request (CR) 3959 on August 19, 2005. This CR instructed Durable Medical Equipment Regional Contractors (DMERCs, since changed to Durable Medical Equipment Medicare Administrative Contractors, or DME MACs) to implement claims processing edits to ensure compliance with CMS regulations found at 42 Code of Federal Regulations § 424.57(c)(1). Such regulations require Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) suppliers wishing to bill Medicare to operate their business and furnish Medicare-covered items in compliance with all applicable Federal and State licensure and regulatory requirements. As a result of CR 3959, the DME MACs implemented an edit, which was programmed to deny claims for prosthetics and certain custom-fabricated orthotics when those items were furnished by personnel who were not licensed/certified as a orthotist or prosthetist by the State in which they practice. At the time, CR 3959 was issued and the DME MACs implemented the edit. There were nine (9) states, which required the use of a licensed/certified orthotist or prosthetist for furnishing of orthotics or prosthetics. Since that time, five (5) additional states have instituted requirements for the use of a licensed/certified orthotist or prosthetist for furnishing of orthotics or prosthetics. These five (5) states are Arkansas, Georgia, Kentucky, Mississippi, and Tennessee. Since these five (5) states were not originally programmed into the edit implemented via CR 3959, it is possible that DME MACs have been inappropriately paying for prosthetics and certain custom-fabricated orthotics when personnel who were not properly licensed/certified by the State in which they practice furnished those items. CR 8390 instructed the DME MACs to revise the programming edits so that Arkansas, Georgia, Kentucky, Mississippi, and Tennessee are added to the logic, in accordance with CR 3959. CR 8730 instructed the DME MACs to revise the programming edits so that North Dakota, Iowa, and Pennsylvania are added to the logic, in accordance with CRs 3959 and 8390. The purpose of this CR is to communicate the addition of Healthcare Common Procedure Coding System (HCPCS) codes, which require the use of a licensed/certified orthotist or prosthetist for furnishing of orthotics or prosthetics, under the following product and service codes:

1. OR01 Orthoses: Custom Fabricated 2. OR02 Orthoses: Prefabricated (Custom Fitted)

B. Policy: In those seventeen states that have indicated that provision of prosthetics and orthotics must be made by licensed/certified orthotist or prosthetist, Medicare payment may only be made for prosthetics and certain custom-fabricated orthotics when furnished by physicians, pedorthists, physical therapists, occupational therapists, orthotics personnel and prosthetics personnel. These specialties shall bill for Medicare services when State law permits such entity to furnish an item of prosthetic or orthotic.

• Medical Supply Company with Orthotics Personnel – Specialty Code 51; • Medical Supply Company with Prosthetics Personnel – Specialty Code 52; • Medical Supply Company with Orthotics and Prosthetics Personnel – Specialty Code 53; • Orthotics Personnel – Specialty Code 55; • Prosthetics Personnel – Specialty Code 56; • Orthotics Personnel, Prosthetics Personnel, and Pedorthists – Specialty Code 57; • Physical Therapist – Specialty Code 65; • Occupational Therapist – Specialty Code 67; • Pedorthic Personnel - Specialty Code B2; • Medical Supply Company with Pedorthic Personnel - Specialty Code B3 • Ocularist – Specialty Code B5

If a supplier is located in one of the applicable states and wishes to bill Medicare for the prosthetics and custom-fabricated orthotics attached to this CR, it must properly enroll with the National Supplier Clearinghouse (NSC) to ensure the correct specialty code(s) is on file. A copy of the State license should be sent to the NSC if the supplier is in one of the seventeen states requiring a license. If a supplier should need to update its’ file with the correct specialty, the supplier must submit a “Change of Information” on Form CMS-855S to the NSC along with all applicable licenses or certifications. The NSC is responsible for maintaining a central data repository for information regarding suppliers, which is transmitted to the DME MACs. The effective date for the new or revised specialty code for prosthetics and orthotic claims will be the date the NSC issues the specialty code. The new or revised specialty code shall not be applied retroactively. ViPS Medicare System (VMS) shall implement system changes to load specialty codes as listed in the Business Requirements Table as required specialties for all HCPCS in the attachment to this CR. This includes the addition of the HCPCS codes in product categories OR01 (Orthoses: Custom Fabricated) and OR02 (Orthoses: Prefabricated (Custom Fitted)). This system change will allow for auto denial of claims paid for these codes unless the DMEPOS supplier has been identified as licensed and verified on their CMS-855S. II. BUSINESS REQUIREMENTS TABLE "Shall" denotes a mandatory requirement, and "should" denotes an optional requirement. Number Requirement Responsibility A/B

MAC DME

MAC

Shared-System

Maintainers

Other

A B HHH

FISS

MCS

VMS

CWF

12282.1 The VMS shall systematically load the following specialties in the VMS subsystem All Pricing, Provider, and Procedure Lookup (APPL) as required

X

Number Requirement Responsibility A/B

MAC DME

MAC

Shared-System

Maintainers

Other

A B HHH

FISS

MCS

VMS

CWF

specialties for all HCPCS in the attachment to this CR:

• Medical Supply Company with Orthotics Personnel – Specialty Code 51;

• Medical Supply Company with Prosthetics Personnel – Specialty Code 52;

• Medical Supply Company with Orthotics and Prosthetics Personnel – Specialty Code 53;

• Orthotics Personnel – Specialty Code 55; • Prosthetics Personnel – Specialty Code 56; • Orthotics Personnel, Prosthetics Personnel,

and Pedorthists – Specialty Code 57; • Physical Therapist – Specialty Code 65; • Occupational Therapist – Specialty Code 67; • Pedorthic Personnel - Specialty Code B2; • Medical Supply Company with Pedorthic

Personnel - Specialty Code B3 • Ocularist – Specialty Code B5

Note: VMS has hard coded logic in place to accept the physician specialties.

12282.2 CMS shall continue to provide the DME MACs with an updated listing of the 17 states that require use of an orthotist or prosthetist for furnishing of orthotics or prosthetics.

CMS

12282.3 Contractors shall continue their programming edits so that all 17 states listed above remain in the logic, in accordance with CR 3959, CR 8390, and CR 8730.

X NSC

12282.4 Contractors shall provide CMS with updates to this listing, as necessary. CMS will then issue a CR to change and/or update the list of states.

NSC

12282.5 The contractor’s claims processing system shall note the specific prosthetic and orthotic HCPCS Codes previously identified in CR 3959, CR 8390, and CR 8730 as well as the new codes identified via this CR and shall continue to edit claims from suppliers for the current 17 states identified in this CR.

X

Number Requirement Responsibility A/B

MAC DME

MAC

Shared-System

Maintainers

Other

A B HHH

FISS

MCS

VMS

CWF

12282.6 The DME MACs shall continue to deny a claim for the prosthetics and orthotic codes previously identified in CR 3959, CR 8390, and CR 8730 if submitted by a supplier that is located in one of the current 17 states identified in this CR.

X

12282.7 In addition to continuing to deny a claim for the prosthetics and orthotic codes previously identified in CR 3959, CR 8390, and CR 8730 if the supplier does not have the required State License, the DME MACs shall also deny a claim for the additional prosthetics and orthotic codes identified in this CR under Product and Service Codes OR01 and OR02.

X

12282.8 The DME MACs shall exempt beneficiary submitted claims from license editing.

X

12282.9 DME MACs shall continue to process claims with dates of service prior to the implementation date of this CR.

X

12282.10 Adjustment claims: Claims previously approved and subsequently adjusted shall be exempt from these edits.

X

12282.11 DME MACs shall pay claims with date of service prior to the implementation date of this CR regardless of the date the supplier is deemed licensed.

X

12282.12 The DME MACs shall automatically deny effected line items submitted on a supplier’s claim (as the supplier is liable), if the rendering DMEPOS supplier has not been identified by the NSC as being licensed to supply the specific product/service at the time of date of service (between the effective and expiration dates of licensure).

X

12282.13 The DME MACs shall update the list of states to include the addition of five states (Connecticut, Idaho, Maryland, Minnesota, and Nevada) and the removal of one state (Rhode Island) that were previously included in CRs 3959, 8390, and 8730.

X

Number Requirement Responsibility A/B

MAC DME

MAC

Shared-System

Maintainers

Other

A B HHH

FISS

MCS

VMS

CWF

12282.14 The NSC shall identify and provide a list of suppliers to CMS whose enrollments require the NSC to make manual updates to their specialty in order to bill for OR02.

NSC

12282.15 The NSC shall manually update the suppliers’ enrollments to reflect the correct specialty.

NSC

12282.16 The NSC shall identify and provide a list of suppliers to CMS whose enrollments allow them to bill for both OR01 and OR02, but they are only licensed to bill for OR02. This shall be provided to CMS on a cumulative and ongoing quarterly basis.

NSC

12282.17 The NSC shall notify CMS of any new states or updates to previous states with OR01 and OR02 license requirements on a quarterly basis.

NSC

III. PROVIDER EDUCATION TABLE Number Requirement Responsibility

A/B

MAC DME

MAC

CEDI A B H

HH

12282.18 CR as Provider Education: Contractors shall post this entire instruction, or a direct link to this instruction, on their Web sites and include information about it in a listserv message within 5 business days after receipt of the notification from CMS announcing the availability of the article. In addition, the entire instruction must be included in the contractor's next regularly scheduled bulletin. Contractors are free to supplement it with localized information that would benefit their provider community in billing and administering the Medicare program correctly.

X

IV. SUPPORTING INFORMATION Section A: Recommendations and supporting information associated with listed requirements: N/A

"Should" denotes a recommendation.

X-Ref Requirement Number

Recommendations or other supporting information:

Section B: All other recommendations and supporting information: N/A V. CONTACTS Pre-Implementation Contact(s): Andrew Stouder, 410-786-0222 or Andrew.Stouder@cms.hhs.gov , Sarah Kuznear, 410-786-0967 or sarah.kuznear1@cms.hhs.gov Post-Implementation Contact(s): Contact your Contracting Officer's Representative (COR). VI. FUNDING Section A: For Medicare Administrative Contractors (MACs): The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined in your contract. CMS does not construe this as a change to the MAC Statement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the Contracting Officer. If the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the Contracting Officer, in writing or by e-mail, and request formal directions regarding continued performance requirements. ATTACHMENTS: 1

Report Type: Adhoc

Tracking Number: PD-210407-01

Report Objective:Provide the latest HCPCS Codes pertaining to the product and service code categories OR01 & OR02.

Sorted by:HCPCS Code

CONFIDENTIALITY NOTICE: This document may contain confidential and privileged information or may otherwise be protected by law.It is intended for use by CMS and Medicare contractors as approved per the PDAC contract administered by Palmetto GBA LLC.Any unauthorized review, use, disclosure or distribution is prohibited.

PD-210407-01

Source of Report: PDAC ReportingReport Run Date: 04/12/2021

HCPCSHCPCS LongD i ti

Policy GroupN b

Policy GroupN

Product andS i C d

Product andService CodeD i ti

RequiresAccreditation(Y/N)

CrosswalkEffectiveD t

CrosswalkE d D t

HCPCSEffectiveD t

HCPCSTerminationD t

A8000 HELMET PROTECTIVE SOFT PREFABRICATED INCLUDES ALL COMPONENTS AND ACCESSORIES 620 ROUTINELY DENIED ITEMS OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/2007 A8001 HELMET PROTECTIVE HARD PREFABRICATED INCLUDES ALL COMPONENTS AND ACCESSORIES 620 ROUTINELY DENIED ITEMS OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/2007 A8004 SOFT INTERFACE FOR HELMET REPLACEMENT ONLY 620 ROUTINELY DENIED ITEMS OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/2007 A9283 FOOT PRESSURE OFF LOADING/SUPPORTIVE DEVICE ANY TYPE EACH 620 ROUTINELY DENIED ITEMS OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/2008 K0672 ADDITION TO LOWER EXTREMITY ORTHOSIS REMOVABLE SOFT INTERFACE ALL COMPONENTS REPLACEMENT ONLY EACH 310 LOWER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 04/01/2008 L0112 CRANIAL CERVICAL ORTHOSIS CONGENITAL TORTICOLLIS TYPE WITH OR WITHOUT SOFT INTERFACE MATERIAL ADJUSTABLE RANGE OF MOTION JOINT CUSTOM FABRICATED 458 SO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/2004 L0113 CRANIAL CERVICAL ORTHOSIS TORTICOLLIS TYPE WITH OR WITHOUT JOINT WITH OR WITHOUT SOFT INTERFACE MATERIAL PREFABRICATED INCLUDES FITTING AND ADJUSTMENT 458 SO OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/2009 L0130 CERVICAL FLEXIBLE THERMOPLASTIC COLLAR MOLDED TO PATIENT 458 SO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L0140 CERVICAL SEMI RIGID ADJUSTABLE (PLASTIC COLLAR) 458 SO OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L0150 CERVICAL SEMI RIGID ADJUSTABLE MOLDED CHIN CUP (PLASTIC COLLAR WITH MANDIBULAR/OCCIPITAL PIECE) 458 SO OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L0170 CERVICAL COLLAR MOLDED TO PATIENT MODEL 458 SO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L0180 CERVICAL MULTIPLE POST COLLAR OCCIPITAL/MANDIBULAR SUPPORTS ADJUSTABLE 458 SO OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L0190 CERVICAL MULTIPLE POST COLLAR OCCIPITAL/MANDIBULAR SUPPORTS ADJUSTABLE CERVICAL BARS (SOMI GUILFORD TAYLOR TYPES) 458 SO OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L0200 CERVICAL MULTIPLE POST COLLAR OCCIPITAL/MANDIBULAR SUPPORTS ADJUSTABLE CERVICAL BARS AND THORACIC EXTENSION 458 SO OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L0220 THORACIC RIB BELT CUSTOM FABRICATED 458 SO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L0452 TLSO FLEXIBLE PROVIDES TRUNK SUPPORT UPPER THORACIC REGION PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISKS WITH RIGID STAYS OR PANEL(S) INCLUDES SHOULDER STRAPS AND CLOSURES CUSTOM FABRICATED 512 TLSO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/2003 L0454

SO , O S U SU O , S O S C OCOCC G JU C O O O 9 , S C S G OSS U O O S G , O UC S C SSU O UC O O S S G S S O PANEL(S) INCLUDES SHOULDER STRAPS AND CLOSURES PREFABRICATED ITEM THAT HAS BEEN TRIMMED BENT MOLDED ASSEMBLED OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE 512 TLSO OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/2003

L0456, , , , , , ,

PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISKS INCLUDES STRAPS AND CLOSURES PREFABRICATED ITEM THAT HAS BEEN TRIMMED BENT MOLDED ASSEMBLED OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH 512 TLSO OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/2003 L0458

, , , , , , LINER RESTRICTS GROSS TRUNK MOTION IN THE SAGITTAL CORONAL AND TRANVERSE PLANES LATERAL STRENGTH IS PROVIDED BY OVERLAPPING PLASTIC AND STABILIZING CLOSURES INCLUDES STRAPS AND CLOSURES PREFABRICATED INCLUDES FITTING AND ADJUSTMENT 512 TLSO OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/2003

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SOFT LINER RESTRICTS GROSS TRUNK MOTION IN THE SAGITTAL CORONAL AND TRANSVERSE PLANES LATERAL STRENGTH IS PROVIDED BY OVERLAPPING PLASTIC AND STABILIZING CLOSURES INCLUDES STRAPS AND CLOSURES PREFABRICATED ITEM THAT HAS BEEN TRIMMED BENT MOLDED 512 TLSO OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/2003 L0462

, , , , , NOTCH SOFT LINER RESTRICTS GROSS TRUNK MOTION IN THE SAGITTAL CORONAL AND TRANSVERSE PLANES LATERAL STRENGTH IS PROVIDED BY OVERLAPPING PLASTIC AND STABILIZING CLOSURES INCLUDES STRAPS AND CLOSURES PREFABRICATED INCLUDES FITTING AND ADJUSTMENT 512 TLSO OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/2003

L0464SO, CO O , O U S G S S S , OU G S C S S, OS O S O S C OCOCC G JU C O S JUS O O SC U S , O S O S S S U S O S O C , SO

LINER RESTRICTS GROSS TRUNK MOTION IN SAGITTAL CORONAL AND TRANSVERSE PLANES LATERAL STRENGTH IS PROVIDED BY OVERLAPPING PLASTIC AND STABILIZING CLOSURES INCLUDES STRAPS AND CLOSURES PREFABRICATED INCLUDES FITTING AND ADJUSTMENT 512 TLSO OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/2003 L0466

SO, S G CO O , G OS O SO O O S S, C OSU S G, S C S G OSS U O O S G , O UC S C SSU O UC O O S S, C THAT HAS BEEN TRIMMED BENT MOLDED ASSEMBLED OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE 512 TLSO OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/2003

L0468SO, S G CO O CO O , G OS O SO O O S S, C OSU S G, S O S C OCOCC G JU C O O SC U , S G O C, O C C, C S,

RESTRICTS GROSS TRUNK MOTION IN SAGITTAL AND CORONAL PLANES PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON INTERVERTEBRAL DISKS PREFABRICATED ITEM THAT HAS BEEN TRIMMED BENT MOLDED ASSEMBLED OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT 512 TLSO OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/2003 L0470

SO, CO O , G OS O SO O O S S, C OSU S G, S O S C OCOCC G JU C O O SC U , S G O C, O C C, C S, O O STRENGTH PROVIDED BY SUBCLAVICULAR EXTENSIONS RESTRICTS GROSS TRUNK MOTION IN SAGITTAL CORONAL AND TRANVERSE PLANES PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISKS INCLUDES FITTING AND SHAPING THE FRAME PREFABRICATED 512 TLSO OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/2003

L0472SO, CO O , S O , G O S O S S S U S O S O C O O CO O S (O U C O S ), OS O S S S C OSU S, S S

FLEXION RESTRICTS GROSS TRUNK MOTION IN SAGITTAL CORONAL AND TRANSVERSE PLANES INCLUDES FITTING AND SHAPING THE FRAME PREFABRICATED INCLUDES FITTING AND ADJUSTMENT 512 TLSO OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/2003 L0480

SO, CO O , O C G S C S OU C , U S S C OSU S, OS O S O S C OCOCC G JU C O S JUS O O SC U S , O S O S S S U S O STERNAL NOTCH ANTERIOR OR POSTERIOR OPENING RESTRICTS GROSS TRUNK MOTION IN SAGITTAL CORONAL AND TRANSVERSE PLANES INCLUDES A CARVED PLASTER OR CAD CAM MODEL CUSTOM FABRICATED 512 TLSO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/2003

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NOTCH ANTERIOR OR POSTERIOR OPENING RESTRICTS GROSS TRUNK MOTION IN SAGITTAL CORONAL AND TRANSVERSE PLANES INCLUDES A CARVED PLASTER OR CAD CAM MODEL CUSTOM FABRICATED 512 TLSO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/2003 L0484

SO, CO O , O C G S C S OU C , U S S C OSU S, OS O S O S C OCOCC G JU C O S JUS O O SC U S , O S O S S S U S O STERNAL NOTCH LATERAL STRENGTH IS ENHANCED BY OVERLAPPING PLASTIC RESTRICTS GROSS TRUNK MOTION IN THE SAGITTAL CORONAL AND TRANSVERSE PLANES INCLUDES A CARVED PLASTER OR CAD CAM MODEL CUSTOM FABRICATED 512 TLSO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/2003

L0486SO, CO O , O C G S C S C , U S S C OSU S, OS O S O S C OCOCC G JU C O S JUS O O SC U S , O S O S S S U S O S

NOTCH LATERAL STRENGTH IS ENHANCED BY OVERLAPPING PLASTIC RESTRICTS GROSS TRUNK MOTION IN THE SAGITTAL CORONAL AND TRANSVERSE PLANES INCLUDES A CARVED PLASTER OR CAD CAM MODEL CUSTOM FABRICATED 512 TLSO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/2003 L0488

SO, CO O , O C G S C S C , U S S C OSU S, OS O S O S C OCOCC G JU C O S JUS O O SC U S , O S O S S S U S O S NOTCH ANTERIOR OR POSTERIOR OPENING RESTRICTS GROSS TRUNK MOTION IN SAGITTAL CORONAL AND TRANSVERSE PLANES PREFABRICATED INCLUDES FITTING AND ADJUSTMENT 512 TLSO OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/2003

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SYMPHYSIS PUBIS TO XIPHOID ANTERIOR OPENING RESTRICTS GROSS TRUNK MOTION IN SAGITTAL AND CORONAL PLANES PREFABRICATED INCLUDES FITTING AND ADJUSTMENT 512 TLSO OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/2003 L0491

SO, S G CO O CO O , O U S G S S S , O G S C S S, OS O S O S C OCOCC G JU C O S JUS O O SC U S , O S O S S S U S O O SOFT LINER RESTRICTS GROSS TRUNK MOTION IN THE SAGITTAL AND CORONAL PLANES LATERAL STRENGTH IS PROVIDED BY OVERLAPPING PLASTIC AND STABILIZING CLOSURES INCLUDES STRAPS AND CLOSURES PREFABRICATED INCLUDES FITTING AND ADJUSTMENT 512 TLSO OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/2006

L0492, , , , ,

XIPHOID SOFT LINER RESTRICTS GROSS TRUNK MOTION IN THE SAGITTAL AND CORONAL PLANES LATERAL STRENGTH IS PROVIDED BY OVERLAPPING PLASTIC AND STABILIZING CLOSURES INCLUDES STRAPS AND CLOSURES PREFABRICATED INCLUDES FITTING AND ADJUSTMENT 512 TLSO OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/2006 L0622 SACROILIAC ORTHOSIS FLEXIBLE PROVIDES PELVIC SACRAL SUPPORT REDUCES MOTION ABOUT THE SACROILIAC JOINT INCLUDES STRAPS CLOSURES MAY INCLUDE PENDULOUS ABDOMEN DESIGN CUSTOM FABRICATED 457 SIO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/2006 L0624 SACROILIAC ORTHOSIS PROVIDES PELVIC SACRAL SUPPORT WITH RIGID OR SEMI RIGID PANELS PLACED OVER THE SACRUM AND ABDOMEN REDUCES MOTION ABOUT THE SACROILIAC JOINT INCLUDES STRAPS CLOSURES MAY INCLUDE PENDULOUS ABDOMEN DESIGN CUSTOM FABRICATED 457 SIO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/2006 L0626

, , ( ), , , , , , , SHOULDER STRAPS PENDULOUS ABDOMEN DESIGN PREFABRICATED ITEM THAT HAS BEEN TRIMMED BENT MOLDED ASSEMBLED OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE 297 LSO OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/2006

L0627 , , , , , , , ,

SHOULDER STRAPS PENDULOUS ABDOMEN DESIGN PREFABRICATED ITEM THAT HAS BEEN TRIMMED BENT MOLDED ASSEMBLED OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE 297 LSO OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/2006 L0629

, , , , , , , STAYS SHOULDER STRAPS PENDULOUS ABDOMEN DESIGN CUSTOM FABRICATED 297 LSO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/2006

L0630 , , ( ), , , , ,

INCLUDE PADDING STAYS SHOULDER STRAPS PENDULOUS ABDOMEN DESIGN PREFABRICATED ITEM THAT HAS BEEN TRIMMED BENT MOLDED ASSEMBLED OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE 297 LSO OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/2006 L0631

U S C O OS S, S G CO O , G O OS O S, OS O S O S C OCOCC G JU C O O 9 , O UC S C SSU O UC O O SCS, C U S S S, CLOSURES MAY INCLUDE PADDING SHOULDER STRAPS PENDULOUS ABDOMEN DESIGN PREFABRICATED ITEM THAT HAS BEEN TRIMMED BENT MOLDED ASSEMBLED OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE 297 LSO OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/2006

L0632U S C O OS S, S G CO O , G O OS O S, OS O S O S C OCOCC G JU C O O 9 , O UC S C SSU O UC O O SCS, C U S S S,

CLOSURES MAY INCLUDE PADDING SHOULDER STRAPS PENDULOUS ABDOMEN DESIGN CUSTOM FABRICATED 297 LSO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/2006 L0633

, , ( ), , , REDUCE LOAD ON INTERVERTEBRAL DISCS INCLUDES STRAPS CLOSURES MAY INCLUDE PADDING STAYS SHOULDER STRAPS PENDULOUS ABDOMEN DESIGN PREFABRICATED ITEM THAT HAS BEEN TRIMMED BENT MOLDED ASSEMBLED OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT 297 LSO OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/2006

L0634 , , ( ), , ( ),

REDUCE LOAD ON INTERVERTEBRAL DISCS INCLUDES STRAPS CLOSURES MAY INCLUDE PADDING STAYS SHOULDER STRAPS PENDULOUS ABDOMEN DESIGN CUSTOM FABRICATED 297 LSO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/2006 L0635

, , , ( ), , , LATERAL FRAME/PANEL(S) PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON INTERVERTEBRAL DISCS INCLUDES STRAPS CLOSURES MAY INCLUDE PADDING ANTERIOR PANEL PENDULOUS ABDOMEN DESIGN PREFABRICATED INCLUDES FITTING AND ADJUSTMENT 297 LSO OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/2006

L0636U S C O OS S, S G CO O CO O , U O , G OS O / S, CU G S G O U S , OS O S O S C OCOCC G JU C O O 9 , S G O G

LATERAL FRAME/PANELS PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON INTERVERTEBRAL DISCS INCLUDES STRAPS CLOSURES MAY INCLUDE PADDING ANTERIOR PANEL PENDULOUS ABDOMEN DESIGN CUSTOM FABRICATED 297 LSO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/2006 L0637

, , , , , PRESSURE TO REDUCE LOAD ON INTERVERTEBRAL DISCS INCLUDES STRAPS CLOSURES MAY INCLUDE PADDING SHOULDER STRAPS PENDULOUS ABDOMEN DESIGN PREFABRICATED ITEM THAT HAS BEEN TRIMMED BENT MOLDED ASSEMBLED OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC 297 LSO OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/2006

L0638 , , , , ,

PRESSURE TO REDUCE LOAD ON INTERVERTEBRAL DISCS INCLUDES STRAPS CLOSURES MAY INCLUDE PADDING SHOULDER STRAPS PENDULOUS ABDOMEN DESIGN CUSTOM FABRICATED 297 LSO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/2006 L0639

, , ( ) ( ), , , INTERVERTEBRAL DISCS OVERALL STRENGTH IS PROVIDED BY OVERLAPPING RIGID MATERIAL AND STABILIZING CLOSURES INCLUDES STRAPS CLOSURES MAY INCLUDE SOFT INTERFACE PENDULOUS ABDOMEN DESIGN PREFABRICATED ITEM THAT HAS BEEN TRIMMED BENT MOLDED ASSEMBLED 297 LSO OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/2006

L0640 , , ( ) ( ), , ,

INTERVERTEBRAL DISCS OVERALL STRENGTH IS PROVIDED BY OVERLAPPING RIGID MATERIAL AND STABILIZING CLOSURES INCLUDES STRAPS CLOSURES MAY INCLUDE SOFT INTERFACE PENDULOUS ABDOMEN DESIGN CUSTOM FABRICATED 297 LSO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/2006 L0700 CERVICAL THORACIC LUMBAR SACRAL ORTHOSES (CTLSO) ANTERIOR POSTERIOR LATERAL CONTROL MOLDED TO PATIENT MODEL (MINERVA TYPE) 458 SO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L0710 CTLSO ANTERIOR POSTERIOR LATERAL CONTROL MOLDED TO PATIENT MODEL WITH INTERFACE MATERIAL (MINERVA TYPE) 458 SO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L0810 HALO PROCEDURE CERVICAL HALO INCORPORATED INTO JACKET VEST 458 SO OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L0820 HALO PROCEDURE CERVICAL HALO INCORPORATED INTO PLASTER BODY JACKET 458 SO OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L0830 HALO PROCEDURE CERVICAL HALO INCORPORATED INTO MILWAUKEE TYPE ORTHOSIS 458 SO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L0830 HALO PROCEDURE CERVICAL HALO INCORPORATED INTO MILWAUKEE TYPE ORTHOSIS 458 SO OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L0859 ADDITION TO HALO PROCEDURE MAGNETIC RESONANCE IMAGE COMPATIBLE SYSTEMS RINGS AND PINS ANY MATERIAL 458 SO OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/2006 L0861 ADDITION TO HALO PROCEDURE REPLACEMENT LINER/INTERFACE MATERIAL 458 SO OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/2004 L0970 TLSO CORSET FRONT 512 TLSO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L0970 TLSO CORSET FRONT 512 TLSO OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L0972 LSO CORSET FRONT 297 LSO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L0972 LSO CORSET FRONT 297 LSO OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L0974 TLSO FULL CORSET 512 TLSO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L0974 TLSO FULL CORSET 512 TLSO OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L0976 LSO FULL CORSET 297 LSO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L0976 LSO FULL CORSET 297 LSO OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L0978 AXILLARY CRUTCH EXTENSION 458 SO OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L0999 ADDITION TO SPINAL ORTHOSIS NOT OTHERWISE SPECIFIED 458 SO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/1998 L0999 ADDITION TO SPINAL ORTHOSIS NOT OTHERWISE SPECIFIED 458 SO OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/1998 L1000 CERVICAL THORACIC LUMBAR SACRAL ORTHOSIS (CTLSO) (MILWAUKEE) INCLUSIVE OF FURNISHING INITIAL ORTHOSIS INCLUDING MODEL 458 SO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L1001 CERVICAL THORACIC LUMBAR SACRAL ORTHOSIS IMMOBILIZER INFANT SIZE PREFABRICATED INCLUDES FITTING AND ADJUSTMENT 458 SO OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/2007 L1005 TENSION BASED SCOLIOSIS ORTHOSIS AND ACCESSORY PADS INCLUDES FITTING AND ADJUSTMENT 458 SO OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/2002 L1010 ADDITION TO CERVICAL THORACIC LUMBAR SACRAL ORTHOSIS (CTLSO) OR SCOLIOSIS ORTHOSIS AXILLA SLING 458 SO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L1020 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS KYPHOSIS PAD 458 SO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L1025 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS KYPHOSIS PAD FLOATING 458 SO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L1030 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS LUMBAR BOLSTER PAD 458 SO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L1040 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS LUMBAR OR LUMBAR RIB PAD 458 SO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L1050 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS STERNAL PAD 458 SO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L1060 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS THORACIC PAD 458 SO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L1070 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS TRAPEZIUS SLING 458 SO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L1080 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS OUTRIGGER 458 SO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L1085 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS OUTRIGGER BILATERAL WITH VERTICAL EXTENSIONS 458 SO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L1090 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS LUMBAR SLING 458 SO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L1100 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS RING FLANGE PLASTIC OR LEATHER 458 SO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L1110 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS RING FLANGE PLASTIC OR LEATHER MOLDED TO PATIENT MODEL 458 SO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L1120 ADDITION TO CTLSO SCOLIOSIS ORTHOSIS COVER FOR UPRIGHT EACH 458 SO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L1200 THORACIC LUMBAR SACRAL ORTHOSIS (TLSO) INCLUSIVE OF FURNISHING INITIAL ORTHOSIS ONLY 458 SO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L1210 ADDITION TO TLSO (LOW PROFILE) LATERAL THORACIC EXTENSION 458 SO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L1220 ADDITION TO TLSO (LOW PROFILE) ANTERIOR THORACIC EXTENSION 458 SO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L1230 ADDITION TO TLSO (LOW PROFILE) MILWAUKEE TYPE SUPERSTRUCTURE 458 SO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L1240 ADDITION TO TLSO (LOW PROFILE) LUMBAR DEROTATION PAD 458 SO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L1250 ADDITION TO TLSO (LOW PROFILE) ANTERIOR ASIS PAD 458 SO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L1260 ADDITION TO TLSO (LOW PROFILE) ANTERIOR THORACIC DEROTATION PAD 458 SO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L1270 ADDITION TO TLSO (LOW PROFILE) ABDOMINAL PAD 458 SO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L1280 ADDITION TO TLSO (LOW PROFILE) RIB GUSSET (ELASTIC) EACH 458 SO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L1290 ADDITION TO TLSO (LOW PROFILE) LATERAL TROCHANTERIC PAD 458 SO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L1300 OTHER SCOLIOSIS PROCEDURE BODY JACKET MOLDED TO PATIENT MODEL 458 SO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L1310 OTHER SCOLIOSIS PROCEDURE POST OPERATIVE BODY JACKET 458 SO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L1499 SPINAL ORTHOSIS NOT OTHERWISE SPECIFIED 458 SO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L1499 SPINAL ORTHOSIS NOT OTHERWISE SPECIFIED 458 SO OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L1600 HIP ORTHOSIS ABDUCTION CONTROL OF HIP JOINTS FLEXIBLE FREJKA TYPE WITH COVER PREFABRICATED ITEM THAT HAS BEEN TRIMMED BENT MOLDED ASSEMBLED OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INIDIVIDUAL WITH EXPERTISE 310 LOWER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L1610 HIP ORTHOSIS ABDUCTION CONTROL OF HIP JOINTS FLEXIBLE (FREJKA COVER ONLY) PREFABRICATED ITEM THAT HAS BEEN TRIMMED BENT MOLDED ASSEMBLED OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE 310 LOWER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L1620 HIP ORTHOSIS ABDUCTION CONTROL OF HIP JOINTS FLEXIBLE (PAVLIK HARNESS) PREFABRICATED ITEM THAT HAS BEEN TRIMMED BENT MOLDED ASSEMBLED OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE 310 LOWER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L1630 HIP ORTHOSIS ABDUCTION CONTROL OF HIP JOINTS SEMI FLEXIBLE (VON ROSEN TYPE) CUSTOM FABRICATED 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L1640 HIP ORTHOSIS ABDUCTION CONTROL OF HIP JOINTS STATIC PELVIC BAND OR SPREADER BAR THIGH CUFFS CUSTOM FABRICATED 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L1650 HIP ORTHOSIS ABDUCTION CONTROL OF HIP JOINTS STATIC ADJUSTABLE (ILFLED TYPE) PREFABRICATED INCLUDES FITTING AND ADJUSTMENT 310 LOWER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L1652 HIP ORTHOSIS BILATERAL THIGH CUFFS WITH ADJUSTABLE ABDUCTOR SPREADER BAR ADULT SIZE PREFABRICATED INCLUDES FITTING AND ADJUSTMENT ANY TYPE 310 LOWER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/2003 L1660 HIP ORTHOSIS ABDUCTION CONTROL OF HIP JOINTS STATIC PLASTIC PREFABRICATED INCLUDES FITTING AND ADJUSTMENT 310 LOWER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L1680 HIP ORTHOSIS ABDUCTION CONTROL OF HIP JOINTS DYNAMIC PELVIC CONTROL ADJUSTABLE HIP MOTION CONTROL THIGH CUFFS (RANCHO HIP ACTION TYPE) CUSTOM FABRICATED 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L1685 HIP ORTHOSIS ABDUCTION CONTROL OF HIP JOINT POSTOPERATIVE HIP ABDUCTION TYPE CUSTOM FABRICATED 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L1686 HIP ORTHOSIS ABDUCTION CONTROL OF HIP JOINT POSTOPERATIVE HIP ABDUCTION TYPE PREFABRICATED INCLUDES FITTING AND ADJUSTMENT 310 LOWER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L1690 COMBINATION BILATERAL LUMBO SACRAL HIP FEMUR ORTHOSIS PROVIDING ADDUCTION AND INTERNAL ROTATION CONTROL PREFABRICATED INCLUDES FITTING AND ADJUSTMENT 310 LOWER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/1999 L1700 LEGG PERTHES ORTHOSIS (TORONTO TYPE) CUSTOM FABRICATED 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L1710 LEGG PERTHES ORTHOSIS (NEWINGTON TYPE) CUSTOM FABRICATED 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L1720 LEGG PERTHES ORTHOSIS TRILATERAL (TACHDIJAN TYPE) CUSTOM FABRICATED 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L1730 LEGG PERTHES ORTHOSIS (SCOTTISH RITE TYPE) CUSTOM FABRICATED 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L1755 LEGG PERTHES ORTHOSIS (PATTEN BOTTOM TYPE) CUSTOM FABRICATED 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L1810 KNEE ORTHOSIS ELASTIC WITH JOINTS PREFABRICATED ITEM THAT HAS BEEN TRIMMED BENT MOLDED ASSEMBLED OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE 310 LOWER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L1820 KNEE ORTHOSIS ELASTIC WITH CONDYLAR PADS AND JOINTS WITH OR WITHOUT PATELLAR CONTROL PREFABRICATED INCLUDES FITTING AND ADJUSTMENT 310 LOWER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L1831 KNEE ORTHOSIS LOCKING KNEE JOINT(S) POSITIONAL ORTHOSIS PREFABRICATED INCLUDES FITTING AND ADJUSTMENT 310 LOWER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/2004 L1832 KNEE ORTHOSIS ADJUSTABLE KNEE JOINTS (UNICENTRIC OR POLYCENTRIC) POSITIONAL ORTHOSIS RIGID SUPPORT PREFABRICATED ITEM THAT HAS BEEN TRIMMED BENT MOLDED ASSEMBLED OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE 310 LOWER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L1834 KNEE ORTHOSIS WITHOUT KNEE JOINT RIGID CUSTOM FABRICATED 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L1840 KNEE ORTHOSIS DEROTATION MEDIAL LATERAL ANTERIOR CRUCIATE LIGAMENT CUSTOM FABRICATED 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L1843

, , , ( ), , , , , , ASSEMBLED OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE 310 LOWER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/1998

L1844 KNEE ORTHOSIS SINGLE UPRIGHT THIGH AND CALF WITH ADJUSTABLE FLEXION AND EXTENSION JOINT (UNICENTRIC OR POLYCENTRIC) MEDIAL LATERAL AND ROTATION CONTROL WITH OR WITHOUT VARUS/VALGUS ADJUSTMENT CUSTOM FABRICATED 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L1845

O OS S, OU U G , G C , JUS O S O JO (U C C O O C C), O O CO O , O OU US/ GUS JUS , C S , , O , ASSEMBLED OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE 310 LOWER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993

L1846 KNEE ORTHOSIS DOUBLE UPRIGHT THIGH AND CALF WITH ADJUSTABLE FLEXION AND EXTENSION JOINT (UNICENTRIC OR POLYCENTRIC) MEDIAL LATERAL AND ROTATION CONTROL WITH OR WITHOUT VARUS/VALGUS ADJUSTMENT CUSTOM FABRICATED 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L1847 KNEE ORTHOSIS DOUBLE UPRIGHT WITH ADJUSTABLE JOINT WITH INFLATABLE AIR SUPPORT CHAMBER(S) PREFABRICATED ITEM THAT HAS BEEN TRIMMED BENT MOLDED ASSEMBLED OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE 310 LOWER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/1999 L1860 KNEE ORTHOSIS MODIFICATION OF SUPRACONDYLAR PROSTHETIC SOCKET CUSTOM FABRICATED (SK) 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L1900 ANKLE FOOT ORTHOSIS SPRING WIRE DORSIFLEXION ASSIST CALF BAND CUSTOM FABRICATED 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L1904 ANKLE ORTHOSIS ANKLE GAUNTLET OR SIMILAR WITH OR WITHOUT JOINTS CUSTOM FABRICATED 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L1907 ANKLE ORTHOSIS SUPRAMALLEOLAR WITH STRAPS WITH OR WITHOUT INTERFACE/PADS CUSTOM FABRICATED 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/2004 L1910 ANKLE FOOT ORTHOSIS POSTERIOR SINGLE BAR CLASP ATTACHMENT TO SHOE COUNTER PREFABRICATED INCLUDES FITTING AND ADJUSTMENT 310 LOWER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L1920 ANKLE FOOT ORTHOSIS SINGLE UPRIGHT WITH STATIC OR ADJUSTABLE STOP (PHELPS OR PERLSTEIN TYPE) CUSTOM FABRICATED 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L1930 ANKLE FOOT ORTHOSIS PLASTIC OR OTHER MATERIAL PREFABRICATED INCLUDES FITTING AND ADJUSTMENT 310 LOWER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L1932 AFO RIGID ANTERIOR TIBIAL SECTION TOTAL CARBON FIBER OR EQUAL MATERIAL PREFABRICATED INCLUDES FITTING AND ADJUSTMENT 310 LOWER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/2005 L1940 ANKLE FOOT ORTHOSIS PLASTIC OR OTHER MATERIAL CUSTOM FABRICATED 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L1945 ANKLE FOOT ORTHOSIS PLASTIC RIGID ANTERIOR TIBIAL SECTION (FLOOR REACTION) CUSTOM FABRICATED 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L1950 ANKLE FOOT ORTHOSIS SPIRAL (INSTITUTE OF REHABILITATIVE MEDICINE TYPE) PLASTIC CUSTOM FABRICATED 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L1951 ANKLE FOOT ORTHOSIS SPIRAL (INSTITUTE OF REHABILITATIVE MEDICINE TYPE) PLASTIC OR OTHER MATERIAL PREFABRICATED INCLUDES FITTING AND ADJUSTMENT 310 LOWER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/2004 L1960 ANKLE FOOT ORTHOSIS POSTERIOR SOLID ANKLE PLASTIC CUSTOM FABRICATED 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L1970 ANKLE FOOT ORTHOSIS PLASTIC WITH ANKLE JOINT CUSTOM FABRICATED 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L1971 ANKLE FOOT ORTHOSIS PLASTIC OR OTHER MATERIAL WITH ANKLE JOINT PREFABRICATED INCLUDES FITTING AND ADJUSTMENT 310 LOWER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/2004 L1980 ANKLE FOOT ORTHOSIS SINGLE UPRIGHT FREE PLANTAR DORSIFLEXION SOLID STIRRUP CALF BAND/CUFF (SINGLE BAR BK ORTHOSIS) CUSTOM FABRICATED 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L1990 ANKLE FOOT ORTHOSIS DOUBLE UPRIGHT FREE PLANTAR DORSIFLEXION SOLID STIRRUP CALF BAND/CUFF (DOUBLE BAR BK ORTHOSIS) CUSTOM FABRICATED 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2000 KNEE ANKLE FOOT ORTHOSIS SINGLE UPRIGHT FREE KNEE FREE ANKLE SOLID STIRRUP THIGH AND CALF BANDS/CUFFS (SINGLE BAR AK ORTHOSIS) CUSTOM FABRICATED 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2005 KNEE ANKLE FOOT ORTHOSIS ANY MATERIAL SINGLE OR DOUBLE UPRIGHT STANCE CONTROL AUTOMATIC LOCK AND SWING PHASE RELEASE ANY TYPE ACTIVATION INCLUDES ANKLE JOINT ANY TYPE CUSTOM FABRICATED 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/2005 L2006

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L2010 KNEE ANKLE FOOT ORTHOSIS SINGLE UPRIGHT FREE ANKLE SOLID STIRRUP THIGH AND CALF BANDS/CUFFS (SINGLE BAR AK ORTHOSIS) WITHOUT KNEE JOINT CUSTOM FABRICATED 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2020 KNEE ANKLE FOOT ORTHOSIS DOUBLE UPRIGHT FREE ANKLE SOLID STIRRUP THIGH AND CALF BANDS/CUFFS (DOUBLE BAR AK ORTHOSIS) CUSTOM FABRICATED 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2030 KNEE ANKLE FOOT ORTHOSIS DOUBLE UPRIGHT FREE ANKLE SOLID STIRRUP THIGH AND CALF BANDS/CUFFS (DOUBLE BAR AK ORTHOSIS) WITHOUT KNEE JOINT CUSTOM FABRICATED 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2034 KNEE ANKLE FOOT ORTHOSIS FULL PLASTIC SINGLE UPRIGHT WITH OR WITHOUT FREE MOTION KNEE MEDIAL LATERAL ROTATION CONTROL WITH OR WITHOUT FREE MOTION ANKLE CUSTOM FABRICATED 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/2006 L2035 KNEE ANKLE FOOT ORTHOSIS FULL PLASTIC STATIC(PEDIATRIC SIZE) WITHOUT FREE MOTION ANKLE PREFABRICATED INCLUDES FITTING AND ADJUSTMENT 310 LOWER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/1998 L2036 KNEE ANKLE FOOT ORTHOSIS FULL PLASTIC DOUBLE UPRIGHT WITH OR WITHOUT FREE MOTION KNEE WITH OR WITHOUT FREE MOTION ANKLE CUSTOM FABRICATED 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2037 KNEE ANKLE FOOT ORTHOSIS FULL PLASTIC SINGLE UPRIGHT WITH OR WITHOUT FREE MOTION KNEE WITH OR WITHOUT FREE MOTION ANKLE CUSTOM FABRICATED 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2038 KNEE ANKLE FOOT ORTHOSIS FULL PLASTIC WITH OR WITHOUT FREE MOTION KNEE MULTI AXIS ANKLE CUSTOM FABRICATED 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2040 HIP KNEE ANKLE FOOT ORTHOSIS TORSION CONTROL BILATERAL ROTATION STRAPS PELVIC BAND/BELT CUSTOM FABRICATED 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2050 HIP KNEE ANKLE FOOT ORTHOSIS TORSION CONTROL BILATERAL TORSION CABLES HIP JOINT PELVIC BAND/BELT CUSTOM FABRICATED 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2060 HIP KNEE ANKLE FOOT ORTHOSIS TORSION CONTROL BILATERAL TORSION CABLES BALL BEARING HIP JOINT PELVIC BAND/ BELT CUSTOM FABRICATED 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2070 HIP KNEE ANKLE FOOT ORTHOSIS TORSION CONTROL UNILATERAL ROTATION STRAPS PELVIC BAND/BELT CUSTOM FABRICATED 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2080 HIP KNEE ANKLE FOOT ORTHOSIS TORSION CONTROL UNILATERAL TORSION CABLE HIP JOINT PELVIC BAND/BELT CUSTOM FABRICATED 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2090 HIP KNEE ANKLE FOOT ORTHOSIS TORSION CONTROL UNILATERAL TORSION CABLE BALL BEARING HIP JOINT PELVIC BAND/ BELT CUSTOM FABRICATED 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2106 ANKLE FOOT ORTHOSIS FRACTURE ORTHOSIS TIBIAL FRACTURE CAST ORTHOSIS THERMOPLASTIC TYPE CASTING MATERIAL CUSTOM FABRICATED 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2108 ANKLE FOOT ORTHOSIS FRACTURE ORTHOSIS TIBIAL FRACTURE CAST ORTHOSIS CUSTOM FABRICATED 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2112 ANKLE FOOT ORTHOSIS FRACTURE ORTHOSIS TIBIAL FRACTURE ORTHOSIS SOFT PREFABRICATED INCLUDES FITTING AND ADJUSTMENT 310 LOWER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L2114 ANKLE FOOT ORTHOSIS FRACTURE ORTHOSIS TIBIAL FRACTURE ORTHOSIS SEMI RIGID PREFABRICATED INCLUDES FITTING AND ADJUSTMENT 310 LOWER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L2116 ANKLE FOOT ORTHOSIS FRACTURE ORTHOSIS TIBIAL FRACTURE ORTHOSIS RIGID PREFABRICATED INCLUDES FITTING AND ADJUSTMENT 310 LOWER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L2126 KNEE ANKLE FOOT ORTHOSIS FRACTURE ORTHOSIS FEMORAL FRACTURE CAST ORTHOSIS THERMOPLASTIC TYPE CASTING MATERIAL CUSTOM FABRICATED 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2128 KNEE ANKLE FOOT ORTHOSIS FRACTURE ORTHOSIS FEMORAL FRACTURE CAST ORTHOSIS CUSTOM FABRICATED 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2132 KAFO FRACTURE ORTHOSIS FEMORAL FRACTURE CAST ORTHOSIS SOFT PREFABRICATED INCLUDES FITTING AND ADJUSTMENT 310 LOWER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L2134 KAFO FRACTURE ORTHOSIS FEMORAL FRACTURE CAST ORTHOSIS SEMI RIGID PREFABRICATED INCLUDES FITTING AND ADJUSTMENT 310 LOWER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L2136 KAFO FRACTURE ORTHOSIS FEMORAL FRACTURE CAST ORTHOSIS RIGID PREFABRICATED INCLUDES FITTING AND ADJUSTMENT 310 LOWER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L2180 ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS PLASTIC SHOE INSERT WITH ANKLE JOINTS 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2182 ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS DROP LOCK KNEE JOINT 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2184 ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS LIMITED MOTION KNEE JOINT 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2186 ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS ADJUSTABLE MOTION KNEE JOINT LERMAN TYPE 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2188 ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS QUADRILATERAL BRIM 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2190 ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS WAIST BELT 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2192 ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS HIP JOINT PELVIC BAND THIGH FLANGE AND PELVIC BELT 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2200 ADDITION TO LOWER EXTREMITY LIMITED ANKLE MOTION EACH JOINT 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2210 ADDITION TO LOWER EXTREMITY DORSIFLEXION ASSIST (PLANTAR FLEXION RESIST) EACH JOINT 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2220 ADDITION TO LOWER EXTREMITY DORSIFLEXION AND PLANTAR FLEXION ASSIST/RESIST EACH JOINT 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2230 ADDITION TO LOWER EXTREMITY SPLIT FLAT CALIPER STIRRUPS AND PLATE ATTACHMENT 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2232 ADDITION TO LOWER EXTREMITY ORTHOSIS ROCKER BOTTOM FOR TOTAL CONTACT ANKLE FOOT ORTHOSIS FOR CUSTOM FABRICATED ORTHOSIS ONLY 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/2005 L2240 ADDITION TO LOWER EXTREMITY ROUND CALIPER AND PLATE ATTACHMENT 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2250 ADDITION TO LOWER EXTREMITY FOOT PLATE MOLDED TO PATIENT MODEL STIRRUP ATTACHMENT 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2260 ADDITION TO LOWER EXTREMITY REINFORCED SOLID STIRRUP (SCOTT CRAIG TYPE) 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2265 ADDITION TO LOWER EXTREMITY LONG TONGUE STIRRUP 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2270 ADDITION TO LOWER EXTREMITY VARUS/VALGUS CORRECTION (T) STRAP PADDED/LINED OR MALLEOLUS PAD 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2275 ADDITION TO LOWER EXTREMITY VARUS/VALGUS CORRECTION PLASTIC MODIFICATION PADDED/LINED 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/1994 L2280 ADDITION TO LOWER EXTREMITY MOLDED INNER BOOT 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2300 ADDITION TO LOWER EXTREMITY ABDUCTION BAR (BILATERAL HIP INVOLVEMENT) JOINTED ADJUSTABLE 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2310 ADDITION TO LOWER EXTREMITY ABDUCTION BAR STRAIGHT 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2320 ADDITION TO LOWER EXTREMITY NON MOLDED LACER FOR CUSTOM FABRICATED ORTHOSIS ONLY 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2330 ADDITION TO LOWER EXTREMITY LACER MOLDED TO PATIENT MODEL FOR CUSTOM FABRICATED ORTHOSIS ONLY 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2335 ADDITION TO LOWER EXTREMITY ANTERIOR SWING BAND 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2340 ADDITION TO LOWER EXTREMITY PRE TIBIAL SHELL MOLDED TO PATIENT MODEL 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2350 ADDITION TO LOWER EXTREMITY PROSTHETIC TYPE (BK) SOCKET MOLDED TO PATIENT MODEL (USED FOR PTB AFO ORTHOSES) 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2360 ADDITION TO LOWER EXTREMITY EXTENDED STEEL SHANK 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2370 ADDITION TO LOWER EXTREMITY PATTEN BOTTOM 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2375 ADDITION TO LOWER EXTREMITY TORSION CONTROL ANKLE JOINT AND HALF SOLID STIRRUP 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2380 ADDITION TO LOWER EXTREMITY TORSION CONTROL STRAIGHT KNEE JOINT EACH JOINT 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2385 ADDITION TO LOWER EXTREMITY STRAIGHT KNEE JOINT HEAVY DUTY EACH JOINT 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2387 ADDITION TO LOWER EXTREMITY POLYCENTRIC KNEE JOINT FOR CUSTOM FABRICATED KNEE ANKLE FOOT ORTHOSIS EACH JOINT 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/2006 L2390 ADDITION TO LOWER EXTREMITY OFFSET KNEE JOINT EACH JOINT 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2395 ADDITION TO LOWER EXTREMITY OFFSET KNEE JOINT HEAVY DUTY EACH JOINT 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2397 ADDITION TO LOWER EXTREMITY ORTHOSIS SUSPENSION SLEEVE 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/1994 L2397 ADDITION TO LOWER EXTREMITY ORTHOSIS SUSPENSION SLEEVE 310 LOWER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/1994 L2405 ADDITION TO KNEE JOINT DROP LOCK EACH 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2415 ADDITION TO KNEE LOCK WITH INTEGRATED RELEASE MECHANISM ( BAIL CABLE OR EQUAL) ANY MATERIAL EACH JOINT 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2425 ADDITION TO KNEE JOINT DISC OR DIAL LOCK FOR ADJUSTABLE KNEE FLEXION EACH JOINT 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2430 ADDITION TO KNEE JOINT RATCHET LOCK FOR ACTIVE AND PROGRESSIVE KNEE EXTENSION EACH JOINT 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/1997 L2492 ADDITION TO KNEE JOINT LIFT LOOP FOR DROP LOCK RING 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2500 ADDITION TO LOWER EXTREMITY THIGH/WEIGHT BEARING GLUTEAL/ ISCHIAL WEIGHT BEARING RING 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2510 ADDITION TO LOWER EXTREMITY THIGH/WEIGHT BEARING QUADRI LATERAL BRIM MOLDED TO PATIENT MODEL 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2520 ADDITION TO LOWER EXTREMITY THIGH/WEIGHT BEARING QUADRI LATERAL BRIM CUSTOM FITTED 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2525 ADDITION TO LOWER EXTREMITY THIGH/WEIGHT BEARING ISCHIAL CONTAINMENT/NARROW M L BRIM MOLDED TO PATIENT MODEL 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2526 ADDITION TO LOWER EXTREMITY THIGH/WEIGHT BEARING ISCHIAL CONTAINMENT/NARROW M L BRIM CUSTOM FITTED 310 LOWER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L2530 ADDITION TO LOWER EXTREMITY THIGH WEIGHT BEARING LACER NON MOLDED 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2540 ADDITION TO LOWER EXTREMITY THIGH/WEIGHT BEARING LACER MOLDED TO PATIENT MODEL 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2550 ADDITION TO LOWER EXTREMITY THIGH/WEIGHT BEARING HIGH ROLL CUFF 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2570 ADDITION TO LOWER EXTREMITY PELVIC CONTROL HIP JOINT CLEVIS TYPE TWO POSITION JOINT EACH 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2580 ADDITION TO LOWER EXTREMITY PELVIC CONTROL PELVIC SLING 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2600 ADDITION TO LOWER EXTREMITY PELVIC CONTROL HIP JOINT CLEVIS TYPE OR THRUST BEARING FREE EACH 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2610 ADDITION TO LOWER EXTREMITY PELVIC CONTROL HIP JOINT CLEVIS OR THRUST BEARING LOCK EACH 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2620 ADDITION TO LOWER EXTREMITY PELVIC CONTROL HIP JOINT HEAVY DUTY EACH 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2622 ADDITION TO LOWER EXTREMITY PELVIC CONTROL HIP JOINT ADJUSTABLE FLEXION EACH 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2624 ADDITION TO LOWER EXTREMITY PELVIC CONTROL HIP JOINT ADJUSTABLE FLEXION EXTENSION ABDUCTION CONTROL EACH 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2627 ADDITION TO LOWER EXTREMITY PELVIC CONTROL PLASTIC MOLDED TO PATIENT MODEL RECIPROCATING HIP JOINT AND CABLES 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2628 ADDITION TO LOWER EXTREMITY PELVIC CONTROL METAL FRAME RECIPROCATING HIP JOINT AND CABLES 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2630 ADDITION TO LOWER EXTREMITY PELVIC CONTROL BAND AND BELT UNILATERAL 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2640 ADDITION TO LOWER EXTREMITY PELVIC CONTROL BAND AND BELT BILATERAL 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2650 ADDITION TO LOWER EXTREMITY PELVIC AND THORACIC CONTROL GLUTEAL PAD EACH 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2660 ADDITION TO LOWER EXTREMITY THORACIC CONTROL THORACIC BAND 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2670 ADDITION TO LOWER EXTREMITY THORACIC CONTROL PARASPINAL UPRIGHTS 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2680 ADDITION TO LOWER EXTREMITY THORACIC CONTROL LATERAL SUPPORT UPRIGHTS 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2750 ADDITION TO LOWER EXTREMITY ORTHOSIS PLATING CHROME OR NICKEL PER BAR 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2755 ADDITION TO LOWER EXTREMITY ORTHOSIS HIGH STRENGTH LIGHTWEIGHT MATERIAL ALL HYBRID LAMINATION/PREPREG COMPOSITE PER SEGMENT FOR CUSTOM FABRICATED ORTHOSIS ONLY 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/1997 L2760 ADDITION TO LOWER EXTREMITY ORTHOSIS EXTENSION PER EXTENSION PER BAR (FOR LINEAL ADJUSTMENT FOR GROWTH) 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2768 ORTHOTIC SIDE BAR DISCONNECT DEVICE PER BAR 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/2002 L2780 ADDITION TO LOWER EXTREMITY ORTHOSIS NON CORROSIVE FINISH PER BAR 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2785 ADDITION TO LOWER EXTREMITY ORTHOSIS DROP LOCK RETAINER EACH 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2795 ADDITION TO LOWER EXTREMITY ORTHOSIS KNEE CONTROL FULL KNEECAP 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2800 ADDITION TO LOWER EXTREMITY ORTHOSIS KNEE CONTROL KNEE CAP MEDIAL OR LATERAL PULL FOR USE WITH CUSTOM FABRICATED ORTHOSIS ONLY 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2810 ADDITION TO LOWER EXTREMITY ORTHOSIS KNEE CONTROL CONDYLAR PAD 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2820 ADDITION TO LOWER EXTREMITY ORTHOSIS SOFT INTERFACE FOR MOLDED PLASTIC BELOW KNEE SECTION 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2830 ADDITION TO LOWER EXTREMITY ORTHOSIS SOFT INTERFACE FOR MOLDED PLASTIC ABOVE KNEE SECTION 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2840 ADDITION TO LOWER EXTREMITY ORTHOSIS TIBIAL LENGTH SOCK FRACTURE OR EQUAL EACH 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2840 ADDITION TO LOWER EXTREMITY ORTHOSIS TIBIAL LENGTH SOCK FRACTURE OR EQUAL EACH 310 LOWER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L2850 ADDITION TO LOWER EXTREMITY ORTHOSIS FEMORAL LENGTH SOCK FRACTURE OR EQUAL EACH 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2850 ADDITION TO LOWER EXTREMITY ORTHOSIS FEMORAL LENGTH SOCK FRACTURE OR EQUAL EACH 310 LOWER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L2999 LOWER EXTREMITY ORTHOSES NOT OTHERWISE SPECIFIED 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L2999 LOWER EXTREMITY ORTHOSES NOT OTHERWISE SPECIFIED 310 LOWER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3000 FOOT INSERT REMOVABLE MOLDED TO PATIENT MODEL UCB TYPE BERKELEY SHELL EACH 350 ORTHOPEDIC FOOTWEAR OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L3001 FOOT INSERT REMOVABLE MOLDED TO PATIENT MODEL SPENCO EACH 350 ORTHOPEDIC FOOTWEAR OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L3002 FOOT INSERT REMOVABLE MOLDED TO PATIENT MODEL PLASTAZOTE OR EQUAL EACH 350 ORTHOPEDIC FOOTWEAR OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L3003 FOOT INSERT REMOVABLE MOLDED TO PATIENT MODEL SILICONE GEL EACH 350 ORTHOPEDIC FOOTWEAR OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L3010 FOOT INSERT REMOVABLE MOLDED TO PATIENT MODEL LONGITUDINAL ARCH SUPPORT EACH 350 ORTHOPEDIC FOOTWEAR OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L3020 FOOT INSERT REMOVABLE MOLDED TO PATIENT MODEL LONGITUDINAL/ METATARSAL SUPPORT EACH 350 ORTHOPEDIC FOOTWEAR OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L3030 FOOT INSERT REMOVABLE FORMED TO PATIENT FOOT EACH 350 ORTHOPEDIC FOOTWEAR OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L3031 FOOT INSERT/PLATE REMOVABLE ADDITION TO LOWER EXTREMITY ORTHOSIS HIGH STRENGTH LIGHTWEIGHT MATERIAL ALL HYBRID LAMINATION/PREPREG COMPOSITE EACH 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/2004 L3040 FOOT ARCH SUPPORT REMOVABLE PREMOLDED LONGITUDINAL EACH 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3050 FOOT ARCH SUPPORT REMOVABLE PREMOLDED METATARSAL EACH 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3060 FOOT ARCH SUPPORT REMOVABLE PREMOLDED LONGITUDINAL/ METATARSAL EACH 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3070 FOOT ARCH SUPPORT NON REMOVABLE ATTACHED TO SHOE LONGITUDINAL EACH 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3080 FOOT ARCH SUPPORT NON REMOVABLE ATTACHED TO SHOE METATARSAL EACH 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3090 FOOT ARCH SUPPORT NON REMOVABLE ATTACHED TO SHOE LONGITUDINAL/METATARSAL EACH 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3140 FOOT ABDUCTION ROTATION BAR INCLUDING SHOES 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3150 FOOT ABDUCTION ROTATATION BAR WITHOUT SHOES 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3160 FOOT ADJUSTABLE SHOE STYLED POSITIONING DEVICE 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3201 ORTHOPEDIC SHOE OXFORD WITH SUPINATOR OR PRONATOR INFANT 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3202 ORTHOPEDIC SHOE OXFORD WITH SUPINATOR OR PRONATOR CHILD 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3203 ORTHOPEDIC SHOE OXFORD WITH SUPINATOR OR PRONATOR JUNIOR 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3204 ORTHOPEDIC SHOE HIGHTOP WITH SUPINATOR OR PRONATOR INFANT 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3206 ORTHOPEDIC SHOE HIGHTOP WITH SUPINATOR OR PRONATOR CHILD 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3207 ORTHOPEDIC SHOE HIGHTOP WITH SUPINATOR OR PRONATOR JUNIOR 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3208 SURGICAL BOOT EACH INFANT 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3209 SURGICAL BOOT EACH CHILD 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3211 SURGICAL BOOT EACH JUNIOR 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3212 BENESCH BOOT PAIR INFANT 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3213 BENESCH BOOT PAIR CHILD 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3214 BENESCH BOOT PAIR JUNIOR 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3215 ORTHOPEDIC FOOTWEAR LADIES SHOE OXFORD EACH 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3216 ORTHOPEDIC FOOTWEAR LADIES SHOE DEPTH INLAY EACH 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3217 ORTHOPEDIC FOOTWEAR LADIES SHOE HIGHTOP DEPTH INLAY EACH 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3219 ORTHOPEDIC FOOTWEAR MENS SHOE OXFORD EACH 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3221 ORTHOPEDIC FOOTWEAR MENS SHOE DEPTH INLAY EACH 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3222 ORTHOPEDIC FOOTWEAR MENS SHOE HIGHTOP DEPTH INLAY EACH 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3224 ORTHOPEDIC FOOTWEAR WOMANS SHOE OXFORD USED AS AN INTEGRAL PART OF A BRACE (ORTHOSIS) 350 ORTHOPEDIC FOOTWEAR OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/1995 L3224 ORTHOPEDIC FOOTWEAR WOMANS SHOE OXFORD USED AS AN INTEGRAL PART OF A BRACE (ORTHOSIS) 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/1995 L3225 ORTHOPEDIC FOOTWEAR MANS SHOE OXFORD USED AS AN INTEGRAL PART OF A BRACE (ORTHOSIS) 350 ORTHOPEDIC FOOTWEAR OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/1995 L3225 ORTHOPEDIC FOOTWEAR MANS SHOE OXFORD USED AS AN INTEGRAL PART OF A BRACE (ORTHOSIS) 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/1995 L3230 ORTHOPEDIC FOOTWEAR CUSTOM SHOE DEPTH INLAY EACH 350 ORTHOPEDIC FOOTWEAR OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L3250 ORTHOPEDIC FOOTWEAR CUSTOM MOLDED SHOE REMOVABLE INNER MOLD PROSTHETIC SHOE EACH 350 ORTHOPEDIC FOOTWEAR OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L3251 FOOT SHOE MOLDED TO PATIENT MODEL SILICONE SHOE EACH 350 ORTHOPEDIC FOOTWEAR OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L3252 FOOT SHOE MOLDED TO PATIENT MODEL PLASTAZOTE (OR SIMILAR) CUSTOM FABRICATED EACH 350 ORTHOPEDIC FOOTWEAR OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L3253 FOOT MOLDED SHOE PLASTAZOTE (OR SIMILAR) CUSTOM FITTED EACH 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3254 NON STANDARD SIZE OR WIDTH 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3255 NON STANDARD SIZE OR LENGTH 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3257 ORTHOPEDIC FOOTWEAR ADDITIONAL CHARGE FOR SPLIT SIZE 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3260 SURGICAL BOOT/SHOE EACH 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3265 PLASTAZOTE SANDAL EACH 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3300 LIFT ELEVATION HEEL TAPERED TO METATARSALS PER INCH 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3310 LIFT ELEVATION HEEL AND SOLE NEOPRENE PER INCH 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3320 LIFT ELEVATION HEEL AND SOLE CORK PER INCH 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3330 LIFT ELEVATION METAL EXTENSION (SKATE) 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3334 LIFT ELEVATION HEEL PER INCH 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3340 HEEL WEDGE SACH 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3350 HEEL WEDGE 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3360 SOLE WEDGE OUTSIDE SOLE 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3370 SOLE WEDGE BETWEEN SOLE 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3380 CLUBFOOT WEDGE 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3390 OUTFLARE WEDGE 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3400 METATARSAL BAR WEDGE ROCKER 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3410 METATARSAL BAR WEDGE BETWEEN SOLE 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3420 FULL SOLE AND HEEL WEDGE BETWEEN SOLE 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3430 HEEL COUNTER PLASTIC REINFORCED 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3440 HEEL COUNTER LEATHER REINFORCED 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3450 HEEL SACH CUSHION TYPE 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3455 HEEL NEW LEATHER STANDARD 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3460 HEEL NEW RUBBER STANDARD 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3465 HEEL THOMAS WITH WEDGE 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3470 HEEL THOMAS EXTENDED TO BALL 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3500 ORTHOPEDIC SHOE ADDITION INSOLE LEATHER 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3510 ORTHOPEDIC SHOE ADDITION INSOLE RUBBER 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3520 ORTHOPEDIC SHOE ADDITION INSOLE FELT COVERED WITH LEATHER 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3530 ORTHOPEDIC SHOE ADDITION SOLE HALF 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3540 ORTHOPEDIC SHOE ADDITION SOLE FULL 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3550 ORTHOPEDIC SHOE ADDITION TOE TAP STANDARD 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3560 ORTHOPEDIC SHOE ADDITION TOE TAP HORSESHOE 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3570 ORTHOPEDIC SHOE ADDITION SPECIAL EXTENSION TO INSTEP (LEATHER WITH EYELETS) 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3580 ORTHOPEDIC SHOE ADDITION CONVERT INSTEP TO VELCRO CLOSURE 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3590 ORTHOPEDIC SHOE ADDITION CONVERT FIRM SHOE COUNTER TO SOFT COUNTER 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3595 ORTHOPEDIC SHOE ADDITION MARCH BAR 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3600 TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER CALIPER PLATE EXISTING 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3610 TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER CALIPER PLATE NEW 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3620 TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER SOLID STIRRUP EXISTING 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3630 TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER SOLID STIRRUP NEW 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3640 TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER DENNIS BROWNE SPLINT (RIVETON) BOTH SHOES 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3649 ORTHOPEDIC SHOE MODIFICATION ADDITION OR TRANSFER NOT OTHERWISE SPECIFIED 350 ORTHOPEDIC FOOTWEAR OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L3649 ORTHOPEDIC SHOE MODIFICATION ADDITION OR TRANSFER NOT OTHERWISE SPECIFIED 350 ORTHOPEDIC FOOTWEAR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3671 SHOULDER ORTHOSIS SHOULDER JOINT DESIGN WITHOUT JOINTS MAY INCLUDE SOFT INTERFACE STRAPS CUSTOM FABRICATED INCLUDES FITTING AND ADJUSTMENT 540 UPPER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/2006 L3674 SHOULDER ORTHOSIS ABDUCTION POSITIONING (AIRPLANE DESIGN) THORACIC COMPONENT AND SUPPORT BAR WITH OR WITHOUT NONTORSION JOINT/TURNBUCKLE MAY INCLUDE SOFT INTERFACE STRAPS CUSTOM FABRICATED INCLUDES FITTING AND ADJUSTMENT 540 UPPER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/2011 L3677 SHOULDER ORTHOSIS SHOULDER JOINT DESIGN WITHOUT JOINTS MAY INCLUDE SOFT INTERFACE STRAPS PREFABRICATED ITEM THAT HAS BEEN TRIMMED BENT MOLDED ASSEMBLED OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE 540 UPPER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/2002 L3702 ELBOW ORTHOSIS WITHOUT JOINTS MAY INCLUDE SOFT INTERFACE STRAPS CUSTOM FABRICATED INCLUDES FITTING AND ADJUSTMENT 540 UPPER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/2006 L3720 ELBOW ORTHOSIS DOUBLE UPRIGHT WITH FOREARM/ARM CUFFS FREE MOTION CUSTOM FABRICATED 540 UPPER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L3730 ELBOW ORTHOSIS DOUBLE UPRIGHT WITH FOREARM/ARM CUFFS EXTENSION/ FLEXION ASSIST CUSTOM FABRICATED 540 UPPER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L3740 ELBOW ORTHOSIS DOUBLE UPRIGHT WITH FOREARM/ARM CUFFS ADJUSTABLE POSITION LOCK WITH ACTIVE CONTROL CUSTOM FABRICATED 540 UPPER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L3760 ELBOW ORTHOSIS (EO) WITH ADJUSTABLE POSITION LOCKING JOINT(S) PREFABRICATED ITEM THAT HAS BEEN TRIMMED BENT MOLDED ASSEMBLED OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE 540 UPPER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/2001 L3763 ELBOW WRIST HAND ORTHOSIS RIGID WITHOUT JOINTS MAY INCLUDE SOFT INTERFACE STRAPS CUSTOM FABRICATED INCLUDES FITTING AND ADJUSTMENT 540 UPPER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/2006 L3764 ELBOW WRIST HAND ORTHOSIS INCLUDES ONE OR MORE NONTORSION JOINTS ELASTIC BANDS TURNBUCKLES MAY INCLUDE SOFT INTERFACE STRAPS CUSTOM FABRICATED INCLUDES FITTING AND ADJUSTMENT 540 UPPER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/2006 L3765 ELBOW WRIST HAND FINGER ORTHOSIS RIGID WITHOUT JOINTS MAY INCLUDE SOFT INTERFACE STRAPS CUSTOM FABRICATED INCLUDES FITTING AND ADJUSTMENT 540 UPPER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/2006 L3766 ELBOW WRIST HAND FINGER ORTHOSIS INCLUDES ONE OR MORE NONTORSION JOINTS ELASTIC BANDS TURNBUCKLES MAY INCLUDE SOFT INTERFACE STRAPS CUSTOM FABRICATED INCLUDES FITTING AND ADJUSTMENT 540 UPPER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/2006 L3806 WRIST HAND FINGER ORTHOSIS INCLUDES ONE OR MORE NONTORSION JOINT(S) TURNBUCKLES ELASTIC BANDS/SPRINGS MAY INCLUDE SOFT INTERFACE MATERIAL STRAPS CUSTOM FABRICATED INCLUDES FITTING AND ADJUSTMENT 540 UPPER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/2007 L3807 WRIST HAND FINGER ORTHOSIS WITHOUT JOINT(S) PREFABRICATED ITEM THAT HAS BEEN TRIMMED BENT MOLDED ASSEMBLED OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE 540 UPPER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/2000 L3808 WRIST HAND FINGER ORTHOSIS RIGID WITHOUT JOINTS MAY INCLUDE SOFT INTERFACE MATERIAL STRAPS CUSTOM FABRICATED INCLUDES FITTING AND ADJUSTMENT 540 UPPER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/2007 L3900 WRIST HAND FINGER ORTHOSIS DYNAMIC FLEXOR HINGE RECIPROCAL WRIST EXTENSION/ FLEXION FINGER FLEXION/EXTENSION WRIST OR FINGER DRIVEN CUSTOM FABRICATED 540 UPPER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L3901 WRIST HAND FINGER ORTHOSIS DYNAMIC FLEXOR HINGE RECIPROCAL WRIST EXTENSION/ FLEXION FINGER FLEXION/EXTENSION CABLE DRIVEN CUSTOM FABRICATED 540 UPPER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L3904 WRIST HAND FINGER ORTHOSIS EXTERNAL POWERED ELECTRIC CUSTOM FABRICATED 540 UPPER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L3905 WRIST HAND ORTHOSIS INCLUDES ONE OR MORE NONTORSION JOINTS ELASTIC BANDS TURNBUCKLES MAY INCLUDE SOFT INTERFACE STRAPS CUSTOM FABRICATED INCLUDES FITTING AND ADJUSTMENT 540 UPPER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/2006 L3906 WRIST HAND ORTHOSIS WITHOUT JOINTS MAY INCLUDE SOFT INTERFACE STRAPS CUSTOM FABRICATED INCLUDES FITTING AND ADJUSTMENT 540 UPPER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L3913 HAND FINGER ORTHOSIS WITHOUT JOINTS MAY INCLUDE SOFT INTERFACE STRAPS CUSTOM FABRICATED INCLUDES FITTING AND ADJUSTMENT 540 UPPER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/2006 L3915

, ( ), , , , , , , , , INDIVIDUAL WITH EXPERTISE 540 UPPER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/2007

Tracking Number: PD-210407-01

HCPCS Codes with Product and Service Codes OR01 and/or OR02

Sorted by: HCPCS Code

HCPCSHCPCS LongD i ti

Policy GroupN b

Policy GroupN

Product andS i C d

Product andService CodeD i ti

RequiresAccreditation(Y/N)

CrosswalkEffectiveD t

CrosswalkE d D t

HCPCSEffectiveD t

HCPCSTerminationD t

Tracking Number: PD-210407-01

HCPCS Codes with Product and Service Codes OR01 and/or OR02

Sorted by: HCPCS Code

L3917 HAND ORTHOSIS METACARPAL FRACTURE ORTHOSIS PREFABRICATED ITEM THAT HAS BEEN TRIMMED BENT MOLDED ASSEMBLED OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE 540 UPPER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/2004 L3919 HAND ORTHOSIS WITHOUT JOINTS MAY INCLUDE SOFT INTERFACE STRAPS CUSTOM FABRICATED INCLUDES FITTING AND ADJUSTMENT 540 UPPER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/2006 L3921 HAND FINGER ORTHOSIS INCLUDES ONE OR MORE NONTORSION JOINTS ELASTIC BANDS TURNBUCKLES MAY INCLUDE SOFT INTERFACE STRAPS CUSTOM FABRICATED INCLUDES FITTING AND ADJUSTMENT 540 UPPER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/2006 L3923 HAND FINGER ORTHOSIS WITHOUT JOINTS MAY INCLUDE SOFT INTERFACE STRAPS PREFABRICATED ITEM THAT HAS BEEN TRIMMED BENT MOLDED ASSEMBLED OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE 540 UPPER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/2001 L3929

G O OS S, C U S O O O O O S O JO (S), U UC S, S C S/S GS, C U SO C , S S, C S , , O , SS , O O S CUS O O S C C PATIENT BY AN INDIVIDUAL WITH EXPERTISE 540 UPPER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/2008

L3931 WRIST HAND FINGER ORTHOSIS INCLUDES ONE OR MORE NONTORSION JOINT(S) TURNBUCKLES ELASTIC BANDS/SPRINGS MAY INCLUDE SOFT INTERFACE MATERIAL STRAPS PREFABRICATED INCLUDES FITTING AND ADJUSTMENT 540 UPPER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/2008 L3933 FINGER ORTHOSIS WITHOUT JOINTS MAY INCLUDE SOFT INTERFACE CUSTOM FABRICATED INCLUDES FITTING AND ADJUSTMENT 540 UPPER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/2006 L3935 FINGER ORTHOSIS NONTORSION JOINT MAY INCLUDE SOFT INTERFACE CUSTOM FABRICATED INCLUDES FITTING AND ADJUSTMENT 540 UPPER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/2006 L3956 ADDITION OF JOINT TO UPPER EXTREMITY ORTHOSIS ANY MATERIAL PER JOINT 540 UPPER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/1997 L3956 ADDITION OF JOINT TO UPPER EXTREMITY ORTHOSIS ANY MATERIAL PER JOINT 540 UPPER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/1997 L3960 SHOULDER ELBOW WRIST HAND ORTHOSIS ABDUCTION POSITIONING AIRPLANE DESIGN PREFABRICATED INCLUDES FITTING AND ADJUSTMENT 540 UPPER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3961 SHOULDER ELBOW WRIST HAND ORTHOSIS SHOULDER CAP DESIGN WITHOUT JOINTS MAY INCLUDE SOFT INTERFACE STRAPS CUSTOM FABRICATED INCLUDES FITTING AND ADJUSTMENT 540 UPPER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/2006 L3962 SHOULDER ELBOW WRIST HAND ORTHOSIS ABDUCTION POSITIONING ERBS PALSEY DESIGN PREFABRICATED INCLUDES FITTING AND ADJUSTMENT 540 UPPER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3967 SHOULDER ELBOW WRIST HAND ORTHOSIS ABDUCTION POSITIONING (AIRPLANE DESIGN) THORACIC COMPONENT AND SUPPORT BAR WITHOUT JOINTS MAY INCLUDE SOFT INTERFACE STRAPS CUSTOM FABRICATED INCLUDES FITTING AND ADJUSTMENT 540 UPPER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/2006 L3971 SHOULDER ELBOW WRIST HAND ORTHOSIS SHOULDER CAP DESIGN INCLUDES ONE OR MORE NONTORSION JOINTS ELASTIC BANDS TURNBUCKLES MAY INCLUDE SOFT INTERFACE STRAPS CUSTOM FABRICATED INCLUDES FITTING AND ADJUSTMENT 540 UPPER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/2006 L3973

S OU O S O OS S, UC O OS O G ( S G ), O C C CO O SU O , C U S O O O O O S O JO S, S C S, U UC S, C U SO C , S S, CUS O C , C U S FITTING AND ADJUSTMENT 540 UPPER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/2006

L3975 SHOULDER ELBOW WRIST HAND FINGER ORTHOSIS SHOULDER CAP DESIGN WITHOUT JOINTS MAY INCLUDE SOFT INTERFACE STRAPS CUSTOM FABRICATED INCLUDES FITTING AND ADJUSTMENT 540 UPPER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/2006 L3976 SHOULDER ELBOW WRIST HAND FINGER ORTHOSIS ABDUCTION POSITIONING (AIRPLANE DESIGN) THORACIC COMPONENT AND SUPPORT BAR WITHOUT JOINTS MAY INCLUDE SOFT INTERFACE STRAPS CUSTOM FABRICATED INCLUDES FITTING AND ADJUSTMENT 540 UPPER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/2006 L3977 SHOULDER ELBOW WRIST HAND FINGER ORTHOSIS SHOULDER CAP DESIGN INCLUDES ONE OR MORE NONTORSION JOINTS ELASTIC BANDS TURNBUCKLES MAY INCLUDE SOFT INTERFACE STRAPS CUSTOM FABRICATED INCLUDES FITTING AND ADJUSTMENT 540 UPPER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/2006 L3978

, ( ), , , , , , , , INCLUDES FITTING AND ADJUSTMENT 540 UPPER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/2006

L3980 UPPER EXTREMITY FRACTURE ORTHOSIS HUMERAL PREFABRICATED INCLUDES FITTING AND ADJUSTMENT 540 UPPER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3981 UPPER EXTREMITY FRACTURE ORTHOSIS HUMERAL PREFABRICATED INCLUDES SHOULDER CAP DESIGN WITH OR WITHOUT JOINTS FOREARM SECTION MAY INCLUDE SOFT INTERFACE STRAPS INCLUDES FITTING AND ADJUSTMENTS 540 UPPER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/2015 L3982 UPPER EXTREMITY FRACTURE ORTHOSIS RADIUS/ULNAR PREFABRICATED INCLUDES FITTING AND ADJUSTMENT 540 UPPER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3984 UPPER EXTREMITY FRACTURE ORTHOSIS WRIST PREFABRICATED INCLUDES FITTING AND ADJUSTMENT 540 UPPER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3995 ADDITION TO UPPER EXTREMITY ORTHOSIS SOCK FRACTURE OR EQUAL EACH 540 UPPER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L3995 ADDITION TO UPPER EXTREMITY ORTHOSIS SOCK FRACTURE OR EQUAL EACH 540 UPPER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L3999 UPPER LIMB ORTHOSIS NOT OTHERWISE SPECIFIED 540 UPPER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L3999 UPPER LIMB ORTHOSIS NOT OTHERWISE SPECIFIED 540 UPPER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L4000 REPLACE GIRDLE FOR SPINAL ORTHOSIS (CTLSO OR SO) 458 SO OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L4002 REPLACEMENT STRAP ANY ORTHOSIS INCLUDES ALL COMPONENTS ANY LENGTH ANY TYPE 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/2005 L4010 REPLACE TRILATERAL SOCKET BRIM 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L4020 REPLACE QUADRILATERAL SOCKET BRIM MOLDED TO PATIENT MODEL 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L4030 REPLACE QUADRILATERAL SOCKET BRIM CUSTOM FITTED 310 LOWER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L4040 REPLACE MOLDED THIGH LACER FOR CUSTOM FABRICATED ORTHOSIS ONLY 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L4045 REPLACE NON MOLDED THIGH LACER FOR CUSTOM FABRICATED ORTHOSIS ONLY 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L4050 REPLACE MOLDED CALF LACER FOR CUSTOM FABRICATED ORTHOSIS ONLY 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L4055 REPLACE NON MOLDED CALF LACER FOR CUSTOM FABRICATED ORTHOSIS ONLY 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L4060 REPLACE HIGH ROLL CUFF 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L4070 REPLACE PROXIMAL AND DISTAL UPRIGHT FOR KAFO 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L4080 REPLACE METAL BANDS KAFO PROXIMAL THIGH 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L4090 REPLACE METAL BANDS KAFO AFO CALF OR DISTAL THIGH 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L4100 REPLACE LEATHER CUFF KAFO PROXIMAL THIGH 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L4110 REPLACE LEATHER CUFF KAFO AFO CALF OR DISTAL THIGH 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L4130 REPLACE PRETIBIAL SHELL 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L4205 REPAIR OF ORTHOTIC DEVICE LABOR COMPONENT PER 15 MINUTES 360 ORTHOSIS/PROSTHESIS REPAIR OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/1997 L4205 REPAIR OF ORTHOTIC DEVICE LABOR COMPONENT PER 15 MINUTES 360 ORTHOSIS/PROSTHESIS REPAIR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/1997 L4210 REPAIR OF ORTHOTIC DEVICE REPAIR OR REPLACE MINOR PARTS 360 ORTHOSIS/PROSTHESIS REPAIR OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L4210 REPAIR OF ORTHOTIC DEVICE REPAIR OR REPLACE MINOR PARTS 360 ORTHOSIS/PROSTHESIS REPAIR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L4360 WALKING BOOT PNEUMATIC AND/OR VACUUM WITH OR WITHOUT JOINTS WITH OR WITHOUT INTERFACE MATERIAL PREFABRICATED ITEM THAT HAS BEEN TRIMMED BENT MOLDED ASSEMBLED OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE 310 LOWER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L4386 WALKING BOOT NON PNEUMATIC WITH OR WITHOUT JOINTS WITH OR WITHOUT INTERFACE MATERIAL PREFABRICATED ITEM THAT HAS BEEN TRIMMED BENT MOLDED ASSEMBLED OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE 310 LOWER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/2003 L4392 REPLACEMENT SOFT INTERFACE MATERIAL STATIC AFO 310 LOWER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/1997 L4394 REPLACE SOFT INTERFACE MATERIAL FOOT DROP SPLINT 310 LOWER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/1997 L4396

, , , , , , , , , PATIENT BY AN INDIVIDUAL WITH EXPERTISE 310 LOWER LIMB ORTHOSES OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/1997

L4631 ANKLE FOOT ORTHOSIS WALKING BOOT TYPE VARUS/VALGUS CORRECTION ROCKER BOTTOM ANTERIOR TIBIAL SHELL SOFT INTERFACE CUSTOM ARCH SUPPORT PLASTIC OR OTHER MATERIAL INCLUDES STRAPS AND CLOSURES CUSTOM FABRICATED 310 LOWER LIMB ORTHOSES OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/2011 L7510 REPAIR OF PROSTHETIC DEVICE REPAIR OR REPLACE MINOR PARTS 360 ORTHOSIS/PROSTHESIS REPAIR OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 10/01/1993 L7510 REPAIR OF PROSTHETIC DEVICE REPAIR OR REPLACE MINOR PARTS 360 ORTHOSIS/PROSTHESIS REPAIR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L7520 REPAIR PROSTHETIC DEVICE LABOR COMPONENT PER 15 MINUTES 360 ORTHOSIS/PROSTHESIS REPAIR OR01 ORTHOSES CUSTOM FABRICATED Y 10/01/2017 01/01/1997 L7520 REPAIR PROSTHETIC DEVICE LABOR COMPONENT PER 15 MINUTES 360 ORTHOSIS/PROSTHESIS REPAIR OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 01/01/1997 L8300 TRUSS SINGLE WITH STANDARD PAD 610 MISC DMEPOS OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L8310 TRUSS DOUBLE WITH STANDARD PADS 610 MISC DMEPOS OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L8320 TRUSS ADDITION TO STANDARD PAD WATER PAD 610 MISC DMEPOS OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993 L8330 TRUSS ADDITION TO STANDARD PAD SCROTAL PAD 610 MISC DMEPOS OR02 ORTHOSES PREFABRICATED (CUSTOM FITTED) Y 10/01/2017 10/01/1993

Column Name Column DescriptionHCPCS The five-digit alphanumeric HCPCS code for the supplies provided, together with a KL or UE modifier for certain codes.HCPCS Long Description The long description of the five-digit HCPCS code for the supplies provided.Policy Group Number A numeric code that represents a grouping of procedure codes.Policy Group Name The description of the policy group.Product and Service Code An alphanumeric code representing a category of products and services.Product and Service Code Description The description of the alphanumeric product and service code.Requires Accreditation (Y/N) Indicating (Y/N) if the identified HCPCS code requires accreditation per Change Requests (CR) 6556/7333/9371/9904.Crosswalk Effective Date The effective date of the crosswalk.Crosswalk End Date The end date, if applicable, of the crosswalk.HCPCS Effective Date The most current date on which the procedure code became valid for submission.HCPCS Termination Date The most current termination date for the identified procedure code.

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Tracking Number: PD-210407-01

Column Descriptions

Source of Report: PDAC ReportingReport Run Date: 04/12/2021