Medical, Dental & Pharmacy
- Medical
- Ambulatory Surgical Services
- Children's Services
- Chiropractic
- Clinic Services
- Community First Services and Supports (CFSS)
- Early Intensive Development and Behavioral Intervention (EIDBI)
- Equipment and Supplies
- HCBS
- Hearing Services
- Home Care Services
- Hospice Services
- Hospital Services
- Housing Stabilization Services
- Immunizations and Vaccinations
- Laboratory/Pathology, Radiology, and Diagnostic Services
- Language Interpreter Services
- Long-Term Care
- Medication Reconciliation
- Mental Health Services
- Optical Services
- Personal Care Assistance (PCA) Services
- Physician and Professional Services
- Recuperative Care
- Rehabilitation Services
- Renal Dialysis
- Restricted Recipient Program
- School-Based Community Services
- Substance Use Disorder
- Telehealth Services
- Transportation
- Tribal and Federal Indian Health Services
- Dental
- Pharmacy
Billing
Rehab Billing Entity
Use the organization’s National Provider Identifier (NPI) as the pay-to-provider and report the individual NPI of the therapist providing the service as the rendering or treating provider on the claim.
Independently Enrolled Providers
- Independently enrolled PTs, OTs, SLPs, or audiologists: Bill only for services you provide.
- Use your individual NPI to bill for services.
- Independently enrolled SLPs: Advise dual eligible Medicare/Medicaid members to seek treatment from providers enrolled with both Medicare and MHCP.
- Independently enrolled audiologists: bill for services provided in your own office, the member’s home, LTCF(s), or at DT&H center(s).
Fee-for-Time Compensation and Reciprocal Billing Arrangements for Physical Therapists
Outpatient physical therapy services furnished by physical therapists in a Health Professional Shortage Area (HPSA), Medically Underserved Area (MUA), or in a rural area can be billed under the reciprocal billing or fee-for-time compensation agreements.
Therapy Services Provided in Facility Settings
For therapy purposes, a facility setting includes a physician clinic, outpatient hospital, Community Public Health Clinic, rehabilitation agency, CORF, and CAH.
- Bill physical therapy, occupational therapy, speech-language pathology, and audiology services provided by employees in a facility setting using the facility or agency’s NPI.
- Outpatient hospital services may only be provided in an outpatient hospital facility.
Rehabilitative Services Provided in a Long-Term Care Facility (LTCF)
LTCFs may provide rehabilitative services to their residents and members of the community, using either their own staff or by contracting with an outside service vendor (rehabilitation agency).
Rehabilitative services are not covered by all major programs. Services must be provided on the premises.
PrimeWest Health will not make separate reimbursement for therapy services for residents of an LTCF that includes therapy as part of its per diem rate.
Use the following criteria to determine the correct billing method to use.
Employees of the Long-Term Care Facility (LTCF)
The LTCF bills services provided by PT, OT, or SLP employees.
- Use either the CMS-1500 or UB-04.
- Enter the LTCF’s NPI.
- If Medicare requires the LTCF to bill for Medicare-covered rehabilitative services for dually eligible members, follow Medicare requirements until Medicare benefits are exhausted.
Contracted Rehabilitation Services
The rehabilitation agency or the LTCF may bill physical therapy, occupations therapy, or speech-language pathology services provided by a rehabilitation agency, or provided by an independently enrolled PT, OT, or SLP at an LTCF. The rehabilitation agency or the LTCF designated to do the billing must bill for all rehabilitative services.
- When rehabilitation agencies bill for services:
- Use the 837P or 837I format
- Enter the rehabilitation agency’s NPI
- Enter the LTCF’s NPI in FL 83
- When LTCFs bill for services:
- Use the 837P or 837I format
- Enter the LTCF’s NPI
- If Medicare requires the LTCF to bill for Medicare-covered rehabilitative services for dually eligible members, follow Medicare’s requirements until Medicare benefits are exhausted
- Services provided by an independently enrolled SLP contracted with a LTCF must be billed by the LTCF
- When independently enrolled PT/OT bills for services:
- Use the 837P or 837I format
- Enter the therapist’s individual NPI
- If Medicare requires the LTCF to bill for Medicare-covered rehabilitative services for dually eligible members, follow Medicare’s requirements until Medicare benefits are exhausted
The provider billing for and receiving payment for services is responsible for the accuracy of the claims and for maintaining patient records that fully disclose the extent of the benefits provided.
Codes and Modifiers
- PrimeWest Health uses outpatient rehabilitative services codes as defined in Current Procedural Terminology (CPT)/HCPCS as billable in timed units (15 minutes, 30 minutes, 1 hour). Bill outpatient rehabilitative services with appropriate units.
- Bill CPT/HCPCS codes that do not have a timed component/unit as one unit per visit, regardless of the time spent.
- Bill only one unit for any date of service (DOS) that is a “per visit/session” code.
- Do not bill for services represented by 15-minute timed codes when performed for less than eight minutes on any date of service
- Follow billing guidelines in the following table only for services spent directly with the recipient
- Bill only direct patient contact by the provider as time the patient is treated
- Do not follow Medicare’s rounding rules for speech, occupational, and physical therapy services. Each modality and unit(s) is reported separately by code definition. Do not combine codes to determine total time units.
| If the duration for each service performed equals: | Bill this number of units: | Notes: |
| 8 – 22 minutes | 1 | Do not bill for services you perform for less than eight minutes.
If a service represented by a 15-minute timed code is performed in a single day for at least 8 – 22 minutes, bill that service as one unit. If you perform the same service for at least 23 minutes, bill that service for at least two units, etc.
Billable units are not determined by total session time. |
| 23 – 37 minutes | 2 | |
| 38 – 52 minutes | 3 | |
| 53 – 67 minutes | 4 | |
| 68 – 82 minutes | 5 | |
| 83 – 97 minutes | 6 | |
| 98 – 112 minutes | 7 | |
| 113 – 127 minutes | 8 |
- Use the correct HCPCS code and appropriate modifier from the Casting & Splinting Supplies chart to bill occupational therapy supplies fabricated by the therapist, such as splints, casts, and adaptive aids. Do not bill for ready-made supplies or for prefabricated supplies that can be obtained from a medical supplier.
- Use the following modifiers to indicate which discipline delivered the service for all outpatient rehabilitative services and authorizations:
- GN – speech-language pathology
- GO – occupational therapy
- GP – physical therapy
- Use modifier U7 on claims (not required on authorization requests), in addition to the required modifiers to indicate the service was provided by a physical or occupational therapy assistant
- Use modifier UC only to indicate that the therapy service provided was specialized maintenance therapy. Document specialized maintenance therapy in the patient’s record.
- When services are delivered to a member by two or more therapists in the same block of time (co-therapy session), split the time so that the total time billed does not exceed the actual length of the session.
- Always follow Medicare guidelines for PrimeWest Health members who are dually eligible for Medicare and Medicaid when providing Medicare-covered services.
Occupational Therapy, Physical Therapy, and Speech-Language Pathology | ||
| Code | Required Modifier | Description |
| 90901 | GO, GP | Biofeedback training by any modality. For billing electromyography biofeedback only. Not to be used to bill nerve impulse, blood pressure, blood flow, brain waves, or oculogram biofeedback. Description of service must be included on claim. |
| 92507 | GN | Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual |
| 92508 | Group, 2 or more individuals | |
| 92521 | GN | Evaluation of speech fluency (e.g., stuttering, cluttering) |
| 92522 | GN | Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria) |
| 92523 | GN | Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria) with evaluation of language comprehension and expression (e.g., receptive and expressive language) |
| 92524 | GN | Behavioral and qualitative analysis of voice and resonance |
| 92606 | GN | Therapeutic service(s) for the use of non-speech-generating device, including programming and modification |
| 92609 | GN | Therapeutic services for the use of speech-generating device, including programming and modification |
| 92526 | GN, GO | Treatment of swallowing dysfunction and/or oral function for feeding |
| 92626 | GN | Evaluation of auditory rehabilitation status; first hour |
| 92627 | Each additional 15 minutes (List separately in addition to code for primary procedure) | |
| 92630 | Auditory rehabilitation; pre-lingual hearing loss | |
| 92633 | Post-lingual hearing loss | |
| 92700 | GN | Unlisted otorhinolaryngological service or procedure |
| 97533 | GN, GO, GP | Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct patient contact by provider – 15 minutes |
| 92597 | GN | Evaluation for use and/or fitting of voice prosthetic device to supplement oral speech |
| 92605 | Evaluation for prescription of non-speech-generating augmentative and alternative communication devices | |
| 92607 | Evaluation for prescription speech-generating augmentative and alternative communication device, face-to-face with the patient; first hour | |
| 92608 | Evaluation for prescription for speech-generating augmentative and alternative communication device, face-to-face with the patient; each additional 30 minutes (list separately in addition to code for primary procedure) | |
| 92618 | GN | Evaluation for prescription of non-speech-generating augmentative and alternative communication device, face-to-face with the patient; each additional 30 minutes (list separately in addition to code for primary procedure) |
| 92610 | GN, GO | Evaluation of oral and pharyngeal swallowing function |
| 92611 | Motion fluoroscopic evaluation of swallowing function by cine or video recording | |
| 92612 | GN | Flexible fiber optic endoscopic evaluation of swallowing by cine or video recording |
| 92614 | Flexible fiber optic endoscopic evaluation, laryngeal sensory testing by cine or video recording | |
| 92616 | Flexible fiber optic endoscopic evaluation of swallowing | |
| 95851 | GP, GO | Range of motion measure and report; each extremity (excluding hand) or each trunk section |
| 95852 | Range of motion measurement – hand with or without comparison to normal side | |
| 96105 | GN | Assessment of aphasia (includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, writing [e.g., by Boston Diagnostic Aphasia Examination]) with interpretation and report, per hour |
| 96110 | GO, GN, GP | Developmental screening (e.g., developmental milestone survey, speech and language delay screen) with scoring and documentation, per standardized instrument |
| 96112 | Developmental test administration by qualified health care professional with interpretation and report, first 60 minutes | |
| 96113 | Developmental test administration by qualified health care professional with interpretation and report, additional 30 minutes | |
| 97161 | GP | Physical therapy evaluation, low complexity |
| 97162 | GP | Physical therapy evaluation, moderate complexity |
| 97163 | GP | Physical therapy evaluation, high complexity |
| 97164 | GP | Physical therapy re-evaluation, EST plan care |
| 97165 | GO | Occupational therapy evaluation, low complexity |
| 97166 | GO | Occupational therapy evaluation, moderate complexity |
| 97167 | GO | Occupational therapy evaluation, high complexity |
| 97168 | GO | Re-evaluation of occupational therapy established plan of care |
| 97550 | GN, GO, GP | Caregiver training in strategies and techniques to facilitate the patient's functional performance in the home or community, initial 30 minutes |
| 97551 | Caregiver training in strategies and techniques to facilitate the patient's functional performance in the home or community, each additional 15 minutes | |
| 97552 | Group caregiver training in strategies and techniques to facilitate the patient's functional performance in the home or community | |
| G2250 | GN | Remote assessment of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related service provided within the previous 7 days nor leading to a service or procedure within the next 24 hours or soonest available appointment |
| G2251 | Brief communication technology-based service, e.g. virtual check-in, by a qualified health care professional who cannot report evaluation and management services, provided to an established patient, not originating from a related service provided within the previous 7 days nor leading to a service or procedure within the next 24 hours or soonest available appointment; 5 – 10 minutes of clinical discussion | |
Occupational Therapy and Physical Therapy | ||
| Code | Required Modifier | Description |
| Unattended Modalities | ||
| 97010 | GP, GO | Hot or cold packs |
| 97012 | Traction | |
| 97014 | Electrical stimulation | |
| 97016 | Vasopneumatic devices | |
| 97018 | Paraffin bath | |
| 97022 | Whirlpool | |
| 97024 | Diathermy | |
| 97026 | Infrared | |
| 97028 | Ultraviolet | |
| G0283 | Electrical stimulation to one or more areas for indication(s) other than wound care, as part of a therapy plan of care – do not bill with 97014 | |
| Attended Modalities: Require Constant Attendance of Therapist | ||
| 95992 | GO, GP | Canalith repositioning procedure(s) (e.g., Epley maneuver, Semont maneuver), per day |
| 97032 | Application of a modality to one or more areas; electrical stimulation – 15 minutes | |
| 97033 | Iontophoresis – 15 minutes | |
| 97034 | Contrast bath – 15 minutes | |
| 97035 | Ultrasound – 15 minutes | |
| 97036 | Hubbard tank – 15 minutes | |
| Therapeutic Techniques with Direct Patient Contact | ||
| 97110 | GO, GP | Therapeutic procedure, exercises – 15 minutes |
| 97112 | Neuromuscular (use for Canalith repositioning) – 15 minutes | |
| 97113 | Aquatic therapy – 15 minutes | |
| 97116 | Gait training – 15 minutes | |
| 97124 | Massage – 15 minutes | |
| 97140 | Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions – 15 minutes | |
| 97530 | Therapeutic activities – 15 minutes | |
| 97532 | Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct patient contact by provider – 15 minutes | |
| 97533 | Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct patient contact by provider – 15 minutes | |
| 97535 | Self-care home management training (e.g., ADL compensatory training, meal preparation, safety procedures, and instructions in use of adaptive equipment) – 15 minutes | |
| 97537 |
| Community work reintegration training (e.g., shopping, transportation, money management, vocational activities) – 15 minutes |
| 97542 | Wheelchair management propulsion training – 15 minutes | |
| Wound Care | ||
| 97597 | GO,GP | Removal of devitalized tissue from wound(s) selective debridement, without anesthesia (e.g., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), with or without topical application(s) for ongoing to 20 square centimeters |
| 97598 | GO, GP | Removal of devitalized tissue from wound(s), selective debridement, without anesthesia (e.g., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), with or without topical application(s), wound assessment, and instruction(s) for ongoing care, may include use of a whirl pool, per session; total wounds(s) surface area greater than 20 square centimeters |
| 97602 | Removal of devitalized tissues from wound(s), non-selective debridement, without anesthesia (e.g., Wet-to-moist dressings, enzymatic, abrasion), including topical application(s), wound assessment, and instruction(s) for ongoing care | |
| 97605 | Negative pressure wound therapy (e.g., vacuum-assisted drainage collection), including topical application(s), wound assessment, and instruction(s), wound assessment, and instruction(s) for ongoing care, per session; total wounds(s) surface area less than or equal to 50 square centimeters | |
| 97606 | Negative pressure wound therapy (e.g., vacuum-assisted drainage collection), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area greater than 50 square centimeters | |
| 97607 |
| Negative pressure wound therapy (e.g., vacuum-assisted drainage collection), utilizing disposable, non-durable medical equipment, including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters |
| 97608 |
| Negative pressure wound therapy (e.g., vacuum-assisted drainage collection), utilizing disposable, non-durable medical equipment, including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session; total wound(s) surface area greater than 50 square centimeters |
| 97610 Service Authorization required |
| Low frequency, non-contact, non-thermal ultrasound, including topical application(s) when performed, wound assessment, and instructions for ongoing care, per day |
| Orthotic/Prosthetic: Assessment and Training | ||
| 97760 | GO, GP | Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(s), lower extremity(s) and/or trunk – 15 minutes |
| 97761 | Prosthetic training, upper and/or lower extremity(s) – 15 minutes | |
| 97763 | Orthotic(s)/prosthetic(s) management and/or training, upper extremity(ies), lower extremity(ies), and/or trunk, subsequent orthotic(s)/prosthetic(s) encounter, each 15 minutes | |
| 97799 | Unlisted physical medicine/rehabilitation service or procedure – Requires a description or claim attachment | |
Evaluative/Therapeutic/Rehabilitative | ||
| Code | Required Modifier | Description |
| 92606 | GN | Therapeutic service(s) for the use of non-speech generating device, including programming and modification |
| 92609 | Therapeutic services for the use of speech-generating device, including programming and modification | |
| 92700 | Unlisted otorhinolaryngological service or procedure: description required | |
| 96125 | GN, GO | Standardized cognitive performance testing (e.g., Ross Information Processing Assessment) per hour of a qualified health care professional’s time, both face-to-face time administering tests to the member and time interpreting these test results and preparing the report |
| 97039 | GO, GP | Unlisted modality – Requires a description or claim attachment; specify type and time if constant attendance |
| 97129 | GN, GO | Therapeutic interventions that focus on cognitive function (e.g., attention, memory, reasoning, executive function, problem solving or pragmatic functioning) and compensatory strategies to manage the performance of an activity (e.g., managing time or schedules, initiating, organizing and sequencing tasks), direct one-on-one patient contact, initial 15 minutes |
| 97130 | GN, GO | Each additional 15 minutes (list separately from primary procedure) |
| 97139 | GO, GP | Unlisted therapeutic procedure – 15 minutes |
| 97150 | Therapeutic procedures group, two or more people | |
| 97545 Not covered through PrimeWest Health | Work hardening/conditioning, initial 2 hours | |
| 97546 Not covered through PrimeWest Health | Work hardening, each additional hour | |
| 97750 Service Authorization required | Physical performance test or measurement (functional capacity) – 15 minutes | |
| 97755 | Assistive technology assessment (e.g., to restore, augment, or compensate for existing function, optimize functional task, and/or maximize environmental accessibility), direct one-to-one contact by provider, with written report, each 15 minutes | |
| 97799 | Unlisted physical medicine/rehabilitation service or procedure – Requires a description or claim attachment | |
| 98975 | GN, GO, GP | Remote therapeutic monitoring (e.g., respiratory system status, musculoskeletal system status, therapy adherence, therapy response); initial set-up and patient education on use of equipment |
| 98976 | Supplying one or more devices for remote therapeutic monitoring for respiratory system status; includes scheduled recording and programmed alert transmission, each 30 days | |
| 98977 | Supplying one or more devices for remote therapeutic monitoring for musculoskeletal system status; includes scheduled recording and programmed alert transmission, each 30 days | |
| 98980 | Treatment management services for remote therapeutic monitoring, such as for respiratory or musculoskeletal system status; first 20 minutes time in a calendar month, includes at least one interactive communication with the patient or caregiver | |
| 98981 | Treatment management services for remote therapeutic monitoring, such as for respiratory or musculoskeletal system status; additional 20 minutes in a calendar month, includes at least one interactive communication with the patient or caregiver (list separately in addition to code for primary procedure) | |
Speech-Language Screening | ||
| Code | Required Modifier | Description |
| V5362 | GN | Speech screening (articulation) |
| V5363 | Language screening (receptive or expressive) | |
| V5364 | Dysphagia screening | |
Casting and Strapping Services/SuppliesThe services listed in this grid do not have an authorization requirement | ||
| Code | Required Modifier | Description |
| 29065 | GO, GP | Application, cast; shoulder to hand (long arm) |
| 29075 | Elbow to finger (short arm) | |
| 29085 | Hand and lower forearm (gauntlet) | |
| 29086 | Finger (e.g., contracture) | |
| 29105 | Application of long arm splint (shoulder to hand) | |
| 29125 | Application of short arm splint (forearm to hand); static | |
| 29126 | Dynamic | |
| 29130 | Application of finger splint; static | |
| 29131 | Dynamic | |
| 29200 | Strapping; thorax | |
| 29240 | Shoulder (e.g., Velpeau) | |
| 29260 | Elbow or wrist | |
| 29280 | Hand or finger | |
| 29345 | Application of long leg cast (thigh to toes) | |
| 29355 | Walker or ambulatory type | |
| 29365 | Application of cylinder cast (thigh to ankle) | |
| 29405 | Application of short leg cast (below knee to toes) | |
| 29425 | Walking or ambulatory type | |
| 29445 | Application of short leg cast (below knee to toes) | |
| 29505 | Application of long leg splint (thigh to ankle or toes) | |
| 29515 | Application of short leg splint (calf to foot) | |
| 29520 | Strapping; hip | |
| 29530 | Knee | |
| 29540 | Ankle and/or foot | |
| 29550 | Toes | |
| 29580 | Unna boot | |
| 29581 | Application of multi-layer venous would compression system, below knee | |
| 29582 | Thigh and leg, including ankle and foot, when performed | |
| 29583 | Upper arm and forearm | |
| 29584 | Upper arm, forearm, hand, and fingers | |
Casting and Splinting SuppliesThere are no requirements for medical authorization of casting or splinting supplies provided by physical therapists and occupational therapists in the course of providing rehabilitative services. | ||
| Code | Required Modifier | Description |
| Q4017 | GP, GO | Cast supplies; long arm splint, adult (11 years+), plaster |
| Q4018 | Long arm splint, adult (11 years+), fiberglass | |
| Q4019 | Long arm splint, pediatric (0 – 10 years), plaster | |
| Q4020 | Long arm splint, pediatric (0 – 10 years), fiberglass | |
| Q4021 | Short arm splint, adult (11 years+), plaster | |
| Q4022 | Short arm splint, adult (11 years+), fiberglass | |
| Q4023 | Short arm splint, pediatric (0 – 10 years), plaster | |
| Q4024 | Short arm splint, pediatric (0 – 10 years), fiberglass | |
| Q4041 | Long leg splint, adult (11 years+), plaster | |
| Q4042 | Long leg splint, adult (11 years+), fiberglass | |
| Q4043 | Long leg splint, pediatric (11 years+), plaster | |
| Q4044 | Long leg splint, pediatric (11 years+), fiberglass | |
| Q4045 | Short leg splint, adult (11 years+), plaster | |
| Q4046 | Short leg splint, adult (11 years+), fiberglass | |
| Q4047 | Short leg splint, pediatric (0 – 10 years), plaster | |
| Q4048 | Short leg splint, pediatric (0 – 10 years), fiberglass | |
| Q4049 | Finger splint, static | |
| Q4051 | Splint supplies, misc. (includes thermoplastics, strapping, fasteners, padding, and other supplies) | |
Orthotic Procedures | ||
| Procedure Code | Description | |
| Orthotic Devices – Cervical-Thoracic-Lumbar-Sacral (CTLSO) | ||
| L0623 | Sacroiliac orthosis, provides pelvic-sacral support, with rigid or semi-rigid panels over the sacrum and abdomen, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, prefabricated, includes fitting and adjustment | |
| Spinal Orthosis | ||
| L0999 | Addition to spinal orthosis, not otherwise specified; requires authorization always | |
| Lower Limb Hip Orthotic (HO), Knee Orthotic (KO), Ankle-Foot Orthotic (AFO) | ||
| L1610 | HO, abduction control of hip joints, flexible, prefabricated, includes fitting and adjustment | |
| L1620 | HO, abduction control of hip joints, flexible, prefabricated, includes fitting and adjustment | |
| L1650 | HO, abduction control of hip joints, static, adjustable, prefabricated, includes fitting and adjustment | |
| L1652 | HO, bilateral thigh cuffs with adjustable abductor spreader bar, adult size, prefabricated, includes fitting and adjustment, any type | |
| L1660 | HO, abduction control of hip joints, static, plastic, prefabricated, includes fitting and adjustment | |
| L1686 | HO, abduction control of hip joint, postoperative hip abduction type, prefabricated, includes fitting and adjustments | |
| L1690 | Combination, bilateral, lumbo-sacral, hip, femur orthosis providing adduction and internal rotation control, prefabricated, includes fitting and adjustment | |
| L1810 | KO, elastic with joints, prefabricated, includes fitting and adjustment | |
| L1820 | KO, elastic with condylar pads and joints, with or without patellar control, prefabricated, includes fitting and adjustment | |
| L1830 | KO, immobilizer, canvas longitudinal, prefabricated, includes fitting and adjustment | |
| L1831 | KO, locking knee joint(s), positional orthosis, prefabricated, includes fitting and adjustment | |
| L1832 | KO, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, includes fitting and adjustment | |
| L1836 | KO, rigid, without joint(s), includes soft interface material, prefabricated, includes fitting and adjustment | |
| L1843 | KO, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, includes fitting and adjustment | |
| L1845 | KO, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, includes fitting and adjustment | |
| L1847 | KO, double upright with adjustable joint, with inflatable air support chamber(s), prefabricated, includes fitting and adjustment | |
| L1850 | KO, Swedish type, prefabricated, includes fitting and adjustment | |
| L1902 | AFO, ankle gauntlet, prefabricated, includes fitting and adjustment | |
| L1906 | AFO, multipligamentus ankle support, prefabricated, includes fitting and adjustment | |
| L1910 | AFO, posterior, single bar, clasp attachment to shoe counter, prefabricated, includes fitting and adjustment | |
| L1930 | AFO, plastic or other material, prefabricated, includes fitting and adjustment | |
| L1932 | AFO, rigid anterior tibial section, total carbon fiber or equal material, prefabricated, includes fitting and adjustment | |
| L1951 | AFO, spiral, plastic or other material, prefabricated, includes fitting and adjustment | |
| L1971 | AFO, plastic or other material with ankle joint, prefabricated, includes fitting and adjustment | |
| L2005 | KAFO, any material, single or double upright, stance control, automatic Lock and swing phase release, mechanical activation, includes ankle joint, any type, custom fabricated | |
| L2035 | KAFO, full plastic, static (pediatric size), without free motion ankle, prefabricated, includes fitting and adjustment | |
| L2112 | AFO, fracture orthosis, tibial fracture orthosis, soft, prefabricated, includes fitting and adjustment | |
| L2114 | AFO, fracture orthosis, tibial fracture orthosis, semi-rigid, prefabricated, includes fitting and adjustment | |
| L2116 | AFO, fracture orthosis, tibial fracture orthosis, rigid, prefabricated, includes fitting and adjustment | |
| L2132 | KAFO, fracture orthosis, femoral fracture cast orthosis, soft, prefabricated, includes fitting and adjustment | |
| L2134 | KAFO, fracture orthosis, femoral fracture cast orthosis, semi-rigid, prefabricated, includes fitting and adjustment | |
| L2136 | KAFO, fracture orthosis, femoral fracture cast orthosis, rigid, prefabricated, includes fitting and adjustment | |
| Upper Limb, Shoulder Orthotic (SO) | ||
| L3650 | SO, figure of 8 design, prefabricated, includes fitting and adjustment | |
| L3660 | SO, figure of 8 design abduction restrainer, canvas and webbing, prefabricated, includes fitting and adjustment | |
| L3670 | SO, acromio/clavicular (canvas and webbing type), prefabricated, includes fitting and adjustment | |
| L3671 | SO, shoulder cap design, without joints, may include soft interface, straps, custom fabricated includes fitting and adjustment | |
| L3674 | SO, abduction positioning (airplane design), thoracic component and support bar, with or without non-torsion joint/turnbuckle, may include soft interface, straps, custom fabricated, includes fitting and adjustment | |
| L3675 | SO, vest type abduction restrainer, canvas webbing type or equal, prefabricated, includes fitting and adjustment | |
| L3677 | SO, hard plastic, should stabilizer, includes fitting and adjustment | |
| Elbow Orthotic (EO) | ||
| L3702 | EO, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment | |
| L3710 | EO, elastic with metal joints, prefab, includes fitting and adjustment | |
| L3720 | EO, double upright with forearm/arm cuffs, extension/flexion assist, custom fabricated | |
| L3730 | EO, double upright with forearm/arm cuffs, extension/flexion assist, custom fabricated | |
| L3740 | EO, double upright with forearm/arm cuffs, adjustable position lock with active control, custom fabricated | |
| L3760 | EO, with adjustable position locking joint(s), prefabricated, includes fitting and adjustments any type | |
| L3762 | EO, rigid, without joints includes soft interface material, prefabricated, includes fitting and adjustment | |
| L3763 | Elbow-wrist-hand orthotic (EWHO), rigid, without joints may include soft interface, straps, custom fabricated, includes fitting and adjustment | |
| L3764 | EWHO, includes one or more non-torsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment | |
| L3765 | Elbow-wrist-hand-finger orthotic (EWHFO), rigid, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment | |
| L3766 | EWHFO, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment | |
| Wrist-Hand-Finger Orthotic (WHFO) | ||
| L3806 | WHRO, includes one of more non-torsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, custom fabricated, includes fitting and adjustment | |
| L3807 | WHFO, without joint(s), prefabricated, includes fitting and adjustments, any type | |
| L3808 | WHFO, rigid without joints, may include soft interface material; straps, custom fabricated includes fitting and adjustment | |
| Dynamic Flexor Hinge, Reciprocal Wrist Extension/Flexion, Finger Flexion/Extension (WHFO) | ||
| L3900 | WHFO, dynamic flexor hinge, reciprocal wrist extension/flexion, finger flexion;/extension, wrist or finger driven, custom fabricated | |
| L3901 | WHFO, dynamic flexor hinge, reciprocal wrist extension/flexion, finger flexion/extension, cable driven, custom fabricated | |
| External Power | ||
| L3904 | WHFO, external powered, electric, custom fabricated | |
| L3905 | Wrist-hand orthotic (WHO), includes one or more non-torsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment | |
| Other – Custom Fitted | ||
| L3906 | WHO, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment | |
| L3908 | WHO, wrist extension control cock-up, nonmolded, prefabricated, includes fitting and adjustment | |
| L3912 | Hand-finger orthotic (HFO), flexion glove with elastic finger control, prefabricated, includes fitting and adjustment | |
| L3913 | HFO, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment | |
| L3915 | WHO, includes one or more non-torsion joints(s), elastic bands, turnbuckles, may include soft interface, straps prefabricated, includes fitting and adjustment | |
| L3917 | Hand orthotic (HO), metacarpal fracture orthotic, prefabricated, includes fitting and adjustment | |
| L3919 | HS, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment | |
| L3921 | HFO, includes one or more non-torsion joints, elastic bands turnbuckles, may include soft interface, straps, custom fabricated includes fitting and adjustment | |
| L3923 | HFO, without joints, may include soft interface, straps, prefabricated, includes fitting and adjustment | |
| L3925 | Finger orthotic (FO), proximal interphalangeal (PIP)/distal interphalangeal (DIP), non-torsion joint/spring, extension/flexion, may include soft interface material, prefabricated, includes fitting and adjustment | |
| L3927 | FO, proximal interphalangeal (PIP)/distal interphalangeal (DIP), without joint/spring, extension/flexion (e.g., static or ring type), may include soft interface material, prefabricated, includes fitting and adjustment | |
| L3929 | HFO, includes one or more non-torsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, prefabricated, includes fitting and adjustment | |
| L3931 | WHFO, includes one or more non-torsion joint(s), turnbuckles, elastic band/springs, may include soft interface material, straps, prefabricated, includes fitting and adjustment | |
| L3933 | FO, without joints, may include soft interface, custom fabricated, includes fitting and adjustment | |
| L3935 | FO, non-torsion joint, may include soft interface, custom fabricated, includes fitting and adjustment | |
| L3956 | Addition of joint to upper extremity orthosis, any material; per joint | |
| Shoulder-Elbow-Wrist-Hand Orthosis (SEWHO) | ||
| L3960 | SEWHO, abduction positioning, airplane design, prefabricated, includes, fitting and adjustment | |
| L3961 | SEWHO, shoulder cap design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment | |
| L3962 | SEWHO, abduction positioning, Erb’s palsy design, prefabricated, includes fitting and adjustment | |
| L3967 | SEWHO, abduction positioning (airplane design), thoracic component and support bar, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment | |
| Additions to Mobile Arm Supports | ||
| L3971 | SEWHO, shoulder cap design, includes one or more non-torsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated includes fitting and adjustment | |
| L3973 | SWEHO, abduction positioning (airplane design), thoracic component and support bar, includes one or more non-torsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment | |
| L3974 | SEO, addition to mobile arm support, supinator | |
| L3975 | SEWHO, shoulder cap design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment | |
| L3976 | SEWHO, abduction positioning (airplane design), thoracic component and support bar, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment | |
| L3977 | SEWHO, shoulder cap design, include one or more non-torsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment | |
| L3978 | SEWHO, abduction positioning (airplane design), thoracic component and support bar, includes one or more non-torsion joints, elastic bands, turnbuckles, may include soft interface straps, custom fabricated, includes fitting and adjustment | |
| Fracture Orthoses | ||
| L3980 | Upper extremity fracture orthotic, humeral, prefabricated, includes fitting and adjustment | |
| L3981 | Upper extremity fracture orthosis, humeral, prefabricated, includes shoulder cap design, with or without joints, forearm section, may include soft interface, straps, includes fitting and adjustments | |
| L3982 | Upper extremity fracture orthotic, radius/ulnar, prefabricated, includes fitting and adjustment | |
| L3984 | Upper extremity fracture orthotic, wrist, prefabricated, includes fitting and adjustment | |
| L3995 | Addition to upper extremity orthotic, sock, fracture or equal, each | |
| L3999 | Upper limb orthosis, not otherwise specified | |
| Specific Repair/Repairs | ||
| L4002 | Replacement strap, any orthotic, includes all components, any length, any type | |
| L4205 | Repair of orthotic device, labor component, per 15 minutes | |
| L4210 | Repair of orthotic device, repair or replace minor parts | |
| L4350 | Ankle control orthosis stirrup style, rigid, includes any type interface (e.g., pneumatic, gel), prefabricated, includes fitting and adjustment | |
| L4360 | Walking boot, pneumatic, and/or vacuum, with or without joints, with or without interface material, prefabricated, includes fitting and adjustment | |
| L4370 | Pneumatic full leg splint, prefabricated, includes fitting and adjustment | |
| L4386 | Walking boot, nonpneumatic, with or without joints, with or without interface material, prefabricated, includes fitting and adjustment | |
| L4392 | Replacement soft interface material, static AFO | |
| L4394 | Replace soft interface material, foot drop splint | |
| L4396 | Static ankle-foot orthosis, including soft interface material, adjustable for fit, for positioning, pressure reduction, may be used for minimal ambulation, prefabricated, includes fitting and adjustment | |
| L4398 | Foot drop splint, recumbent positioning device, prefabricated, includes fitting and adjustment | |
| Additions: Upper Limb | ||
| L6624 | Upper extremity addition, flexion/extension and rotation wrist unit | |
Audiology Service Thresholds | ||
| Code | Description | Threshold |
| 92506 | Evaluation of speech, language, voice, communication, and/or auditory processing |
|
| 92517 | Vestibular evoked myogenic potential testing, with interpretation and report; cervical | |
| 92518 | Vestibular evoked myogenic potential testing, with interpretation and report; ocular | |
| 92519 | Vestibular evoked myogenic potential testing, with interpretation and report; cervical and ocular | |
| 92531 – 92547 | Audiologic function tests | No limit; bill 1 treatment session per test |
| 92550 – 92557 | ||
| 92562 – 92588 | ||
| 92558 | Evoked otoacoustic emissions, screening (qualitative measurement of distortion product or transient evoked otoacoustic emission), automated analysis | |
| 92601 | Diagnostic analysis of cochlear implant, patient under age 7 years; with programming | |
| 92602 | Subsequent reprogramming | |
| 92603 | Diagnostic analysis of cochlear implant, age 7 years or over; with programming | |
| 92604 | Subsequent reprogramming | |
| 92620 | Evaluation of central auditory function, with report; initial 60 minutes |
|
| 92621 | Each additional 15 minutes | |
| 92625 | Assessment of tinnitus (includes pitch, loudness matching, and masking) | |
| 92597 | Evaluation and use and/or fitting of voice prosthetic device to supplement oral speech | |
| 92650 | Auditory evoked potentials; screening of auditory potential with broadband stimuli; automated analysis | |
| 92651 | Auditory evoked potentials; for hearing status determination, broadband stimuli; with interpretation and report | |
| 92652 | Auditory evoked potentials; for threshold estimation at multiple frequencies, interpretation, and report | |
| 92653 | Auditory evoked potentials; neurodiagnostic with interpretation and report | |
| 92700 | Unlisted otorhinolaryngological service or procedure.* | No authorization requirement or threshold for audiology providers. |
| 92592 | Monaural hearing aid check – service includes cleaning; do not bill cleaning separately. Do not bill with V5011. | 4 checks per calendar year; 1 unit maximum per check
Claims with DOS prior to 90 days following the dispensing date will deny. May not be billed during trial period. |
| 92593 | Binaural hearing aid check – service includes cleaning; do not bill cleaning separately. Do not bill with V5011. | |
| 92590 | Monaural hearing aid exam and selection | 1 treatment session per calendar year, any combination of codes |
| 92591 | Binaural hearing aid exam and selection | |
| 92594 | Electroacoustic evaluation for monaural hearing aid | |
| 92595 | Electroacoustic evaluation for binaural hearing aid | |
| 92596 | Ear protector attenuation measurement | |
| 92510 | Aural rehabilitation following cochlear implant | Counts toward SLP 80 treatment session service threshold |
*Each modality equals one treatment session.
PW_11-19_588
Updated_09/20/2024
