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L4000 |
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Replace girdle for spinal orthosis (ctlso or so)
| short | Repl girdle milwaukee orth |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
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L4002 |
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Replacement strap, any orthosis, includes all components, any length, any type
| short | Replace strap, any orthosis |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 4.0 | 3 Date of Service Edit: Clinical | Clinical: Data | | DME | 8.0 | 3 Date of Service Edit: Clinical | Clinical: Data |
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L4010 |
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Replace trilateral socket brim
| short | Replace trilateral socket br |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
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L4020 |
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Replace quadrilateral socket brim, molded to patient model
| short | Replace quadlat socket brim |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
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L4030 |
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Replace quadrilateral socket brim, custom fitted
| short | Replace socket brim cust fit |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
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L4040 |
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Replace molded thigh lacer, for custom fabricated orthosis only
| short | Replace molded thigh lacer |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
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L4045 |
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Replace non-molded thigh lacer, for custom fabricated orthosis only
| short | Replace non-molded thigh lac |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
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L4050 |
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Replace molded calf lacer, for custom fabricated orthosis only
| short | Replace molded calf lacer |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
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L4055 |
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Replace non-molded calf lacer, for custom fabricated orthosis only
| short | Replace non-molded calf lace |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
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L4060 |
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Replace high roll cuff
| short | Replace high roll cuff |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
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L4070 |
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Replace proximal and distal upright for kafo
| short | Replace prox & dist upright |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 2.0 | 3 Date of Service Edit: Clinical | Anatomic Consideration | | DME | 2.0 | 3 Date of Service Edit: Clinical | Clinical: Data |
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L4080 |
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Replace metal bands kafo, proximal thigh
| short | Repl met band kafo-afo prox |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
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L4090 |
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Replace metal bands kafo-afo, calf or distal thigh
| short | Repl met band kafo-afo calf/ |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 4.0 | 2 Date of Service Edit: Policy | Clinical: CMS Workgroup | | DME | 4.0 | 2 Date of Service Edit: Policy | Clinical: Data |
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L4100 |
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Replace leather cuff kafo, proximal thigh
| short | Repl leath cuff kafo prox th |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
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L4110 |
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Replace leather cuff kafo-afo, calf or distal thigh
| short | Repl leath cuff kafo-afo cal |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 4.0 | 2 Date of Service Edit: Policy | Clinical: CMS Workgroup | | DME | 4.0 | 2 Date of Service Edit: Policy | Clinical: Data |
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L4130 |
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Replace pretibial shell
| short | Replace pretibial shell |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
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L4205 |
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Repair of orthotic device, labor component, per 15 minutes
| short | Ortho dvc repair per 15 min |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 8.0 | 3 Date of Service Edit: Clinical | Clinical: Data | | DME | 8.0 | 3 Date of Service Edit: Clinical | Clinical: Data |
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L4210 |
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Repair of orthotic device, repair or replace minor parts
| short | Orth dev repair/repl minor p |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 4.0 | 3 Date of Service Edit: Clinical | Clinical: Data | | DME | 4.0 | 3 Date of Service Edit: Clinical | Clinical: Data |
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