| L1 |
Separately payable lab test |
Provider attestation that the hospital laboratory test(s) is not packaged under the hospital opps |
| L1000 |
Ctlso milwauke initial model |
Cervical-thoracic-lumbar-sacral orthosis (ctlso) (milwaukee), inclusive of furnishing initial orthosis, including model |
| L1001 |
Ctlso infant immobilizer |
Cervical thoracic lumbar sacral orthosis, immobilizer, infant size, prefabricated, includes fitting and adjustment |
| L1005 |
Tension based scoliosis orth |
Tension based scoliosis orthosis and accessory pads, includes fitting and adjustment |
| L1010 |
Ctlso axilla sling |
Addition to cervical-thoracic-lumbar-sacral orthosis (ctlso) or scoliosis orthosis, axilla sling |
| L1020 |
Kyphosis pad |
Addition to ctlso or scoliosis orthosis, kyphosis pad |
| L1025 |
Kyphosis pad floating |
Addition to ctlso or scoliosis orthosis, kyphosis pad, floating |
| L1030 |
Lumbar bolster pad |
Addition to ctlso or scoliosis orthosis, lumbar bolster pad |
| L1040 |
Lumbar or lumbar rib pad |
Addition to ctlso or scoliosis orthosis, lumbar or lumbar rib pad |
| L1050 |
Sternal pad |
Addition to ctlso or scoliosis orthosis, sternal pad |
| L1060 |
Thoracic pad |
Addition to ctlso or scoliosis orthosis, thoracic pad |
| L1070 |
Trapezius sling |
Addition to ctlso or scoliosis orthosis, trapezius sling |
| L1080 |
Outrigger |
Addition to ctlso or scoliosis orthosis, outrigger |
| L1085 |
Outrigger bil w/ vert extens |
Addition to ctlso or scoliosis orthosis, outrigger, bilateral with vertical extensions |
| L1090 |
Lumbar sling |
Addition to ctlso or scoliosis orthosis, lumbar sling |
| L1100 |
Ring flange plastic/leather |
Addition to ctlso or scoliosis orthosis, ring flange, plastic or leather |
| L1110 |
Ring flange plas/leather mol |
Addition to ctlso or scoliosis orthosis, ring flange, plastic or leather, molded to patient model |
| L1120 |
Covers for upright each |
Addition to ctlso, scoliosis orthosis, cover for upright, each |
| L1200 |
Furnsh initial orthosis only |
Thoracic-lumbar-sacral-orthosis (tlso), inclusive of furnishing initial orthosis only |
| L1210 |
Lateral thoracic extension |
Addition to tlso, (low profile), lateral thoracic extension |
| L1220 |
Anterior thoracic extension |
Addition to tlso, (low profile), anterior thoracic extension |
| L1230 |
Milwaukee type superstructur |
Addition to tlso, (low profile), milwaukee type superstructure |
| L1240 |
Lumbar derotation pad |
Addition to tlso, (low profile), lumbar derotation pad |
| L1250 |
Anterior asis pad |
Addition to tlso, (low profile), anterior asis pad |
| L1260 |
Anterior thoracic derotation |
Addition to tlso, (low profile), anterior thoracic derotation pad |
| L1270 |
Abdominal pad |
Addition to tlso, (low profile), abdominal pad |
| L1280 |
Rib gusset (elastic) each |
Addition to tlso, (low profile), rib gusset (elastic), each |
| L1290 |
Lateral trochanteric pad |
Addition to tlso, (low profile), lateral trochanteric pad |
| L1300 |
Body jacket mold to patient |
Other scoliosis procedure, body jacket molded to patient model |
| L1310 |
Post-operative body jacket |
Other scoliosis procedure, post-operative body jacket |
| L1320 |
Pectus carinatum ortho cust |
Thoracic, pectus carinatum orthosis, sternal compression, rigid circumferential frame with anterior and posterior rigid pads, custom fabricated |
| L1499 |
Spinal orthosis nos |
Spinal orthosis, not otherwise specified |
| L1600 |
Ho flex frejka w/cov pre cst |
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 |
| L1610 |
Ho frejka cov only pre cst |
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 |
| L1620 |
Ho flex pavlik harns pre cst |
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 |
| L1630 |
Abduct control hip semi-flex |
Hip orthosis, abduction control of hip joints, semi-flexible (von rosen type), custom fabricated |
| L1640 |
Pelv band/spread bar thigh c |
Hip orthosis, abduction control of hip joints, static, pelvic band or spreader bar, thigh cuffs, custom fabricated |
| L1650 |
Ho abduction hip adjustable |
Hip orthosis, abduction control of hip joints, static, adjustable, (ilfled type), prefabricated, includes fitting and adjustment |
| L1652 |
Ho bi thighcuffs w sprdr bar |
Hip orthosis, bilateral thigh cuffs with adjustable abductor spreader bar, adult size, prefabricated, includes fitting and adjustment, any type |
| L1660 |
Ho abduction static plastic |
Hip orthosis, abduction control of hip joints, static, plastic, prefabricated, includes fitting and adjustment |
| L1680 |
Pelvic & hip control thigh c |
Hip orthosis, abduction control of hip joints, dynamic, pelvic control, adjustable hip motion control, thigh cuffs (rancho hip action type), custom fabricated |
| L1681 |
Ho bilateral hip abduction |
Hip orthosis, bilateral hip joints and thigh cuffs, adjustable flexion, extension, abduction control of hip joint, postoperative hip abduction type, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise |
| L1685 |
Post-op hip abduct custom fa |
Hip orthosis, abduction control of hip joint, postoperative hip abduction type, custom fabricated |
| L1686 |
Ho post-op hip abduction |
Hip orthosis, abduction control of hip joint, postoperative hip abduction type, prefabricated, includes fitting and adjustment |
| L1690 |
Combination bilateral ho |
Combination, bilateral, lumbo-sacral, hip, femur orthosis providing adduction and internal rotation control, prefabricated, includes fitting and adjustment |
| L1700 |
Leg perthes orth toronto typ |
Legg perthes orthosis, (toronto type), custom fabricated |
| L1710 |
Legg perthes orth newington |
Legg perthes orthosis, (newington type), custom fabricated |
| L1720 |
Legg perthes orthosis trilat |
Legg perthes orthosis, trilateral, (tachdijan type), custom fabricated |
| L1730 |
Legg perthes orth scottish r |
Legg perthes orthosis, (scottish rite type), custom fabricated |
| L1755 |
Legg perthes patten bottom t |
Legg perthes orthosis, (patten bottom type), custom fabricated |
| L1810 |
Ko elastic with joints |
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 |
| L1812 |
Ko elastic w/joints pre ots |
Knee orthosis, elastic with joints, prefabricated, off-the-shelf |
| L1820 |
Ko elas w/ condyle pads & jo |
Knee orthosis, elastic with condylar pads and joints, with or without patellar control, prefabricated, includes fitting and adjustment |
| L1830 |
Ko immob canvas long pre ots |
Knee orthosis, immobilizer, canvas longitudinal, prefabricated, off-the-shelf |
| L1831 |
Knee orth pos locking joint |
Knee orthosis, locking knee joint(s), positional orthosis, prefabricated, includes fitting and adjustment |
| L1832 |
Ko adj jnt pos r sup pre cst |
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 |
| L1833 |
Ko adj jnt pos r sup pre ots |
Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the shelf |
| L1834 |
Ko w/0 joint rigid molded to |
Knee orthosis, without knee joint, rigid, custom fabricated |
| L1836 |
Ko rigid w/o joints pre ots |
Knee orthosis, rigid, without joint(s), includes soft interface material, prefabricated, off-the-shelf |
| L1840 |
Ko derot ant cruciate custom |
Knee orthosis, derotation, medial-lateral, anterior cruciate ligament, custom fabricated |
| L1843 |
Ko single upright pre cst |
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, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise |
| L1844 |
Ko w/adj jt rot cntrl molded |
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 |
| L1845 |
Ko double upright pre cst |
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, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise |
| L1846 |
Ko w adj flex/ext rotat mold |
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 |
| L1847 |
Ko dbl upright w/air pre cst |
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 |
| L1848 |
Ko dbl upright w/air pre ots |
Knee orthosis, double upright with adjustable joint, with inflatable air support chamber(s), prefabricated, off-the-shelf |
| L1850 |
Ko swedish type pre ots |
Knee orthosis, swedish type, prefabricated, off-the-shelf |
| L1851 |
Ko single upright prefab ots |
Knee orthosis (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, off-the-shelf |
| L1852 |
Ko double upright prefab ots |
Knee orthosis (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, off-the-shelf |
| L1860 |
Ko supracondylar socket mold |
Knee orthosis, modification of supracondylar prosthetic socket, custom fabricated (sk) |
| L1900 |
Afo sprng wir drsflx calf bd |
Ankle foot orthosis, spring wire, dorsiflexion assist calf band, custom fabricated |
| L1902 |
Afo ankle gauntlet pre ots |
Ankle orthosis, ankle gauntlet or similar, with or without joints, prefabricated, off-the-shelf |
| L1904 |
Afo molded ankle gauntlet |
Ankle orthosis, ankle gauntlet or similar, with or without joints, custom fabricated |
| L1906 |
Afo multilig ank sup pre ots |
Ankle foot orthosis, multiligamentous ankle support, prefabricated, off-the-shelf |
| L1907 |
Afo supramalleolar custom |
Ankle orthosis, supramalleolar with straps, with or without interface/pads, custom fabricated |
| L1910 |
Afo sing bar clasp attach sh |
Ankle foot orthosis, posterior, single bar, clasp attachment to shoe counter, prefabricated, includes fitting and adjustment |
| L1920 |
Afo sing upright w/ adjust s |
Ankle foot orthosis, single upright with static or adjustable stop (phelps or perlstein type), custom fabricated |
| L1930 |
Afo plastic |
Ankle foot orthosis, plastic or other material, prefabricated, includes fitting and adjustment |
| L1932 |
Afo rig ant tib prefab tcf/= |
Afo, rigid anterior tibial section, total carbon fiber or equal material, prefabricated, includes fitting and adjustment |
| L1940 |
Afo molded to patient plasti |
Ankle foot orthosis, plastic or other material, custom fabricated |
| L1945 |
Afo molded plas rig ant tib |
Ankle foot orthosis, plastic, rigid anterior tibial section (floor reaction), custom fabricated |
| L1950 |
Afo spiral molded to pt plas |
Ankle foot orthosis, spiral, (institute of rehabilitative medicine type), plastic, custom fabricated |
| L1951 |
Afo spiral prefabricated |
Ankle foot orthosis, spiral, (institute of rehabilitative medicine type), plastic or other material, prefabricated, includes fitting and adjustment |
| L1960 |
Afo pos solid ank plastic mo |
Ankle foot orthosis, posterior solid ankle, plastic, custom fabricated |
| L1970 |
Afo plastic molded w/ankle j |
Ankle foot orthosis, plastic with ankle joint, custom fabricated |
| L1971 |
Afo w/ankle joint, prefab |
Ankle foot orthosis, plastic or other material with ankle joint, prefabricated, includes fitting and adjustment |
| L1980 |
Afo sing solid stirrup calf |
Ankle foot orthosis, single upright free plantar dorsiflexion, solid stirrup, calf band/cuff (single bar 'bk' orthosis), custom fabricated |
| L1990 |
Afo doub solid stirrup calf |
Ankle foot orthosis, double upright free plantar dorsiflexion, solid stirrup, calf band/cuff (double bar 'bk' orthosis), custom fabricated |
