Commonwealth of Massachusetts
Executive Office of Health and Human Services
Division of Medical Assistance
600 Washington Street Boston, MA 02111 www.mass.gov/dma

MASSHEALTH
TRANSMITTAL LETTER ORT-14
November 2002
TO:      Orthotic Providers Participating in MassHealth
FROM:      Wendy E. Warring, Commissioner
RE:      Orthotics Manual (Revised Regulations, Subchapter 6, and Shoe Prescription Form)
Revised Regulations
The Division has revised its orthotics regulations at 130 CMR 442.000 to add several definitions, include more specific coverage restrictions, update the payment methodology, and establish that the Division pays for podiatry services only when the member’s primary care physician certifies on letterhead these such services are medically necessary for the life and safety of the member. Prescriptions from podiatrists for any orthotic or pedorthic equipment must be accompanied by a copy of this letter from the member’s primary care physician. The regulations have also been generally revised and reorganized to conform to the Division’s current editorial style and format. This letter transmits these revised regulations, which are effective November 22, 2002.
Revised Subchapter 6 (Service Codes and Descriptions)
This letter also transmits changes for Subchapter 6 of your provider manual that contain the new and revised service codes. These codes are effective for services provided on or after June 1, 2002. We will accept either the new or the old codes for dates of service through December 31, 2002. For dates of service on or after January 1, 2003, you must use the new codes in order to obtain payment.
If you wish to obtain a fee schedule, you may purchase Division of Health Care Finance and Policy regulations from either the Massachusetts State Bookstore or from the Division of Health Care Finance and Policy (see addresses and telephone numbers below). You must contact them first to find out the price of the publication. The Division of Health Care Finance and Policy also has the regulations available on disk. The regulation title for orthotic and prosthetic services is 114 CMR 34.00.

Massachusetts State Bookstore State House, Room 116 Boston, MA 02133 Telephone: 617-727-2834

Division of Health Care Finance and Policy Two Boylston Street Boston, MA 02116 Telephone: 617-988-3100

The rates listed in the fee schedule apply to claims with dates of service on or after June 1, 2002. If you have been paid the incorrect rate for a service, you may submit an adjustment claim according to the billing instructions listed in Subchapter 5 of your provider manual.

MASSHEALTH
TRANSMITTAL LETTER ORT-14 November 2002 Page 2
Revised Shoe Medical Necessity Form
The Division has also revised its Shoe Medical Necessity Form, which must be completed for all claims for shoes by both the provider and the prescriber. Providers should begin using this new Shoe Medical Necessity Form immediately; however, the Division will accept either form for claims with dates of service before January 1, 2003. A sample of this revised form is attached to this letter. Orthotics providers may photocopy these forms or request supplies of this form from the following address:
MassHealth
Forms Distribution Center P.O. Box 9101 Somerville, MA 02145
When requesting forms, include the MassHealth provider number, address (no post office boxes), name and telephone number of contact person, name of form, and quantity requested. If you choose to photocopy the form, remember to copy both sides of the form.
Changes in Billing Procedures
The rest of this transmittal letter describes specific changes in the billing procedures that are effective for dates of service on or after January 1, 2003.
•	The following codes require individual consideration. Providers must attach an invoice to
the claim form when billing with any of the following codes.
 ♦	L3201 through L3265
 ♦	L5000
•	The Division is clarifying its policy and billing instructions regarding place of service. Subject
to the limitations specified in the regulations, orthotic and prosthetic providers may only bill
for services provided to members residing at home, in a nursing facility, or in a rest home.
For the purposes of this policy, an intermediate care facility for the mentally retarded is the
member's home. When completing Item 15 of claim no. 9, providers should only use one of
the following place-of-service codes.
 ♦	02 - member's home (including intermediate care facilities for the mentally retarded)
 ♦	06 - nursing facility
 ♦	07 - rest home
Please disregard the instructions for Item 15 in the current billing instructions appearing in Subchapter 5 of your provider manual. The Division will reissue updated billing instructions at a later date.
•	All claims for orthotic and pedorthic services, except for labor (L4205), must contain a
diagnosis name in Item 22, and an ICD-9-CM diagnosis code in Item 23, of claim form no. 9.

MASSHEALTH
TRANSMITTAL LETTER ORT-14 November 2002 Page 3

All orthotic codes, except those listed below, must include modifier LT (left), RT (right), or LTRT (left and right /bilateral).

L0100 through L0950	♦ L2040	
L0970 through L0976	♦ L2050	
L0985 through L0986	♦ L2060	
L1000 through L1310	♦ L2070	
L1500 through L1710	♦ L2190	
L1730	♦ L4205	
L1750	♦ L4210	

NEW MATERIAL
(The pages listed here contain new or revised language.)
Orthotics Manual
Pages iv, vi, 4-1 through 4-12, and 6-1 through 6-24
OBSOLETE MATERIAL
(The pages listed here are no longer in effect.)
Orthotics Manual
Pages iv, vi, vi-a, 4-1 through 4-10, and 6-1 through 6-24 — transmitted by Transmittal Letter ORT-13

Commonwealth of Massachusetts • Executive Office of Health and Human Services • Division of Medical Assistance

■assHea

Shoe Medical Necessity Form

To the shoe provider:2 You must attach a completed Shoe Medical Necessity Form to all claims for shoes and shoe accessories. Claims with incomplete or missing forms will be denied. Please fill out Sections 1 and 2 of this form, and submit it with your written foot evaluation to the prescriber.
To the prescriber:2 Please review the shoe provider’s written foot evaluation, complete Section 3 of this form, and return the completed form to the shoe provider. Important: Please keep a copy of the completed form and foot evaluation in the member’s medical record.

Section 1: Member Information
Member name:

MassHealth ID no.:

Address:
SECTION 2 MUST BE COMPLETED BY THE SHOE PROVIDER.

Section 2: Shoe Provider.
Shoe provider name:
Address:

Tel. no.: Provider no.:

Describe the shoes and shoe accessories to be prepared for this member:
Complete the following for each shoe and shoe accessory:

Manufacturer’s name	Manufacturer’s model number	Supplier’s submitted charge	Supplier’s invoice charge	MassHealth service code	

					

					
					
I certify that the information I have completed on this form is true, accurate, and complete. I further certify that I have chosen the least costly method to provide medically necessary1 shoes and shoe accessories. I understand that any falsification, omission, or concealment of material fact on this form may subject me to civil or criminal liability. ( 1 See 130 CMR 450.204. )

Shoe provider’s signature:

Date:

ORT-1 (Rev. 11/02)

continued   ►

SECTION 3 MUST BE COMPLETED AND SIGNED BY THE PRESCRIBER.

Section 3: Prescription.
Prescriber’s name:

Tel. no.:

Address:

Provider no.:

Primary diagnosis:
Secondary diagnosis (Enter n/a if not related to items requested.):

I currently treat this patient for: □ Primary diagnosis □ Secondary diagnosis □ Both The following items are medically necessary.
D Shoes
□ right foot	□ left foot	□ both feet	
□ right foot	□ left foot	□ both feet	
□ right foot	□ left foot	□ both feet	
□ right foot	□ left foot	□ both feet	
□ right foot	□ left foot	□ both feet	
□ right foot	□ left foot	□ both feet	
□ right foot	□ left foot	□ both feet	
□ right foot	□ left foot	□ both feet	
□ right foot
:	□ left foot	□ both feet	
□ right foot	□ left foot	□ both feet	
□ right foot	□ left foot	□ both feet	
□ right foot	□ left foot	□ both feet	
□ right foot	□ left foot	□ both feet	
□ right foot
:	□ left foot	□ both feet	
 □	Off-the-shelf moldable shoes
 □	Off-the-shelf medical-grade oxford shoes
 □	Off-the-shelf medical-grade oxford shoes, depth or hightop
 □	Off-the-shelf surgical boots
 □	Custom-molded shoes
 □	Other (Specify — use attachment if necessary.):
D Internal Shoe Modifications
 □	Insert, customized
 □	Insert, molded to foot
 □	Arch support
 □	Lift inside shoes
 □	Other (Specify — use attachment if necessary.):
D External Shoe Modifications
 □	Sole or heel wedge
 □	Sole or heel
 □	Rigid rocker bottom
 □	Roller bottom
 □	Lift outside shoes
 □	Other (Specify — use attachment if necessary.):
I certify that I am the treating prescriber identified on this form, and that I have reviewed the description of service and cost (Section 2), which has been certified by the shoe provider. I attest that the items described in Section 2 of this form fulfill the requirements of my prescription. Any attached statement on my letterhead has been reviewed and signed by me. I certify that the information on this form, specifically including medical- necessity1 information, is true, accurate, and complete. I understand that any falsification, omission, or concealment of material fact on this form may subject me to civil or criminal liability. (1 See 130 CMR 450.204.)

Prescriber’s signature and credentials (MD, N P, DO, or DPM):

Date:

(Signature and date stamps are not acceptable.)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ORTHOTICS MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 442.000)	PAGE
4-1	

	TRANSMITTAL LETTER
ORT-14	DATE
11/22/02	
442.401:  Introduction
130 CMR 442.000 states the requirements and procedures for the purchase and repair of orthotic and pedorthic devices, customized equipment, and supplies under MassHealth. All providers of orthotic and pedorthic services participating in MassHealth must comply with the regulations of the Division governing MassHealth, including, but not limited to, Division regulations set forth in 130 CMR 442.000 and in 130 CMR 450.000.
442.402:  Definitions
The following terms used in 130 CMR 442.000 have the meanings given in 130 CMR 442.402 unless the context clearly requires a different meaning. The reimbursability of services defined in 130 CMR 442.000 is not determined by these definitions, but by application of regulations elsewhere in 130 CMR 442.000 and in 130 CMR 450.000.
Accessory Equipment — equipment that is fabricated primarily and customarily to modify or enhance the usefulness or functional capability of another piece of orthotic or pedorthic equipment and that is generally not useful in the absence of such orthotic or pedorthic equipment.
Adjusted Acquisition Cost — except where the manufacturer is the provider, the price paid by the provider to the manufacturer or any other supplier for orthotic or pedorthic devices, customized equipment, or supplies, excluding all associated costs such as shipping, handling, and insurance costs in accordance with 130 CMR 442.422. Where the manufacturer is the provider, the adjusted acquisition cost is the actual cost of manufacturing such orthotic or pedorthic devices, customized equipment, or supplies.
Custom-Molded Shoe — an individually patterned shoe fabricated to meet the specific needs of an individual. A custom-molded shoe is not off-the-shelf, stock, or prefabricated. The shoe is individually constructed by a molded process over a modified positive model of the individual’s foot. It is made of leather or other suitable material of equal quality, has removable customized inserts that can be replaced if necessary according to the individual’s condition, and has some form of shoe closure.
Date of Service — the date the orthotic or pedorthic device is delivered and fitted to the MassHealth member. If the orthotic or pedorthic service involves a series of fittings and adjustments, the date of service is the date on which the final adjustment is made. If the orthotic or pedorthic service involves only the provision of a service (for example, a repair), then the date of service is the date on which the service was completed.
Diabetic Shoes — therapeutic footwear prescribed to prevent or alleviate painful or disabling conditions associated with diabetes by minimizing pressure on the foot.
Discount — any remuneration or reduction of payment of any kind, whether direct or indirect, received by the provider.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ORTHOTICS MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 442.000)	PAGE
4-2	

	TRANSMITTAL LETTER
ORT-14	DATE
11/22/02	
Last — a model that approximates the shape and size of the foot and over which a shoe is made. A last is usually made of wood, plastic, or plaster.
Moldable Shoe — an off-the shelf, ready-made shoe formed from heat-activated materials. The shoe is molded by a thermo-forming process that first heats the material, then forms it over an individual’s foot or a positive model of the individual’s foot.
Nonstandard Size (Width or Length) — a shoe size made on a standard last pattern, but which is not part of a manufacturer’s regular inventory.
Nursing Facility — a licensed facility that meets the provider-eligibility and certification requirements of 130 CMR 456.404 or 456.405 and whose members meet the medical eligibility criteria under 130 CMR 456.409. Nursing facilities do not include custodial care facilities such as rest homes, state schools, and state hospitals.
Nursing Facility Visit — a visit by a provider to a nursing facility for the purpose of providing orthotic and pedorthic services.
Off-the-Shelf Shoe — a shoe that is made on a standard last and is a regular part of a manufacturer’s or provider’s inventory.
Orthopedic Shoes — shoes that are specially constructed to aid in the correction of a deformity of the musculoskeletal structure of the foot and to preserve or restore the function of the musculoskeletal system of the foot.
Orthosis (or Orthotic Equipment) — a mechanical device that:
 (1)	is fabricated primarily and customarily to support or correct a defect of form or function of the human body;
 (2)	can withstand repeated use over time; and
 (3)	is appropriate for home use.
Orthotic Service — the purchase, customization, fitting, repair, replacement, or adjustment of an orthosis or component part, or other activity performed or equipment provided in accordance with 130 CMR 442.000.
Orthotic Supplies — products that are:
 (1)	fabricated primarily and customarily to fulfill a medical or surgical purpose;
 (2)	used in conjunction with an orthosis or orthotic equipment;
 (3)	generally not useful in the absence of an orthosis; and
 (4)	non-reusable and disposable.
Orthotics — the design and application of external appliances to support a paralyzed muscle, promote a specific motion, or correct musculoskeletal deformities.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ORTHOTICS MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 442.000)	PAGE
4-3	

	TRANSMITTAL LETTER
ORT-14	DATE
11/22/02	
Pedorthic Service — the design, manufacture, modification, and fitting of orthopedic or diabetic shoes, including foot orthosis, prosthetic fillers, and orthotic or pedorthic appliances for use from the ankle and below, provided in accordance with 130 CMR 442.000.
Service Facility — the place of business physically accessible to MassHealth members where orthotic or pedorthic services, especially those involving fitting, adjustment, repair, and replacement of orthoses, are performed. A service facility does not include a MassHealth member’s place of residence.
Split-Size Charge — an additional charge for dispensing an off-the-shelf, medical-grade pair of orthopedic shoes, where one shoe in the pair is a different size or width than the other shoe in the pair.
442.403: Eligible Members
(A)	(1) MassHealth Members. The Division covers orthotic and pedorthic services only when
provided to eligible MassHealth members, subject to the restrictions and limitations in the
Division’s regulations. 130 CMR 450.105 specifically states, for each coverage type, which
services are covered and which members are eligible to receive those services.
(2) Recipients of the Emergency Aid to the Elderly, Disabled and Children Program. For
information on covered services for recipients of the Emergency Aid to the Elderly, Disabled
and Children Program, see 130 CMR 450.106.
(B)	For information on verifying member eligibility and coverage type, see 130 CMR 450.107.
442.404:  Provider Eligibility
For services described in 130 CMR 442.000 the Division pays only those providers of orthotic and pedorthic services who are participating in MassHealth as of the date of service.
(A) In State. To participate in MassHealth, a provider with a service facility in Massachusetts must:
 (1)	(a) primarily engage in the business of providing orthotic, pedorthic, and repair services to the public; and (b) meet all state and local requirements for engaging in such business;
 (2)	(a) for orthotic providers, be or employ an orthotist currently certified by the American Board for Certification in Orthotics and Prosthetics, Inc. or the Board for Orthotics/ Prosthetics Certification; or
(b) for pedorthic providers, be or employ a pedorthist currently certified by the Board for Certification in Pedorthics;
 (3)	be a Medicare provider;
 (4)	have a service facility that is physically accessible to MassHealth members during reasonable business hours;
 (5)	maintain a visible sign identifying the business and hours of operation; and
 (6)	maintain a primary business telephone listed under the name of the business in a local directory. The exclusive use of a pager, answering machine, or cell phone is prohibited.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ORTHOTICS MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 442.000)	PAGE
4-4	

	TRANSMITTAL LETTER
ORT-14	DATE
11/22/02	
(B) Out of State. A provider with no service facility in Massachusetts may participate in MassHealth only if the provider participates in the medical assistance program of the state in which the provider primarily conducts business and otherwise meets the requirements of 130 CMR 442.404(A). Such a provider may receive payment for MassHealth services only as set forth in 130 CMR 450.109.
442.405: Provider Responsibility
(A)	The provider must ensure that all orthotic and pedorthic equipment and supplies are:
 (1)	clean (sterilized when appropriate);
 (2)	in proper working condition;
 (3)	functional;
 (4)	free from defects; and
 (5)	new and unused at the time of purchase. .

 (B)	The provider must ensure that all orthotic and pedorthic services are the most cost effective, given the medical need for which they are prescribed and the member's physical limitations.
 (C)	The provider must make a reasonable effort to purchase the item from the least costly reliable source by comparing prices charged by different suppliers for comparable items.
442.406:  Covered Services
The Division pays for only those orthotic and pedorthic services listed in Subchapter 6 of the Orthotics Manual.
442.407: Service Limitations
(A) Nonstandard Size. A provider may bill an additional charge for a nonstandard size for off-the-shelf, medical-grade orthopedic shoes once per pair.
(B) Split-Size Charge. A provider may bill a split-size charge for off-the-shelf, medical-grade orthopedic shoes once per pair.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ORTHOTICS MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 442.000)	PAGE
4-5	

	TRANSMITTAL LETTER
ORT-14	DATE
11/22/02	
(C)	Shoe Maximum. A member is not entitled to more than two pairs of shoes during a 12-month
period, unless the attending physician or nurse practitioner submits documentation that the
member's physical condition has changed. The shoe provider must make diligent efforts to ensure
that the member has not already received the maximum number of shoes allowed from another
provider within the previous 12 months. Diligent efforts include but are not limited to:
 (1)	asking the member and the prescriber if the member has received shoes from another shoe provider within the previous 12 months; and
 (2)	reviewing the provider’s own records to determine whether the member has already received the maximum number of shoes allowed.
(D)	Closure Modification. When a manufacturer offers an off-the-shelf shoe that comes standard
with either lace or velcro closures, the provider must choose the appropriate shoe to meet the
member’s needs, and not bill separately for closure modification.
(E)	Custom-Shoe Inserts. When a manufacturer offers a customized shoe that includes the insert,
the provider must not bill separately for the insert.
442.408: Noncovered Services
The Division does not pay for any of the following:
 (A)	any orthotic or pedorthic services for which, under comparable circumstances, the provider does not customarily bill private patients who do not have health insurance;
 (B)	nonmedical orthotic or pedorthic services. Equipment that is used primarily and customarily for a nonmedical purpose is not considered medical equipment, even if such equipment has a medically related use;
 (C)	storage of orthotic or pedorthic equipment or associated items;
 (D)	sneakers or athletic shoes;
(E)	an additional charge for nonstandard size (width or length) in custom-molded shoes;
(F)	shoes when there is no diagnosis of associated foot deformities; and
(G)	orthotic or pedorthic services that are not both medically necessary in accordance with
130 CMR 450.204 and reasonable for the treatment of a member's condition. This includes
services that:
 (1)	cannot reasonably be expected to make a meaningful contribution to the treatment of a member's condition or the performance of the member's activities of daily living; and
 (2)	are more costly than a medically comparable and suitable alternative or that serve essentially the same purpose as equipment already available to the member.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ORTHOTICS MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 442.000)	PAGE
4-6	

	TRANSMITTAL LETTER
ORT-14	DATE
11/22/02	
442.409:  Prescription Requirements
(A)	The purchase of orthotic or pedorthic equipment requires a written prescription signed by a
licensed physician, a licensed podiatrist, or an independent nurse practitioner.
(1)	For orthotic equipment other than shoes, the prescriber must write the prescription on the
prescriber’s prescription form and must include the following information:
 (a)	the member's name and address;
 (b)	the member’s MassHealth identification number;
 (c)	specific identification of the prescribed item;
 (d)	medical justification for the use of the item, including the member’s diagnosis;
 (e)	the prescriber's address and telephone number; and
 (f)	the date on which the prescription was signed by the prescriber.
(2)	For shoes, providers must submit with their claim a copy of the completed shoe
prescription form designated by the Division.
 (B)	The Division pays for podiatry services only when the member’s primary care physician certifies on letterhead that such services are medically necessary for the life and safety of the member. Prescriptions from podiatrists for any orthotic or pedorthic equipment must be accompanied by a copy of such a letter from the member’s primary care physician.
 (C)	The provider must keep the prescription on file for the period of time required by 130 CMR 450.205.
442.410: Orthotic and Pedorthic Services and Equipment Provided to Institutionalized Members
(A)	Nursing Facilities. The Division pays orthotic and pedorthic providers for:
 (1)	nursing facility visits;
 (2)	the purchase and repair of orthotic and pedorthic equipment; and
 (3)	orthotic and pedorthic supplies provided for the personal full-time use of a member residing in a nursing facility.

 (B)	Institutions Licensed as Hospitals, Chronic Disease Hospitals, and Rehabilitation Hospitals. The Division does not pay orthotic or pedorthic providers for the purchase or repair of orthotic or pedorthic equipment or for supplies provided to a hospitalized member, except for orthotic or pedorthic equipment that is prescribed for home use after discharge. The hospital record must document the member’s discharge plan and that the date of discharge was before the purchase or repair of the prescribed item.
 (C)	Intermediate Care Facilities for the Mentally Retarded with 16 Beds or More (State Schools).

 (1)	The Division pays orthotic and pedorthic providers for the purchase and repair of customized orthotic and pedorthic equipment provided for the personal full-time use of a member residing in an ICF/MR with 16 beds or more (a state school) only if the customization precludes the use of the equipment by subsequent residents in that institution.
 (2)	The Division does not pay orthotic or pedorthic providers for noncustomized equipment or supplies provided to a member residing in a state school.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ORTHOTICS MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 442.000)	PAGE
4-7	

	TRANSMITTAL LETTER
ORT-14	DATE
11/22/02	
(D) Rest Homes. The Division pays orthotic and pedorthic providers for the purchase and repair of orthotic and pedorthic equipment and for associated supplies provided for the personal full-time use of a member residing in a rest home.
442.411: Repairs of Orthotic and Pedorthic Equipment
 (A)	The Division pays for all repair services on an individual-consideration basis as described in 130 CMR 442.422.
 (B)	The provider of repair services is liable for the quality of the workmanship and parts, and for ensuring that repaired equipment is in proper working condition.
 (C)	The provider of repair services must exhaust all manufacturer warrantees before submitting claims for repairs to orthotic or pedorthic equipment to the Division.
442.412: Prior Authorization
 (A)	Services that require prior authorization as a prerequisite for payment are identified in the Division’s regulations at 130 CMR 442.000 or are listed in Subchapter 6 of the Orthotics Manual with the designation "(P.A.)" appearing after the service description. To determine if prior authorization is required, the provider should review both the regulations and Subchapter 6. Prior authorization determines only the medical necessity of the prescribed item or service and does not waive any other prerequisites to payment such as member eligibility or resort to health-insurance payment.
 (B)	The provider must request prior authorization in accordance with the billing instructions in Subchapter 5 of the Orthotics Manual. The Division may, at its discretion, require the prescriber to submit an assessment of the member's condition and the objectives of the requested service. The Division may also, at its discretion, require an evaluation by a licensed orthotist or pedorthist to determine whether the requested orthotic or pedorthic service is useful to the member, given the member's physical condition and physical environment.
(C)(1) The Division will send notification to the member and the provider of the following prior-authorization decisions:
 (a)	approval;
 (b)	modification; or
 (c)	denial. (2) If the Division defers the prior-authorization decision because additional information is required to determine whether the requested service is medically necessary, the Division will notify the provider.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ORTHOTICS MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 442.000)	PAGE
4-8	

	TRANSMITTAL LETTER
ORT-14	DATE
11/22/02	
(3) If the Division denies or modifies a request, the notification will include the reason for the Division’s determination. The member may appeal the prior-authorization decision within 30 days after the date of the notice. Procedures for such an appeal are set forth in 130 CMR 610.000.
(D)	The Division will make a decision on the request within 15 days after the date of receipt of a
fully completed prior-authorization request. The Division will confirm the date of receipt and the
date of action upon written request.
(E)	The provider must keep the prior-authorization request on file for the period of time required
by 130 CMR 450.205.
442.413:  Procedure for Requesting Prior Authorization
 (A)	The provider must obtain prior authorization from the Division before providing any service that requires prior authorization. The provider must submit the Request for Prior Authorization within 90 days of the date of service requested on the prescription.
 (B)	The Request for Prior Authorization must document the adjusted acquisition cost (see 130 CMR 442.421) and the medical necessity of the requested service. The Request for Prior Authorization must contain the following documentation:

 (1)	a copy of the invoice or invoices from the manufacturer for the equipment, disclosing all discounts;
 (2)	a copy of the current prescription that must not be older than 90 days from the date of service (see 130 CMR 442.409 for information that must be included in the prescription);
 (3)	if requested by the Division, a current orthotic or pedorthic evaluation for the equipment, performed independently of the provider by a licensed physician, orthotist, or pedorthist;
 (4)	the date or projected date of service;
 (5)	the projected duration of need for the equipment; and
 (6)	if replacing existing equipment, the date the existing equipment was purchased.
442.414: Medicare Coverage
 (A)	For Medicare and third-party-liability coverage, see 130 CMR 450.316 through 450.318.
 (B)	For Medicare-covered services that are provided to members who receive Medicare Part B benefits, the Division does not require prior authorization.
 (C)	When Medicare denies a claim for orthotic or pedorthic services or considers the services uncovered, the Division requires prior authorization for those services that would require prior authorization for members without Medicare.
(130 CMR 442.415 through 442.419 Reserved)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ORTHOTICS MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 442.000)	PAGE
4-9	

	TRANSMITTAL LETTER
ORT-14	DATE
11/22/02	
442.420: Payment for Orthotic or Pedorthic Services
(A)	Payment to a provider for orthotic or pedorthic equipment and supplies is subject to the
conditions and limitations in 130 CMR 442.000 and 450.000, and will be the lower of:
 (1)	the provider's usual and customary charge to the general public; or
 (2)	the fee set forth in the schedule of maximum allowable fees established by the Massachusetts Division of Health Care Finance and Policy (DHCFP).
(B)	Payment for the following services is included in the provider payment under
130 CMR 442.420(A). No separate payment is allowed for:
 (1)	the fitting of the orthosis or pedorthic device;
 (2)	instructing the member in the use of the orthosis or pedorthic device;
 (3)	the cost of the component parts and accessory equipment;
 (4)	repairs due to normal wear and tear within 90 days of the date of delivery; and
 (5)	adjustments to the orthosis or pedorthic device and any orthotic or pedorthic component made when fitting the orthosis and for 90 days from the date of delivery, when the adjustments are not necessitated by changes in the member's functional abilities.
442.421: Individual Consideration
When the rate of payment for the purchase or repair of certain orthotic or pedorthic equipment has not been established by the Division of Health Care Finance and Policy, the Division pays for the service based on individual consideration, subject to all other conditions of payment. Such items are identified in Subchapter 6 of the Orthotics Manual by the designation "(I.C.)" next to the description of the item or service. The Division determines the rate of payment for an individual-consideration item or service based on the provider’s report of services and a current invoice that indicates the provider’s adjusted acquisition cost as defined in 130 CMR 442.421 and 442.422(B). Payment for the fitting of an orthosis or pedorthic device is included in the adjusted acquisition cost. The provider must maintain adequate records to document the individual consideration claim and must provide these documents to the Division and the Attorney General’s Medicaid Fraud Control Unit upon demand (see 130 CMR 450.205). Payment to a provider for an individual consideration claim is the lower of:
 (A)	the provider’s usual and customary charge to the general public; or
 (B)	the adjusted acquisition cost of the item plus a markup not to exceed:

 (1)	70 percent for any item whose adjusted acquisition cost is less than $100;
 (2)	50 percent for any item whose adjusted acquisition cost is $100 or greater and less than $200;
 (3)	45 percent for any item whose adjusted acquisition cost is $200 or greater and less than $300; or
 (4)	40 percent for any item whose adjusted acquisition cost is $300 or greater.

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442.422: Adjusted Acquisition Cost
(A) The provider must disclose all discounts, as defined in 130 CMR 442.402, and must reflect such discounts in the provider’s claim for payment pursuant to M.G.L. c. 118E, § 41, and U.S.C. § 1320a-7b(b)(3)(A). Any provider who fails to disclose and pass on any discounts to the Division may be subject to civil and criminal penalties, including imprisonment, in accordance with state and federal laws.
(B)	(1) Except where the manufacturer is the provider, the adjusted acquisition cost must not
exceed the manufacturer’s current wholesale price and must be evidenced by the purchase
price of the equipment or goods listed on a copy of the supplier’s invoice.
(2) Where the manufacturer is the provider, the adjusted acquisition cost must not exceed
the actual cost of manufacturing the items.
 (C)	Where the manufacturer is the provider of any item covered under 130 CMR 442.000, the manufacturer must submit documentation that demonstrates to the Division’s satisfaction the actual cost of manufacturing the item, as set forth in 130 CMR 442.421(B).
 (D)	If the provider has not purchased the equipment at the time of the prior-authorization request, the provider may substitute a price quotation reflecting the absolute lowest price of the item and the catalog (list) price. The quotation must be on the manufacturer’s letterhead or form and be addressed to the provider.
(E)	The provider must maintain the actual receipted invoice in the member’s record, and make
it available to the Division and the Attorney General’s Medicaid Fraud Control Unit pursuant
to 130 CMR 442.423 and 450.205.
(F)	The provider may group together low-cost items (those with an adjusted acquisition cost of
less than $5 each) to equal $5 or less, and bill the total adjusted acquisition cost plus the
allowable markup listed in 130 CMR 442.422(B).
442.423: Recordkeeping Requirements
The provider must keep a record of all orthotic and pedorthic services, nursing facility visits, and the medical necessity of such services, provided to a member for the period of time required by 130 CMR 450.205. This record must include the following:
 (A)	a prescription for all purchases;
 (B)	a copy of the approved prior-authorization request for all orthotic and pedorthic services requiring prior authorization;

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(C)	an acknowledgement of receipt, signed by the member or the member’s representative, of
prescribed equipment or supplies, including:
 (1)	the date of receipt of equipment or supplies;
 (2)	the condition of the equipment or supplies (for example, whether it is in proper working order or is damaged);
 (3)	the manufacturer, brand name, model number, and serial number of the equipment or supplies;
 (4)	for repair services, a complete description of the service, including the manufacturer, brand name, model number, and serial number of the repaired item; and
 (5)	next to the signature, an explanation of the representative’s relationship to the member by the individual acknowledging receipt. This individual cannot be associated with either the provider or the delivery service.

 (a)	For routine delivery of supplies, the member must acknowledge receipt at least monthly.
 (b)	A signature stamp may be used by or on behalf of a MassHealth member whose disability inhibits the member’s ability to write. A signature stamp may only be used by a member or the member’s representative, provided that the stamp is used by the member in his or her normal course of conducting business. A signature stamp cannot be used by anyone associated with either the provider or the delivery service;
(D)	the actual invoice showing the cost to the provider of the materials (if the provider is not the
manufacturer of the materials);
(E)	documentation demonstrating the cost of manufacturing the item provided (if the provider is
the manufacturer);
(F)	copies of written warranties; and
(G)	documentation demonstrating efforts under 130 CMR 442.405(C) to purchase the item from
the least costly reliable source.
REGULATORY AUTHORITY
130 CMR 442.000: M.G.L. c. 118E, §§ 7 and 12

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This page is reserved.

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Subchapter 6 contains service codes and descriptions for orthotic and pedorthic providers. Section 601 contains definitions of terms. Section 602 contains service codes and descriptions for orthotic providers. Section 603 contains service codes and descriptions for pedorthic providers.
601 Definitions
The codes listed in Section 601 represent covered services payable to orthotists participating in MassHealth. For a list of covered services payable to pedorthists participating in MassHealth, see Section 602.
Custom-Fabricated Orthosis — an orthotic item that is fabricated to the individual’s measurements or to a mold for use by an individual in accordance with a prescription and that requires substantial clinical and technical judgment by a certified orthotist in design and fitting.
Custom-Fitted Orthosis — a prefabricated orthotic item sized or modified for use by an individual in accordance with a prescription that requires substantial clinical and technical judgment and alteration by a certified orthotist. A custom-fitted orthosis does not require casting or molding techniques.
Depth Shoe — a medical-grade or off-the-shelf shoe that has full length, heel-to-toe inlay. When the inlay is removed, the shoe provides a minimum of 3/16 inches of additional internal depth.
Insert: Custom-Molded Foot Orthotic — a total-contact insert custom-molded to a modified positive model or computer-generated model of an individual’s foot. The material and thickness of the insert addresses the individual’s condition. The model is modified before the insert is made to address potential problem areas. The insert conforms to the individual’s anatomy, is functional, and is removable from the individual’s footwear. A foot orthotic shaped by a self-molding, self-contouring process or of a generic manufactured design is not a custom-molded foot orthotic.
Insert: Orthotic Formed to Foot — a noncustomized, multiple density, removable insert that is directly molded by the individual’s foot and is made of material suitable for the individual’s condition.
Inlay — a prefabricated, noncustomized, removable material upon which the foot directly rests inside the shoe. An inlay is an integral design component of some shoes. Cutting a prefabricated inlay to an indicated trim line does not constitute customizing a foot orthotic.
Insole — a noncustomized integral design component that is the shoe’s structural anchor to which the upper, toe box, heel counter, welting, and lining are attached. The foot rests directly on the material, which is not removable. The insole is held to the shoe by various methods, including but not limited to a common stitch or cement.

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601	Definitions (cont.)
Oxford Shoe — an off-the-shelf, medical-grade shoe with the following features:
 (1)	some form of shoe closure;
 (2)	shoe upper and sole materials that can accommodate modifications;
 (3)	an upper made of leather or other suitable material of equal quality;
 (4)	a sole attached by stitch or cement;
 (5)	reinforced extended medical heel counter that reaches at least midway through the longitudinal arch, unless contraindicated by an individual’s condition;
 (6)	smooth protective lining that absorbs moisture and vapor;
 (7)	a differential between sole thickness and heel height that does not exceed 1 ¼ inches;
 (8)	a capacity to address medical conditions of the foot that standard ready-made or off-the-shelf shoes cannot address;
 (9)	a sole graded to the size and width of the upper, in accordance with the American standard last-sizing schedule or its equivalent; and
(10) availability in full and half sizes and multiple widths. Adult medical-grade oxfords are available in a complete range of 13 or more full and half sizes and at least four widths; children’s medical grade oxfords are available in two or more widths.
602	Service Codes and Descriptions for Orthotic Providers

Service Code

Service Description

ORTHOTIC DEVICES—SPINAL
Cervical
L0100	Cranial orthosis (helmet), with or without soft interface, molded to patient model
L0110	Cranial orthosis (helmet) with or without soft-interface, non-molded
L0120	Cervical, flexible nonadjustable (foam collar)
L0130	Cervical, flexible, thermoplastic collar, molded to patient
L0140	Cervical, semi-rigid, adjustable (plastic collar)
L0150	Cervical, semi-rigid, adjustable molded chin cup (plastic collar with mandibular/occipital piece)
L0160	Cervical, semi-rigid, wire frame occipital/mandibular support
L0170	Cervical collar, molded to patient model
L0172	Cervical, collar, semi-rigid thermoplastic foam, two piece
L0174	Cervical, collar, semi-rigid, thermoplastic foam, two piece with thoracic extension
Multiple-Post Collar
L0180      Cervical, multiple-post collar, occipital/mandibular supports, adjustable
L0190      Cervical, multiple post collar, occipital/mandibular supports, adjustable cervical bars (Somi,
Guilford, Taylor types) L0200      Cervical, multiple post collar, occipital/mandibular supports, adjustable cervical bars, and thoracic
extension

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602 Service Codes and Descriptions for Orthotic Providers (cont.)
Service
Code       Service Description
Thoracic
L0210      Thoracic, rib belt
L0220      Thoracic, rib belt, custom fabricated
THORACIC-LUMBAR-SACRAL ORTHOSIS (TLSO)
Flexible
L0300      TLSO, flexible (dorso-lumbar surgical support) L0310      TLSO, flexible (dorso-lumbar surgical support), custom fabricated L0315      TLSO, flexible (dorso-lumbar surgical support), elastic type, with rigid posterior panel L0317      TLSO, flexible (dorso-lumbar surgical support), hyperextension, elastic type, with rigid posterior panel
Anterior-Posterior Control
L0320      TLSO, anterior-posterior control (Taylor type), with apron front
L0321      TLSO, anterior-posterior control, with rigid or semi-rigid posterior panel, prefabricated (includes
fitting and adjustment) L0330      TLSO, anterior-posterior-lateral control (Knight-Taylor type), with apron front L0331      TLSO, anterior-posterior-lateral control, with rigid or semi-rigid posterior panel, prefabricated
(includes fitting and adjustment)
Anterior-Posterior-Lateral-Rotary Control
L0340      TLSO, anterior-posterior-lateral-rotary control (Arnold, Magnuson, Steindler types), with apron
front L0350      TLSO, anterior-posterior-lateral-rotary control, flexion compression jacket, custom fitted L0360      TLSO, anterior-posterior-lateral-rotary control, flexion compression jacket, molded to patient
model L0370      TLSO, anterior-posterior-lateral-rotary control, hyperextension (Jewett, Lennox, Baker, Cash
types) L0380      TLSO, anterior-posterior-lateral-rotary control, with extensions L0390      TLSO, anterior-posterior-lateral control molded to patient model L0391      TLSO, anterior-posterior-lateral-rotary control, with rigid or semi-rigid posterior panel,
prefabricated (includes fitting and adjustment) L0400      TLSO, anterior-posterior-lateral control molded to patient model, with interface material L0410      TLSO, anterior-posterior-lateral control, two-piece construction, molded to patient model L0420      TLSO, anterior-posterior-lateral control, two-piece construction, molded to patient model, with
interface material L0430      TLSO, anterior-posterior-lateral control, with interface material, custom fitted L0440      TLSO, anterior-posterior-lateral control, with overlapping front section, spring steel front, custom
fitted

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602 Service Codes and Descriptions for Orthotic Providers (cont.)
Service
Code       Service Description
LUMBAR-SACRAL ORTHOSIS (LSO)
Flexible
L0500      LSO, flexible (lumbo-sacral surgical support)
L0510      LSO, flexible (lumbo-sacral surgical support), custom fabricated
L0515      LSO, anterior-posterior control, with rigid or semi-rigid posterior panel, prefabricated
Anterior-Posterior-Lateral Control
L0520      LSO, anterior-posterior-lateral control (Knight, Wilcox types), with apron front
Anterior-Posterior Control
L0530      LSO, anterior-posterior control (Macausland type), with apron front
Lumbar Flexion
L0540	LSO, lumbar flexion (Williams flexion type)
L0550	LSO, anterior-posterior-lateral control, molded to patient model
L0560	LSO, anterior-posterior-lateral control, molded to patient model, with interface material
L0561	LSO, anterior-posterior-lateral control, with rigid or semi-rigid posterior panel, prefabricated
L0565	LSO, anterior-posterior-lateral control, custom fitted
SACROILIAC
Flexible
L0600      Sacroiliac, flexible (sacroiliac surgical support)
L0610      Sacroiliac, flexible (sacroiliac surgical support), custom fabricated
Semi-Rigid
L0620      Sacroiliac, semi-rigid (Goldthwaite, Osgood types), with apron front
CERVICAL-THORACIC-LUMBAR-SACRAL ORTHOSIS (CTLSO)
Anterior-Posterior-Lateral Control
L0700      CTLSO, anterior-posterior-lateral control, molded to patient model (Minerva type) L0710      CTLSO, anterior-posterior-lateral control, molded to patient model, with interface material (Minerva type)

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602 Service Codes and Descriptions for Orthotic Providers (cont.)
Service
Code       Service Description
Halo Procedure
L0810	Halo procedure, cervical halo incorporated into jacket vest
L0820	Halo procedure, cervical halo incorporated into plaster body jacket
L0830	Halo procedure, cervical halo incorporated into Milwaukee type orthosis
L0860	Addition to halo procedure, magnetic resonance image compatible system
TORSO SUPPORTS
Ptosis Supports
L0900	Torso support, ptosis support
L0910	Torso support, ptosis support, custom fabricated
Pendulous Abdomen Supports
L0920	Torso support, pendulous abdomen support
L0930	Torso support, pendulous abdomen support, custom fabricated
Postsurgical Supports
L0940	Torso support, postsurgical support
L0950	Torso support, postsurgical support, custom fabricated
L0960	Torso support, postsurgical support, pads for postsurgical support
Additions to Spinal Orthosis
L0970	TLSO, corset front
L0972	LSO, corset front
L0974	TLSO, full corset
L0976	LSO, full corset
L0978	Axillary crutch extension
L0980	Peroneal straps, pair
L0982	Stocking supporter grips, set of four
L0984	Protective body sock, each
L0986	Addition to spinal orthosis, rigid or semi-rigid abdominal panel, prefabricated
L0999	Addition to spinal orthosis, not otherwise specified (I.C.)

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602 Service Codes and Descriptions for Orthotic Providers (cont.)
Service
Code       Service Description
SCOLIOSIS PROCEDURES
The orthotic care of scoliosis differs from other orthotic care in that the treatment is more dynamic in nature and uses ongoing, continual modification of the orthosis to the patient's changing condition. This coding structure uses the proper names (or eponyms) of the procedures because they have historic and universal acceptance in the profession. It should be recognized that variations to the basic procedures described by the founders/developers are accepted in various medical and orthotic practices throughout the country. All procedures include model of patient when indicated.
Cervical-Thoracic-Lumbar-Sacral (CTLSO) (Milwaukee)
L1000	CTLSO (Milwaukee), inclusive of furnishing initial orthosis, including model
L1005	Tension based scoliosis orthosis and accessory pads, includes fitting and adjustment
L1010	Addition to CTLSO or scoliosis orthosis, axilla sling
L1020	Addition to CTLSO or scoliosis orthosis, kyphosis pad
L1025	Addition to CTLSO or scoliosis orthosis, kyphosis pad, floating
L1030	Addition to CTLSO or scoliosis orthosis, lumbar bolster pad
L1040	Addition to CTLSO or scoliosis orthosis, lumbar or lumbar rib pad
L1050	Addition to CTLSO or scoliosis orthosis, sternal pad
L1060	Addition to CTLSO or scoliosis orthosis, thoracic pad
L1070	Addition to CTLSO or scoliosis orthosis, trapezius sling
L1080	Addition to CTLSO or scoliosis orthosis, outrigger
L1085	Addition to CTLSO or scoliosis orthosis, outrigger, bilateral with vertical extensions
L1090	Addition to CTLSO or scoliosis orthosis, lumbar sling
L1100	Addition to CTLSO or scoliosis orthosis, ring flange, plastic or leather
L1110	Addition to CTLSO or scoliosis orthosis, ring flange, plastic or leather, molded to patient model
L1120	Addition to CTLSO or scoliosis orthosis, cover for upright, each
Thoracic-Lumbar-Sacral Orthosis (TLSO) (Low Profile)
L1200	TLSO, inclusive of furnishing initial orthosis only
L1210	Addition to TLSO (low profile), lateral thoracic extension
L1220	Addition to TLSO (low profile), anterior thoracic extension
L1230	Addition to TLSO (low profile), Milwaukee type superstructure
L1240	Addition to TLSO (low profile), lumbar derotation pad
L1250	Addition to TLSO (low profile), anterior ASIS pad
L1260	Addition to TLSO (low profile), anterior thoracic derotation pad
L1270	Addition to TLSO (low profile), abdominal pad
L1280	Addition to TLSO (low profile), rib gusset (elastic), each
L1290	Addition to TLSO (low profile), lateral trochanteric pad

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602 Service Codes and Descriptions for Orthotic Providers (cont.)

Service Code
L1300 L1310 L1499
L1500 L1510 L1520
L1600
L1610
L1620
L1630 L1640
L1650
L1660 L1680
L1685 L1686
L1690

Service Description
Other Scoliosis Procedures
Other scoliosis procedure, body jacket molded to patient model Other scoliosis procedure, postoperative body jacket Spinal orthosis, not otherwise specified (I.C.)
Thoracic-Hip-Knee-Ankle Orthosis (THKAO)
THKAO, mobility frame (Newington, Parapodium types) THKAO, standing frame, with or without tray and accessories THKAO, swivel walker
ORTHOTIC DEVICES—LOWER LIMB
The procedures in L1600-L2999 are considered "base" or "basic" procedures and may be modified by listing procedures from the "Additions" sections and adding them to the base procedures.
Hip Orthosis (HO)—Flexible
HO, abduction control of hip joints, flexible, Frejka type with cover, prefabricated, includes fitting
and adjustment HO, abduction control of hip joints, flexible, (Frejka cover only), prefabricated, includes fitting
and adjustment HO, abduction control of hip joints, flexible, (Pavlik harness), prefabricated, includes fitting and
adjustment HO, abduction control of hip joints, semi-flexible (von Rosen type), custom fabricated HO, abduction control of hip joints, static, pelvic band or spreader bar, thigh cuffs, custom
fabricated HO, abduction control of hip joints, static, adjustable, (Ilfled type), prefabricated, includes fitting
and adjustment HO, abduction control of hip joints, static, plastic, prefabricated includes fitting and adjustment HO, abduction control of hip joints, dynamic, pelvic control, adjustable hip motion control, thigh
cuffs (Rancho hip action type), custom fabricated HO, abduction control of hip joint, postoperative hip abduction type, custom fabricated HO, abduction control of hip joint, postoperative hip abduction type, prefabricated, includes fitting
and adjustments Combination, bilateral, lumbo-sacral, hip, femur orthosis providing adduction and internal rotation
control, prefabricated, includes fitting and adjustment

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602 Service Codes and Descriptions for Orthotic Providers (cont.)
Service
Code       Service Description
Legg Perthes
L1700	Legg Perthes orthosis, (Toronto type), custom fabricated
L1710	Legg Perthes orthosis, (Newington type), custom fabricated
L1720	Legg Perthes orthosis, trilateral (Tachdijan type), custom fabricated
L1730	Legg Perthes orthosis, (Scottish Rite type), custom fabricated
L1750	Legg Perthes orthosis, Legg Perthes sling (Sam Brown type), prefabricated, includes fitting and
adjustment
L1755	Legg Perthes orthosis, (Patten bottom type), custom fabricated
Knee Orthosis (KO)
L1800 KO, elastic with stays, prefabricated, includes fitting and adjustment L1810 KO, elastic with joints, prefabricated, includes fitting and adjustment L1815      KO, elastic or other elastic type material with condylar pads, prefabricated, includes fitting and
adjustment L1820      KO, elastic with condylar pads and joints, prefabricated, includes fitting and adjustment L1825      KO, elastic knee cap, prefabricated, includes fitting and adjustment L1830      KO, immobilizer, canvas longitudinal, prefabricated, includes fitting and adjustment L1832      KO, adjustable knee joints, positional orthosis, rigid support, prefabricated, includes fitting and
adjustment L1834      KO, without knee joint, rigid, custom fabricated
L1840      KO, derotation, medial-lateral, anterior cruciate ligament, custom fabricated L1843      KO, single upright, thigh and calf, with adjustable flexion and extension joint, medial-lateral and
rotation control, prefabricated, includes fitting and adjustment L1844      KO, single upright, thigh and calf, with adjustable flexion and extension joint, medial-lateral and
rotation control, custom fabricated L1845      KO, double upright, thigh and calf, with adjustable flexion and extension joint, medial-lateral and
rotation control, prefabricated, includes fitting and adjustment L1846      KO, double upright, thigh and calf, with adjustable flexion and extension joint, medial-lateral and
rotation control, custom fabricated 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
L1855      KO, molded plastic, thigh and calf sections, with double upright knee joints, custom fabricated L1858      KO, molded plastic, polycentric knee joints, pneumatic knee pads (CTI), custom fabricated L1860      KO, modification of supracondylar prosthetic socket, custom fabricated (SK) L1870      KO, double upright, thigh and calf lacers, with knee joints, custom fabricated L1880      KO, double upright, nonmolded thigh and calf cuffs/lacers with knee joints, custom fabricated L1885      KO, single or double upright, thigh and calf, with functional active resistance control,
prefabricated, includes fitting and adjustment

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602 Service Codes and Descriptions for Orthotic Providers (cont.)
Service
Code       Service Description
Ankle-Foot Orthosis (AFO)
L1900      AFO, spring wire, dorsiflexion assist calf band, custom fabricated
L1902      AFO, ankle gauntlet, prefabricated, includes fitting and adjustment
L1904      AFO, molded ankle gauntlet, custom fabricated
L1906      AFO, multiligamentus ankle support, prefabricated, includes fitting and adjustment
L1910      AFO, posterior, single bar, clasp attachment to shoe counter, prefabricated, includes fitting and
adjustment L1920      AFO, single upright with static or adjustable stop (Phelps or Perlstein type), custom fabricated L1930      Ankle foot orthosis, plastic or other material, prefabricated, includes fitting and adjustment L1940      Ankle foot orthosis, plastic or other material, custom fabricated L1945      AFO, molded to patient model, plastic, rigid anterior tibial section (floor reaction), custom
fabricated L1950      AFO, spiral, (IRM type), plastic, custom fabricated L1960      AFO, posterior solid ankle, plastic, custom fabricated L1970      AFO, plastic, with ankle joint, custom fabricated L1980      AFO, single upright free plantar dorsiflexion, solid stirrup, calf band/cuff (single bar "BK"
orthosis), custom fabricated L1990      AFO, double upright free plantar dorsiflexion, solid stirrup, calf band/cuff (double bar "BK"
orthosis), custom fabricated
Knee-Ankle-Foot Orthosis—Or Any Combination
Service Codes L2000, L2020, and L2036 are base procedures to be used with any knee joint. Service Codes L2010 and L2030 are to be used only with no knee joint.
L2000      KAFO, single upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar
"AK" orthosis), custom fabricated L2010      KAFO, single upright, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar "AK"
orthosis), without knee joint, custom fabricated L2020      KAFO, double upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (double bar
"AK" orthosis), custom fabricated L2030      KAFO, double upright, free ankle, solid stirrup, thigh and calf bands/cuffs (double bar "AK"
orthosis), without knee joint, custom fabricated L2035      KAFO, full plastic, static, (pediatric size), prefabricated, includes fitting and adjustment L2036      KAFO, full plastic, double upright, free knee, custom fabricated L2037      KAFO, full plastic, single upright, free knee, custom fabricated L2038      KAFO, full plastic, without knee joint, multiaxis ankle, (Lively orthosis or equal), custom
fabricated L2039      KAFO, full plastic, single upright, poly-axial hinge, medial lateral rotation control, custom
fabricated

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602 Service Codes and Descriptions for Orthotic Providers (cont.)
Service
Code       Service Description
Torsion Control: Hip-Knee-Ankle-Foot Orthosis (HKAFO)
L2040      HKAFO, torsion control, bilateral rotation straps, pelvic band/belt, custom fabricated
L2050      HKAFO, torsion control, bilateral torsion cables, hip joint, pelvic band/belt, custom fabricated
L2060      HKAFO, torsion control, bilateral torsion cables, ball-bearing hip joint, pelvic band/belt, custom
fabricated L2070      HKAFO, torsion control, unilateral rotation straps, pelvic band/belt, custom fabricated L2080      HKAFO, torsion control, unilateral torsion cable, hip joint, pelvic band/belt, custom fabricated L2090      HKAFO, torsion control, unilateral torsion cable, ball-bearing hip joint, pelvic band/belt, custom
fabricated
Fracture Orthosis
L2102      AFO, fracture orthosis, tibial fracture cast orthosis, plaster type casting material, custom fabricated L2104      AFO, fracture orthosis, tibial fracture cast orthosis, synthetic type casting material, custom
fabricated L2106      AFO, fracture orthosis, tibial fracture cast orthosis, thermoplastic type casting material, custom
fabricated L2108      AFO, fracture orthosis, tibial fracture cast orthosis, custom fabricated
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 L2122      KAFO, fracture orthosis, femoral fracture cast orthosis, plaster type casting material custom
fabricated L2124      KAFO, fracture orthosis, femoral fracture cast orthosis, synthetic type casting material, custom
fabricated L2126      KAFO, fracture orthosis, femoral fracture cast orthosis, thermoplastic type casting material,
custom fabricated L2128      KAFO, fracture orthosis, femoral fracture cast orthosis, custom fabricated 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
Additions to Fracture Orthosis
L2180	Addition to lower extremity fracture orthosis, plastic shoe insert with ankle joints
L2182	Addition to lower extremity fracture orthosis, drop lock knee joint
L2184	Addition to lower extremity fracture orthosis, limited motion knee joint
L2186	Addition to lower extremity fracture orthosis, adjustable motion knee joint, Lerman type

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Division of Medical Assistance
Provider Manual Series
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6 SERVICE CODES AND DESCRIPTIONS	PAGE
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	TRANSMITTAL LETTER
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602 Service Codes and Descriptions for Orthotic Providers (cont.)
Service
Code	Service Description
L2188	Addition to lower extremity fracture orthosis, quadrilateral brim
L2190	Addition to lower extremity fracture orthosis, waist belt
L2192	Addition to lower extremity fracture orthosis, hip joint, pelvic band, thigh flange, and pelvic belt
Additions to Lower Extremity Orthosis: Shoe-Ankle-Shin-Knee
L2200	Addition to lower extremity, limited ankle motion, each joint
L2210	Addition to lower extremity, dorsiflexion assist (plantar flexion resist), each joint
L2220	Addition to lower extremity, dorsiflexion and plantar flexion assist/resist, each joint
L2230	Addition to lower extremity, split flat caliper stirrups and plate attachment
L2240	Addition to lower extremity, round caliper and plate attachment
L2250	Addition to lower extremity, foot plate, molded to patient model, stirrup attachment
L2260	Addition to lower extremity, reinforced solid stirrup (Scott-Craig type)
L2265	Addition to lower extremity, long tongue stirrup
L2270	Addition to lower extremity, varus/valgus correction ("T") strap, padded/lined or malleolus pad
L2275	Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined
L2280	Addition to lower extremity, molded inner boot
L2300	Addition to lower extremity, abduction bar (bilateral hip involvement), jointed, adjustable
L2310	Addition to lower extremity, abduction bar, straight
L2320	Addition to lower extremity, nonmolded lacer
L2330	Addition to lower extremity, lacer molded to patient model
L2335	Addition to lower extremity, anterior swing band
L2340	Addition to lower extremity, pretibial shell, molded to patient model
L2350	Addition to lower extremity, prosthetic type ("BK") socket, molded to patient model (used for
"PTB," "AFO" orthoses)
L2360	Addition to lower extremity, extended steel shank
L2370	Addition to lower extremity, Patten bottom
L2375	Addition to lower extremity, torsion control, ankle joint and half-solid stirrup
L2380	Addition to lower extremity, torsion control, straight knee joint, each joint
L2385	Addition to lower extremity, straight knee joint, heavy duty, each joint
L2390	Addition to lower extremity, offset knee joint, each joint
L2395	Addition to lower extremity, offset knee joint, heavy duty, each joint
L2397	Addition to lower extremity orthosis, suspension sleeve
L2405	Addition to knee joint, drop lock, each joint
L2415	Addition to knee lock with integrated release mechanism (bail, cable, or equal), any material, each
joint
L2425	Addition to knee joint, disc or dial lock for adjustable knee flexion, each joint
L2430	Addition to knee joint, ratchet lock for active and progressive knee extension, each joint
L2435	Addition to knee joint, polycentric joint, each joint
L2492	Addition to knee joint, lift loop for drop lock ring
Additions to Straight Knee or Offset Knee Joints

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Division of Medical Assistance
Provider Manual Series
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6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-12	

	TRANSMITTAL LETTER
ORT-14	DATE
11/22/02	
602 Service Codes and Descriptions for Orthotic Providers (cont.)
Service
Code       Service Description
Additions: Thigh/Weight Bearing—Gluteal/Ischial Weight Bearing
L2500      Addition to lower extremity, thigh/weight bearing, gluteal/ischial weight bearing, ring
L2510      Addition to lower extremity, thigh/weight bearing, quadrilateral brim, molded to patient model
L2520      Addition to lower extremity, thigh/weight bearing, quadrilateral brim, custom fitted
L2525      Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim, molded
to patient model L2526      Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim, custom
fitted L2530      Addition to lower extremity, thigh/weight bearing, lacer, nonmolded L2540      Addition to lower extremity, thigh/weight bearing, lacer, molded to patient model L2550      Addition to lower extremity, thigh/weight bearing, high roll cuff

L2570 L2580 L2600 L2610 L2620 L2622 L2624
L2627
L2628 L2630 L2640 L2650 L2660 L2670 L2680
L2750 L2755
L2760
L2768
L2770 L2780

Additions: Pelvic and Thoracic Control
Addition to lower extremity, pelvic control, hip joint, Clevis type, two position joint, each
Addition to lower extremity, pelvic control, pelvic sling
Addition to lower extremity, pelvic control, hip joint, Clevis type or thrust bearing, free, each
Addition to lower extremity, pelvic control, hip joint, Clevis type or thrust bearing, lock, each
Addition to lower extremity, pelvic control, hip joint, heavy duty, each
Addition to lower extremity, pelvic control, hip joint, adjustable flexion, each
Addition to lower extremity, pelvic control, hip joint, adjustable flexion, extension, abduction
control, each Addition to lower extremity, pelvic control, plastic, molded to patient model, reciprocating hip
joint and cables Addition to lower extremity, pelvic control, metal frame, reciprocating hip joint and cables Addition to lower extremity, pelvic control, band and belt, unilateral Addition to lower extremity, pelvic control, band and belt, bilateral Addition to lower extremity, pelvic and thoracic control, gluteal pad, each Addition to lower extremity, thoracic control, thoracic band Addition to lower extremity, thoracic control, paraspinal uprights Addition to lower extremity, thoracic control, lateral support uprights
Additions: General
Addition to lower extremity orthosis, plating chrome or nickel, per bar
Addition to lower extremity orthosis, high strength, lightweight material, all hybrid
lamination/prepreg composite, per segment Addition to lower extremity orthosis, extension, per extension, per bar (for lineal adjustment for
growth) Orthotic side bar disconnect device, per bar Addition to lower extremity orthosis, any material, per bar or joint Addition to lower extremity orthosis, noncorrosive finish, per bar

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ORTHOTICS MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-13	

	TRANSMITTAL LETTER
ORT-14	DATE
11/22/02	
602 Service Codes and Descriptions for Orthotic Providers (cont.)
Service
Code       Service Description
L2785	Addition to lower extremity orthosis, drop lock retainer, each
L2795	Addition to lower extremity orthosis, knee control, full kneecap
L2800	Addition to lower extremity orthosis, knee control, kneecap, medial or lateral pull
L2810	Addition to lower extremity orthosis, knee control, condylar pad
L2820	Addition to lower extremity orthosis, soft interface for molded plastic, below-knee section
L2830	Addition to lower extremity orthosis, soft interface for molded plastic, above-knee section
L2840	Addition to lower extremity orthosis, tibial length sock, fracture or equal, each
L2850	Addition to lower extremity orthosis, femoral length sock, fracture or equal, each
L2860	Addition to lower extremity joint, knee, or ankle, concentric adjustable torsion style mechanism,
each
L2999	Lower extremity orthoses, not otherwise specified (I.C.)
ORTHOPEDIC SHOES
Inserts
L3000	Foot insert, removable, molded to patient model, "UCB" type, Berkeley shell, each
L3001	Foot insert, removable, molded to patient model, Spenco, each
L3002	Foot insert, removable, molded to patient model, Plastazote or equal, each
L3003	Foot insert, removable, molded to patient model, silicone gel, each
L3010	Foot insert, removable, molded to patient model, longitudinal arch support, each
L3020	Foot insert, removable, molded to patient model, longitudinal/metatarsal support, each
L3030	Foot insert, removable, formed to patient foot, each
Arch Support, Removable, Premolded
L3040      Foot, arch support, removable, premolded, longitudinal, each
L3050      Foot, arch support, removable, premolded, metatarsal, each
L3060      Foot, arch support, removable, premolded, longitudinal/metatarsal, each
Arch Support, Nonremovable, Attached to Shoe
L3070	Foot, arch support, nonremovable, attached to shoe, longitudinal, each
L3080	Foot, arch support, nonremovable, attached to shoe, metatarsal, each
L3090	Foot, arch support, nonremovable, attached to shoe, longitudinal/metatarsal, each
L3100	Hallus-Valgus night dynamic splint
Abduction and Rotation Bars
L3140	Foot, abduction rotation bar, including shoes
L3150	Foot, abduction rotation bar, without shoes
L3160	Foot, adjustable shoe-styled positioning device (I.C.)
L3170	Foot, plastic heel stabilizer

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Division of Medical Assistance
Provider Manual Series
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6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-14	

	TRANSMITTAL LETTER
ORT-14	DATE
11/22/02	

602 Service Codes and Descriptions for Orthotic Providers (cont.)
Service
Code	Service Description
Orthopedic Footwear
L3201	Orthopedic shoe, oxford with supinator or pronator, infant (each) (I.C.)
L3202	Orthopedic shoe, oxford with supinator or pronator, child (each) (I.C.)
L3203	Orthopedic shoe, oxford with supinator or pronator, junior (each) (I.C.)
L3204	Orthopedic shoe, hightop with supinator or pronator, infant (each) (I.C.)
L3206	Orthopedic shoe, hightop with supinator or pronator, child (each) (I.C.)
L3207	Orthopedic shoe, hightop with supinator or pronator, junior (each) (I.C.)
L3208	Surgical boot, each, infant (I.C.)
L3209	Surgical boot, each, child (I.C.)
L3211	Surgical boot, each, junior (I.C.)
L3212	Benesch boot, pair, infant (I.C.)
L3213	Benesch boot, pair, child (I.C.)
L3214	Benesch boot, pair, junior (I.C.)
L3215	Orthopedic footwear, woman's shoes, oxford (pair) (I.C.)
L3216	Orthopedic footwear, woman's shoes, depth inlay (pair) (I.C.)
L3217	Orthopedic footwear, woman's shoes, hightop, depth inlay (pair) (I.C.)
L3218	Orthopedic footwear, woman's surgical boot, each (I.C.)
L3219	Orthopedic footwear, man's shoes, oxford (pair) (I.C.)
L3221	Orthopedic footwear, man's shoes, depth inlay (pair) (I.C.)
L3222	Orthopedic footwear, man's shoes, hightop, depth inlay (pair) (I.C.)
L3223	Orthopedic footwear, man's surgical boot, each (I.C.)
L3224	Orthopedic footwear, woman's shoe, oxford, used as an integral part of a brace (orthosis) (each)
(I.C.)
L3225	Orthopedic footwear, man's shoe, oxford, used as an integral part of a brace (orthosis) (each)
(I.C.)
L3230	Orthopedic footwear, custom shoes, depth inlay, each (I.C.)
L3250	Orthopedic footwear, custom-molded shoe, removable inner mold, prosthetic shoe, each (I.C.)
L3251	Foot, shoe molded to patient model, silicone shoe, each (I.C.)
L3252	Foot, shoe molded to patient model, Plastazote (or similar), custom fabricated, each (I.C)
L3253	Foot, molded shoe Plastazote (or similar) custom fitted, each (I.C.)
L3254	Nonstandard size or width (pair) (I.C.)
L3255	Nonstandard size or length (pair) (I.C.)
L3257	Orthopedic footwear, additional charge for split size (pair) (I.C.)
L3265	Plastazote sandal, each (I.C.)
L3300	Lift, elevation, heel, tapered to metatarsals, per inch
L3310	Lift, elevation, heel and sole, neoprene, per inch
L3320	Lift, elevation, heel and sole, cork, per inch
L3332	Lift, elevation, inside shoe, tapered, up to one-half inch
L3334	Lift, elevation, heel, per inch
Shoe Modification—Lifts

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Division of Medical Assistance
Provider Manual Series
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602 Service Codes and Descriptions for Orthotic Providers (cont.)
Service
Code	Service Description
Shoe Modification—Wedges
L3350	Heel wedge (each shoe)
L3360	Sole wedge, outside sole (each shoe)
L3370	Sole wedge, between sole (each shoe)
L3390	Outflare wedge (each shoe)
L3400	Metatarsal bar wedge; rocker (each shoe)
L3420	Full sole and heel wedge, between sole (each shoe)
Shoe Modification—Heels
L3450	Heel, SACH cushion type (each shoe)
L3455	Heel, new leather, standard (each shoe)
L3460	Heel, new rubber, standard (each shoe)
L3465	Heel, Thomas with wedge (each shoe)
L3470	Heel, Thomas extended to ball (each shoe)
L3480	Heel, pad and depression for spur (each shoe)
L3485	Heel, pad, removable for spur (each shoe)
Miscellaneous Shoe Additions
L3500	Orthopedic shoe addition, insole, leather (each shoe)
L3510	Orthopedic shoe addition, insole, rubber (each shoe)
L3530	Orthopedic shoe addition, sole, half (each shoe)
L3540	Orthopedic shoe addition, sole, full (each shoe)
L3570	Orthopedic shoe addition, special extension to instep (leather with eyelets) (each shoe)
L3580	Orthopedic shoe addition, convert instep to Velcro closure (each shoe)
L3590	Orthopedic shoe addition, convert firm shoe counter to soft counter (each shoe)
L3595	Orthopedic shoe addition, March bar (each shoe)
Transfer or Replacement
L3600	Transfer of an orthosis from one shoe to another, caliper plate, existing
L3610	Transfer of an orthosis from one shoe to another, caliper plate, new
L3620	Transfer of an orthosis from one shoe to another, solid stirrup, existing
L3630	Transfer of an orthosis from one shoe to another, solid stirrup, new
L3640	Transfer of an orthosis from one shoe to another, Dennis Browne splint (Riveton), both shoes
L3649	Orthopedic shoe, modification, addition, or transfer, not otherwise specified (each)

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Division of Medical Assistance
Provider Manual Series
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6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-16	

	TRANSMITTAL LETTER
ORT-14	DATE
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602 Service Codes and Descriptions for Orthotic Providers (cont.)
Service
Code       Service Description
ORTHOTIC DEVICES—UPPER LIMB

L3650 L3660
L3670 L3675
L3677
L3700 L3710 L3720 L3730 L3740
L3760
L3800 L3805 L3807
L3810 L3815
L3820 L3825 L3830 L3835 L3840

The services in this section are considered "base" or "basic" procedures and may be modified by listing procedures from the "additions" sections and adding them to the base procedure.
Shoulder Orthosis (SO)
SO, figure of eight design abduction restrainer, prefabricated, includes fitting and adjustment SO, figure of eight design abduction restrainer, canvas and webbing, prefabricated, includes fitting
and adjustment SO, acromio/clavicular (canvas and webbing type), prefabricated, includes fitting and adjustment SO, vest type abduction restrainer, canvas webbing type, or equal, prefabricated, includes fitting
and adjustment Shoulder orthosis, hard plastic, shoulder stabilizer, prefabricated, includes fitting and adjustment
(I.C.)
Elbow Orthosis (EO)
EO, elastic with stays, prefabricated, includes fitting and adjustment
EO, elastic with metal joints, prefabricated, includes fitting and adjustment
EO, double upright with forearm/arm cuffs, free motion, custom fabricated
EO, double upright with forearm/arm cuffs, extension/flexion assist, custom fabricated
EO, double upright with forearm/arm cuffs, adjustable position lock with active control, custom
fabricated Elbow orthosis, with adjustable position locking joint(s), prefabricated, includes fitting and
adjustments, any type
Wrist-Hand-Finger Orthosis (WHFO)
WHFO, short opponens, no attachments, custom fabricated
WHFO, long opponens, no attachment, custom fabricated
WHFO, without joint(s), prefabricated, includes fitting and adjustment, any type
Additions
WHFO, addition to short and long opponens, thumb abduction ("C") bar
WHFO, addition to short and long opponens, second M.P. abduction assist
WHFO, addition to short and long opponens, I.P. extension assist, with M.P. extension stop
WHFO, addition to short and long opponens, M.P. extension stop
WHFO, addition to short and long opponens, M.P. extension assist
WHFO, addition to short and long opponens, M.P. spring extension assist
WHFO, addition to short and long opponens, spring swivel thumb

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
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6 SERVICE CODES AND DESCRIPTIONS	PAGE
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	TRANSMITTAL LETTER
ORT-14	DATE
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602 Service Codes and Descriptions for Orthotic Providers (cont.)
Service
Code       Service Description
L3845      WHFO, addition to short and long opponens, thumb I.P. extension assist, with M.P. stop L3850      WHFO, addition to short and long opponens, action wrist, with dorsiflexion assist L3855      WHFO, addition to short and long opponens, adjustable M.P. flexion control L3860      WHFO, addition to short and long opponens, adjustable M.P. flexion control and I.P. L3890      Addition to upper extremity joint, wrist or elbow, concentric adjustable torsion style mechanism, each
Dynamic Flexor Hinge, Reciprocal Wrist Extension/Flexion, Finger Flexion/Extension
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
L3902      WHFO, external powered, compressed gas, custom fabricated L3904      WHFO, external powered, electric, custom fabricated
Other WHFOs—Custom Fitted
L3906	WHO, wrist gauntlet, molded to patient model, custom fabricated
L3907	WHGO, wrist gauntlet with thumb spica, molded to patient model, custom fabricated
L3908	WHO, wrist extension control cock-up, nonmolded, prefabricated, includes fitting and adjustment
L3910	WHFO, Swanson design, prefabricated, includes fitting and adjustment
L3912	HFO, flexion glove with elastic finger control, prefabricated, includes fitting and adjustment
L3914	WHO, wrist extension cock-up, prefabricated, includes fitting and adjustment
L3916	WHFO, wrist extension cock-up, with outrigger, prefabricated, includes fitting and adjustment
L3918	HFO, knuckle bender, prefabricated, includes fitting and adjustment
L3920	HFO, knuckle bender, with outrigger, prefabricated, includes fitting and adjustment
L3922	HFO, knuckle bender, two segment to flex joints, prefabricated, includes fitting and adjustment
L3923	Hand finger orthosis, without joint(s), prefabricated, includes fitting and adjustment
L3924	WHFO, Oppenheimer, prefabricated, includes fitting and adjustment
L3926	WHFO, Thomas suspension, prefabricated, includes fitting and adjustment
L3928	HFO, finger extension, with clock spring, prefabricated, includes fitting and adjustment
L3930	WHFO, finger extension, with wrist support, prefabricated, includes fitting and adjustment
L3932	FO, safety pin, spring wire, prefabricated, includes fitting and adjustment
L3934	FO, safety pin, modified, prefabricated, includes fitting and adjustment
L3936	WHFO, Palmer, prefabricated, includes fitting and adjustment
L3938	WHFO, dorsal wrist, prefabricated, includes fitting and adjustment
L3940	WHFO, dorsal wrist, with outrigger attachment, prefabricated, includes fitting and adjustment

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Division of Medical Assistance
Provider Manual Series
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	TRANSMITTAL LETTER
ORT-14	DATE
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602 Service Codes and Descriptions for Orthotic Providers (cont.)
Service
Code       Service Description
L3942      HFO, reverse knuckle bender, prefabricated, includes fitting and adjustment
L3944      HFO, reverse knuckle bender, with outrigger, prefabricated, includes fitting and adjustment
L3946      HFO, composite elastic, prefabricated, includes fitting and adjustment
L3948      FO, finger knuckle bender, prefabricated, includes fitting and adjustment
L3950      WHFO, combination Oppenheimer, with knuckle bender and two attachments, prefabricated,
includes fitting and adjustment L3952      WHFO, combination Oppenheimer, with reverse knuckle and two attachments, prefabricated,
includes fitting and adjustment L3954      HFO, spreading hand, prefabricated, includes fitting and adjustment L3956      Addition of joint to upper extremity orthosis, any material, per joint (I.C.)
SHOULDER-ELBOW-WRIST-HAND ORTHOSIS (SEWHO)
Abduction Position—Custom Fitted
L3960      SEWHO, abduction positioning, airplane design, prefabricated, includes fitting and adjustment L3962      SEWHO, abduction positioning, abduction positioning, Erb's palsey design, prefabricated,
includes fitting and adjustment L3963      SEWHO, molded shoulder, arm, forearm, and wrist, with articulating elbow joint, custom
fabricated L3964      SEO, mobile arm support attached to wheelchair, balanced, adjustable, prefabricated, includes
fitting and adjustment L3965      SEO, mobile arm support attached to wheelchair, balanced, adjustable Rancho type, prefabricated,
includes fitting and adjustment L3966      SEO, mobile arm support attached to wheelchair, balanced, reclining, prefabricated, includes
fitting and adjustment L3968      SEO, mobile arm support attached to wheelchair, balanced, friction arm support (friction
dampening to proximal and distal joints), prefabricated, includes fitting and adjustment L3969      SEO, mobile arm support, monosuspension arm and hand support, overhead elbow forearm hand
sling support, yoke type arm suspension support, prefabricated, includes fitting and adjustment
Additions to Mobile Arm Supports
L3970      SEO, addition to mobile arm support, elevating proximal arm
L3972      SEO, addition to mobile arm support, offset or lateral rocker arm with elastic balance control
L3974      SEO, addition to mobile arm support, supinator
Fracture Orthosis
L3980      Upper extremity fracture orthosis, humeral, prefabricated, includes fitting and adjustment L3982      Upper extremity fracture orthosis, radius/ulnar, prefabricated, includes fitting and adjustment L3984      Upper extremity fracture orthosis, wrist, prefabricated, includes fitting and adjustment

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Division of Medical Assistance
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ORT-14	DATE
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602 Service Codes and Descriptions for Orthotic Providers (cont.)
Service
Code       Service Description
L3985	Upper extremity fracture orthosis, forearm, hand with wrist hinge, custom fabricated
L3986	Upper extremity fracture orthosis, combination of humeral, radius/ulnar, wrist (example: Colles'
fracture), custom fabricated
L3995	Addition to upper extremity orthosis, sock, fracture or equal, each
L3999	Upper limb orthosis, not otherwise specified (I.C.)
Specific Repair
L4000	Replace girdle for spinal orthosis (CTLSO or SO)
L4010	Replace trilateral socket brim
L4020	Replace quadrilateral socket brim, molded to patient model
L4030	Replace quadrilateral socket brim, custom fitted
L4040	Replace molded thigh lacer
L4045	Replace nonmolded thigh lacer
L4050	Replace molded calf lacer
L4055	Replace nonmolded calf lacer
L4060	Replace high roll cuff
L4070	Replace proximal and distal upright for KAFO
L4080	Replace metal bands KAFO, proximal thigh
L4090	Replace metal bands KAFO-AFO, calf or distal thigh
L4100	Replace leather cuff KAFO, proximal thigh
L4110	Replace leather cuff KAFO-AFO, calf or distal thigh
L4130	Replace pretibial shell
Repairs
L4205	Repair of orthotic device, labor component, per 15 minutes
L4210	Repair of orthotic device, repair or replace minor parts (I.C.)
L4350	Pneumatic ankle control splint (e.g., aircast), prefabricated, includes fitting and adjustment
L4360	Pneumatic walking splint (e.g., aircast), prefabricated, includes fitting and adjustment
L4370	Pneumatic full leg splint (e.g., aircast), prefabricated, includes fitting and adjustment
L4380	Pneumatic knee splint (e.g., aircast), 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
Y9530	Nursing facility visit

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602	Service Codes and Descriptions for Orthotic Providers (cont.)
Service
Code       Service Description
DIABETIC SHOES, FITTING, AND MODIFICATIONS
A5500     For diabetics only, fitting (including follow-up), custom preparation and supply of off-the-shelf depth-inlay shoe manufactured to accommodate multi-density insert(s), per shoe (I.C.)
A5501     For diabetics only, fitting (including follow-up), custom preparation and supply of shoe molded from cast(s) of patient's foot (custom-molded shoe), per shoe (I.C.)
A5503     For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with roller or rigid rocker bottom, per shoe (I.C.)
A5504     For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe with wedge(s), per shoe (I.C.)
A5505     For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe with metatarsal bar, per shoe (I.C.)
A5506     For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe with off-set heel(s), per shoe (I.C.)
A5507     For diabetics only, not otherwise specified modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe, per shoe (I.C.)
A5508     For diabetics only, deluxe feature of off-the-shelf depth-inlay shoe or custom-molded shoe, per shoe (I.C.)
A5509     For diabetics only, direct formed, molded to foot with external heat source (i.e. heat gun) multiple density insert(s), prefabricated, per shoe (I.C.)
A5510     For diabetics only, direct formed, compression molded to patient’s foot without external heat source, multiple-density insert(s) prefabricated, per shoe (I.C.)
A5511     For diabetics only, custom-molded from model of patient’s foot, multiple density insert(s), custom-fabricated, per shoe (I.C.)
603	Service Codes and Descriptions for Pedorthic Providers
Service Code
Service Description
ORTHOPEDIC SHOES
Inserts
L3000	Foot insert, removable, molded to patient model, "UCB" type, Berkeley shell, each
L3001	Foot insert, removable, molded to patient model, Spenco, each
L3002	Foot insert, removable, molded to patient model, Plastazote or equal, each
L3003	Foot insert, removable, molded to patient model, silicone gel, each
L3010	Foot insert, removable, molded to patient model, longitudinal arch support, each
L3020	Foot insert, removable, molded to patient model, longitudinal/metatarsal support, each
L3030	Foot insert, removable, formed to patient foot, each

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ORTHOTICS MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-21	

	TRANSMITTAL LETTER
ORT-14	DATE
11/22/02	
603 Service Codes and Descriptions for Pedorthic Providers (cont.)
Service
Code       Service Description
Arch Support, Removable, Premolded
L3040      Foot, arch support, removable, premolded, longitudinal, each
L3050      Foot, arch support, removable, premolded, metatarsal, each
L3060      Foot, arch support, removable, premolded, longitudinal/metatarsal, each
Arch Support, Nonremovable, Attached to Shoe
L3070	Foot, arch support, nonremovable, attached to shoe, longitudinal, each
L3080	Foot, arch support, nonremovable, attached to shoe, metatarsal, each
L3090	Foot, arch support, nonremovable, attached to shoe, longitudinal/metatarsal, each
L3100	Hallus-Valgus night dynamic splint
Orthopedic Footwear
L3201	Orthopedic shoe, oxford with supinator or pronator, infant (each) (I.C.)
L3202	Orthopedic shoe, oxford with supinator or pronator, child (each) (I.C.)
L3203	Orthopedic shoe, oxford with supinator or pronator, junior (each) (I.C.)
L3204	Orthopedic shoe, hightop with supinator or pronator, infant (each) (I.C.)
L3206	Orthopedic shoe, hightop with supinator or pronator, child (each) (I.C.)
L3207	Orthopedic shoe, hightop with supinator or pronator, junior (each) (I.C.)
L3208	Surgical boot, each, infant (I.C.)
L3209	Surgical boot, each, child (I.C.)
L3211	Surgical boot, each, junior (I.C.)
L3212	Benesch boot, pair, infant (I.C.)
L3213	Benesch boot, pair, child (I.C.)
L3214	Benesch boot, pair, junior (I.C.)
L3215	Orthopedic footwear, woman's shoes, oxford (pair) (I.C.)
L3216	Orthopedic footwear, woman's shoes, depth inlay (pair) (I.C.)
L3217	Orthopedic footwear, woman's shoes, hightop, depth inlay (pair) (I.C.)
L3218	Orthopedic footwear, woman's surgical boot, each (I.C.)
L3219	Orthopedic footwear, man's shoes, oxford (pair) (I.C.)
L3221	Orthopedic footwear, man's shoes, depth inlay (pair) (I.C.)
L3222	Orthopedic footwear, man's shoes, hightop, depth inlay (pair) (I.C.)
L3223	Orthopedic footwear, man's surgical boot, each (I.C.)
L3224	Orthopedic footwear, woman's shoe, oxford, used as an integral part of a brace (orthosis) (each)
(I.C.)
L3225	Orthopedic footwear, man's shoe, oxford, used as an integral part of a brace (orthosis) (each)
(I.C.)
L3230	Orthopedic footwear, custom shoes, depth inlay (each) (I.C.)
L3250	Orthopedic footwear, custom-molded shoe, removable inner mold, prosthetic shoe, each (I.C.)
L3251	Foot, shoe molded to patient model, silicone shoe, each (I.C.)
L3252	Foot, shoe molded to patient model, Plastazote (or similar), custom fabricated, each (I.C)
L3253	Foot, molded shoe Plastazote (or similar) custom fitted, each (I.C.)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ORTHOTICS MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-22	

	TRANSMITTAL LETTER
ORT-14	DATE
11/22/02	
603 Service Codes and Descriptions for Pedorthic Providers (cont.)
Service
Code	Service Description
L3254	Nonstandard size or width (pair) (I.C.)
L3255	Nonstandard size or length (pair) (I.C.)
L3257	Orthopedic footwear, additional charge for split size (pair) (I.C.)
L3265	Plastazote sandal, each (I.C.)
Shoe Modification—Lifts
L3300	Lift, elevation, heel, tapered to metatarsals, per inch
L3310	Lift, elevation, heel and sole, neoprene, per inch
L3320	Lift, elevation, heel and sole, cork, per inch
L3332	Lift, elevation, inside shoe, tapered, up to one-half inch
L3334	Lift, elevation, heel, per inch
Shoe Modification—Wedges
L3350	Heel wedge (each shoe)
L3360	Sole wedge, outside sole (each shoe)
L3370	Sole wedge, between sole (each shoe)
L3390	Outflare wedge (each shoe)
L3400	Metatarsal bar wedge; rocker (each shoe)
L3420	Full sole and heel wedge, between sole (each shoe)
Shoe Modification—Heels
L3450	Heel, SACH cushion type (each shoe)
L3455	Heel , new leather, standard (each shoe)
L3460	Heel, new rubber, standard (each shoe)
L3465	Heel, Thomas with wedge (each shoe)
L3470	Heel, Thomas extended to ball (each shoe)
L3480	Heel, pad and depression for spur (each shoe)
L3485	Heel, pad, removable for spur (each shoe)
Miscellaneous Shoe Additions
L3500	Orthopedic shoe addition, insole, leather (each shoe)
L3510	Orthopedic shoe addition, insole, rubber (each shoe)
L3530	Orthopedic shoe addition, sole, half (each shoe)
L3540	Orthopedic shoe addition, sole, full (each shoe)
L3570	Orthopedic shoe addition, special extension to instep (leather with eyelets) (each shoe)
L3580	Orthopedic shoe addition, convert instep to Velcro closure (each shoe)
L3590	Orthopedic shoe addition, convert firm shoe counter to soft counter (each shoe)
L3595	Orthopedic shoe addition, March bar (each shoe)
L3649	Orthopedic shoe, modification, addition, or transfer, not otherwise specified (each) (I.C.)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ORTHOTICS MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-23	

	TRANSMITTAL LETTER
ORT-14	DATE
11/22/02	
603 Service Codes and Descriptions for Pedorthic Providers (cont.)
Service
Code       Service Description
Repairs
L4205      Repair of orthotic device, labor component, per 15 minutes L4210      Repair of orthotic device, repair or replace minor parts (I.C.) Y9530     Nursing facility visit
DIABETIC SHOES, FITTING, AND MODIFICATIONS
A5500     For diabetics only, fitting (including follow-up), custom preparation and supply of off-the-shelf depth-inlay shoe manufactured to accommodate multi-density insert(s), per shoe (I.C.)
A5501     For diabetics only, fitting (including follow-up), custom preparation and supply of shoe molded from cast(s) of patient's foot (custom-molded shoe), per shoe (I.C.)
A5503     For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with roller or rigid rocker bottom, per shoe (I.C.)
A5504     For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe with wedge(s), per shoe (I.C.)
A5505     For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe with metatarsal bar, per shoe (I.C.)
A5506     For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe with off-set heel(s), per shoe (I.C.)
A5507     For diabetics only, not otherwise specified modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe, per shoe (I.C.)
A5508     For diabetics only, deluxe feature of off-the-shelf depth-inlay shoe or custom-molded shoe, per shoe (I.C.)
A5509     For diabetics only, direct formed, molded to foot with external heat source (i.e. heat gun) multiple density insert(s), prefabricated, per shoe (I.C.)
A5510     For diabetics only, direct formed, compression molded to patient’s foot without external heat source, multiple-density insert(s) prefabricated, per shoe (I.C.)
A5511     For diabetics only, custom-molded from model of patient’s foot, multiple density insert(s), custom fabricated, per shoe (I.C.)
PROSTHETIC PROCEDURES
LOWER LIMB
Partial Foot
L5000      Partial foot, shoe insert with longitudinal arch, toe filler (each) (I.C.)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ORTHOTICS MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-24	

	TRANSMITTAL LETTER
ORT-14	DATE
11/22/02	
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