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-16
June 2003
TO:      Orthotic Providers Participating in MassHealth
FROM:      Douglas S. Brown, Acting Commissioner.
RE:      Orthotics Manual (Restoration of Certain Orthotic Services and Revised Subchapter 6)

This letter transmits revised regulations for orthotic providers. Effective July 1, 2003, the Division is restoring coverage for certain orthotic services that were previously available to MassHealth members aged 21 and older.
This letter also transmits a revised and reformatted Subchapter 6 for the Orthotics Manual. Subchapter 6 now lists all covered service codes in alphanumeric order, and no longer includes service descriptions. Providers must refer to the St. Anthony’s National HCPCS 2003 code book for the descriptions of the codes listed in Subchapter 6. Subchapter 6 is now also formatted to indicate service limitations according to the member’s age. The limitations listed in Subchapter 6 are in addition to all other conditions and limitations of payment in the Division’s regulations at 130 CMR 442.000 and 450.000.
Subchapter 6 has also been updated to reflect the Centers for Medicare and Medicaid Services revisions to the Healthcare Common Procedure Coding System (HCPCS) for 2003. To ensure that the Division’s codes are compliant with the Health Insurance Portability and Accountability Act (HIPAA) of 1996, new national service codes have been added and obsolete national service codes and MassHealth local codes have been removed.
The revisions to the regulations were filed as an emergency. The revised regulations and Subchapter 6 are effective for dates of service on and after July 1, 2003.
NEW MATERIAL
(The pages listed here contain new or revised language.)
Orthotics Manual
Pages iv, vi, 4-1 through 4-6, and 6-1 through 6-12
OBSOLETE MATERIAL
(The pages listed here are no longer in effect.)
Orthotics Manual
Pages iv, vi, 4-1, 4-2, 4-5, 4-6, and 6-1 through 6-24 — transmitted by Transmittal Letter ORT-14
Pages 4-3 and 4-4 — transmitted by Transmittal Letter ORT-15

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ORTHOTICS MANUAL	SUBCHAPTER NUMBER AND TITLE
TABLE OF CONTENTS	PAGE
iv	

	TRANSMITTAL LETTER
ORT-16	DATE
07/01/03	
4.   PROGRAM REQUIREMENTS
442.401:	Introduction 		4-1
442.402:	Definitions 		4-1
442.403:	Eligible Members 		4-3
442.404:	Provider Eligibility 		4-3
442.405:	Provider Responsibility 		4-4
442.406:	Covered Services 		4-4
442.407:	Service Limitations 		4-4
442.408:	Noncovered Services 		4-5
442.409:	Prescription and Other Documentation Requirements 		4-6
442.410:	Orthotic and Pedorthic Services and Equipment Provided to
Institutionalized Members 		4-6
442.411:	Repairs of Orthotic and Pedorthic Equipment 		4-7
442.412:	Prior Authorization 		4-7
442.413:	Procedure for Requesting Prior Authorization 		4-8
442.414:	Medicare Coverage 		4-8
(130 CMR 442.415 through 442.419 Reserved)
442.420:	Payment for Orthotic or Pedorthic Services 		4-9
442.421:	Individual Consideration 		4-9
442.422:	Adjusted Acquisition Cost 		4-10
442.423:	Recordkeeping Requirements 		4-10

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ORTHOTICS MANUAL	SUBCHAPTER NUMBER AND TITLE
TABLE OF CONTENTS	PAGE
vi	

	TRANSMITTAL LETTER
ORT-16	DATE
07/01/03	
6.   SERVICE CODES
601	Introduction 	       6-1
602	Service Codes and Limitations 	       6-1
Appendix A. DIRECTORY 		A-1
Appendix B. ENROLLMENT CENTERS 		B-1
Appendix C. THIRD-PARTY-LIABILITY CODES 		C-1
Appendix W. EPSDT SERVICES: MEDICAL PROTOCOL AND
PERIODICITY SCHEDULE 		W-1
Appendix X. FAMILY ASSISTANCE COPAYMENTS AND DEDUCTIBLES 		X-1
Appendix Y. REVS/CODES MESSAGES 		Y-1
Appendix Z. EPSDT SERVICES LABORATORY CODES 		Z-1

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-16	DATE
07/01/03	
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, 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-16	DATE
07/01/03	
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 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-16	DATE
07/01/03	
Pedorthic Service — the design, manufacture, modification, and fitting of orthopedic or diabetic shoes, including foot orthoses, 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)	Age Limitations. In addition to any other restrictions and limitations set forth in 130 CMR 442.000 and 450.000, the Division covers orthotic and pedorthic services only when provided to eligible MassHealth members, subject to the age limitations set forth in Subchapter 6 of the Orthotics Manual. No age restriction applies to therapeutic, moldable, or custom-molded shoes and shoe inserts for members who have severe diabetic foot disease.
(3)	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;

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-16	DATE
07/01/03	
(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.
(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, and subject to the service limitations set forth in, 130 CMR 442.407 and 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-16	DATE
07/01/03	
(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.
(F)	Other Service Limitations. The service limitations set forth in Subchapter 6 of the Orthotics
Manual apply, subject to the Early and Periodic Screening, Diagnosis, and Treatment provisions
set forth in 130 CMR 450.144(A).
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.
(1)	
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-16	DATE
07/01/03	
442.409:  Prescription and Other Documentation 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, the provider must complete the shoe prescription form designated by the
Division. A copy of the shoe prescription form must be submitted to the Division to support
the provider’s claim.
(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 shoe prescription form and any accompanying letters, if required, 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.
(1)	
Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ORTHOTICS MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES	PAGE
6-1	

	TRANSMITTAL LETTER
ORT-16	DATE
07/01/03	
601 Introduction
MassHealth providers must refer to the St. Anthony’s National HCPCS 2003 code book for the descriptions of the service codes listed in Section 602.
The Division pays for all codes listed in Section 602 in effect at the time of service, subject to all the conditions and limitations in Subchapter 6 and in the Division’s regulations at 130 CMR 442.000 and 450.000
602 Service Codes and Limitations
HCPCS	Covered	Covered	Service	
Code	Under Age 21?	Age 21 and older?	Limitations	
A5500	Yes	Yes	4 per	12 months	
A5501	Yes	Yes	4 per	12 months	
A5503	Yes	Yes	4 per	12 months	
A5504	Yes	Yes	4 per	12 months	
A5505	Yes	Yes	4 per	12 months	
A5506	Yes	Yes	4 per	12 months	
A5507	Yes	Yes	4 per	12 months	
A5508	Yes	Yes	4 per	12 months	
A5509	Yes	Yes	12 per 12 months	
A5511	Yes	Yes	4 per	12 months	
L0100	Yes	Yes	1 per	12 months	
L0110	Yes	No	1 per	12 months	
L0120	Yes	No	2 per	12 months	
L0130	Yes	No	2 per	12 months	
L0140	Yes	No	1 per	12 months	
L0150	Yes	No	1 per	12 months	
L0160	Yes	Yes	1 per	12 months	
L0170	Yes	Yes	1 per	12 months	
L0172	Yes	Yes	2 per	12 months	
L0174	Yes	Yes	2 per	12 months	
L0180	Yes	No	1 per	12 months	
L0190	Yes	Yes	1 per	12 months	
L0200	Yes	No	1 per	12 months	
L0210	Yes	No	1 per	12 months	
L0220	Yes	No	1 per	12 months	
L0450	Yes	No	1 per	12 months	
L0452	Yes	No	1 per	12 months	
L0454	Yes	No	1 per	12 months	
L0456	Yes	No	1 per	12 months	
L0458	Yes	Yes	1 per	12 months	

Commonwealth of Massachusetts	SUBCHAPTER NUMBER AND TITLE	PAGE	
Division of Medical Assistance Provider Manual Series
ORTHOTICS MANUAL		6 SERVICE CODES	6-2	

		TRANSMITTAL LETTER	DATE	
			ORT-16		07/01/03	
602 Service Codes and Limitations (cont.)				
HCPCS	Covered                    Covered	Service	
Code	Under Age 21?         Age 21 and older?      Limitations	
L0460	Yes	Yes	1 per	12 months	
L0462	Yes	Yes	1 per	12 months	
L0464	Yes	Yes	1 per	12 months	
L0466	Yes	No	1 per	12 months	
L0468	Yes	No	1 per	12 months	
L0470	Yes	No	1 per	12 months	
L0472	Yes	Yes	1 per	12 months	
L0474	Yes	No	1 per	12 months	
L0476	Yes	No	1 per	12 months	
L0478	Yes	No	1 per	12 months	
L0480	Yes	Yes	1 per	12 months	
L0482	Yes	Yes	1 per	12 months	
L0484	Yes	Yes	1 per	12 months	
L0486	Yes	Yes	1 per	12 months	
L0488	Yes	Yes	1 per	12 months	
L0490	Yes	Yes	1 per	12 months	
L0500	Yes	No	1 per	12 months	
L0510	Yes	No	1 per	12 months	
L0515	Yes	Yes	1 per	12 months	
L0520	Yes	No	1 per	12 months	
L0530	Yes	No	1 per	12 months	
L0540	Yes	No	1 per	12 months	
L0550	Yes	Yes	1 per	12 months	
L0560	Yes	Yes	1 per	12 months	
L0561	Yes	No	1 per	12 months	
L0565	Yes	Yes	1 per	12 months	
L0600	Yes	No	1 per	12 months	
L0610	Yes	No	1 per	12 months	
L0620	Yes	No	1 per	12 months	
L0700	Yes	Yes	1 per	12 months	
L0710	Yes	Yes	1 per	12 months	
L0810	Yes	No	1 per	12 months	
L0820	Yes	No	1 per	12 months	
L0830	Yes	No	1 per	12 months	
L0860	Yes	No	1 per	12 months	
L0960	Yes	No	4 per	12 months	
L0970	Yes	No	1 per	12 months	
L0972	Yes	No	1 per	12 months	
L0974	Yes	No	1 per	12 months	
L0976	Yes	No	1 per	12 months	
L0978	Yes	No	1 per	12 months	
L0980	Yes	No	1 per	12 months			

Commonwealth of Massachusetts		SUBCHAPTER NUMBER AND TITLE	PAGE	
Division of Medical Assistance Provider Manual Series
ORTHOTICS MANUAL		6 SERVICE CODES	6-3	

		TRANSMITTAL LETTER	DATE	
			ORT-16	07/01/03	
602 Service Codes and Limitations (cont.)			
HCPCS	Covered                    Covered	Service	
Code	Under Age 21?         Age 21 and older?      Limitations	
L0982	Yes	No	2 per 12 months	
L0984	Yes	No	3 per 6 months	
L0999	Yes	Yes	2 per 12 months	
L1000	Yes	No	1 per 12 months	
L1005	Yes	No	1 per 12 months	
L1010	Yes	No	2 per 12 months	
LI 020	Yes	No	2 per 12 months	
LI 025	Yes	No	2 per 12 months	
L1030	Yes	No	2 per 12 months	
LI 040	Yes	No	2 per 12 months	
L1050	Yes	No	2 per 12 months	
L1060	Yes	No	2 per 12 months	
L1070	Yes	No	2 per 12 months	
L1080	Yes	No	2 per 12 months	
L1085	Yes	No	2 per 12 months	
L1090	Yes	No	2 per 12 months	
L1100	Yes	No	2 per 12 months	
L1110	Yes	No	2 per 12 months	
L1120	Yes	No	4 per 12 months	
L1200	Yes	No	1 per 12 months	
L1210	Yes	No	1 per 12 months	
L1220	Yes	No	1 per 12 months	
L1230	Yes	No	1 per 12 months	
L1240	Yes	No	2 per 12 months	
L1250	Yes	No	2 per 12 months	
L1260	Yes	No	2 per 12 months	
L1270	Yes	No	2 per 12 months	
L1280	Yes	No	2 per 12 months	
L1290	Yes	No	2 per 12 months	
L1300	Yes	No	1 per 12 months	
L1310	Yes	No	1 per 12 months	
L1499	Yes	Yes	~	
L1500	Yes	No	1 per 12 months	
L1510	Yes	No	1 per 12 months	
L1520	Yes	No	1 per 12 months	
L1600	Yes	No	2 per 12 months	
L1610	Yes	No	2 per 12 months	
LI 620	Yes	No	2 per 12 months	
L1630	Yes	No	2 per 12 months	
LI 640	Yes	No	2 per 12 months	
L1650	Yes	No	2 per 12 months	
L1652	Yes	Yes	1 per 12 months			

Commonwealth of Massachusetts	SUBCHAPTER NUMBER AND TITLE	PAGE	
Division of Medical Assistance Provider Manual Series
ORTHOTICS MANUAL		6 SERVICE CODES	6-4	

		TRANSMITTAL LETTER	DATE	
			ORT-16		07/01/03	
602 Service Codes and Limitations (cont.)				
HCPCS	Covered                    Covered	Service	
Code	Under Age 21?         Age 21 and older?      Limitations	
L1660	Yes	No	2 per	12 months	
L1680	Yes	Yes	1 per	12 months	
L1685	Yes	Yes	1 per	12 months	
L1686	Yes	Yes	1 per	12 months	
L1690	Yes	No	2 per	12 months	
L1700	Yes	No	2 per	12 months	
L1710	Yes	No	2 per	12 months	
LI 720	Yes	No	2 per	12 months	
L1730	Yes	No	2 per	12 months	
L1750	Yes	No	2 per	12 months	
L1755	Yes	No	2 per	12 months	
L1800	Yes	No	2 per	12 months	
L1810	Yes	No	2 per	12 months	
L1815	Yes	No	2 per	12 months	
L1820	Yes	No	2 per	12 months	
L1825	Yes	No	2 per	12 months	
L1830	Yes	No	2 per	12 months	
L1832	Yes	Yes	2 per	12 months	
L1834	Yes	Yes	2 per	12 months	
L1836	Yes	Yes	2 per	12 months	
L1840	Yes	Yes	2 per	12 months	
L1843	Yes	Yes	2 per	12 months	
LI 844	Yes	Yes	2 per	12 months	
L1845	Yes	No	2 per	12 months	
L1846	Yes	Yes	2 per	12 months	
L1847	Yes	Yes	2 per	12 months	
L1850	Yes	No	2 per	12 months	
L1855	Yes	Yes	2 per	12 months	
L1858	Yes	Yes	2 per	12 months	
L1860	Yes	No	2 per	12 months	
L1870	Yes	Yes	2 per	12 months	
L1880	Yes	Yes	2 per	12 months	
L1885	Yes	Yes	2 per	12 months	
L1900	Yes	Yes	2 per	12 months	
L1901	Yes	No	2 per	12 months	
LI 902	Yes	No	2 per	12 months	
LI 904	Yes	Yes	2 per	12 months	
L1906	Yes	No	2 per	12 months	
L1910	Yes	Yes	2 per	12 months	
LI 920	Yes	Yes	2 per	12 months	
L1930	Yes	Yes	2 per	12 months	
LI 940	Yes	Yes	2 per	12 months			

Commonwealth of Massachusetts	SUBCHAPTER NUMBER AND TITLE	PAGE	
Division of Medical Assistance Provider Manual Series
ORTHOTICS MANUAL		6 SERVICE CODES	6-5	

		TRANSMITTAL LETTER	DATE	
			ORT-16		07/01/03	
602 Service Codes and Limitations (cont.)				
HCPCS	Covered                    Covered	Service	
Code	Under Age 21?         Age 21 and older?      Limitations	
LI 945	Yes	Yes	2 per	12 months	
L1950	Yes	Yes	2 per	12 months	
L1960	Yes	Yes	2 per	12 months	
L1970	Yes	Yes	2 per	12 months	
L1980	Yes	Yes	2 per	12 months	
L1990	Yes	Yes	2 per	12 months	
L2000	Yes	Yes	2 per	12 months	
L2010	Yes	Yes	2 per	12 months	
L2020	Yes	Yes	2 per	12 months	
L2030	Yes	Yes	2 per	12 months	
L2035	Yes	No	2 per	12 months	
L2036	Yes	Yes	2 per	12 months	
L2037	Yes	Yes	2 per	12 months	
L2038	Yes	Yes	2 per	12 months	
L2039	Yes	Yes	2 per	12 months	
L2040	Yes	Yes	1 per	12 months	
L2050	Yes	Yes	1 per	12 months	
L2060	Yes	Yes	1 per	12 months	
L2070	Yes	Yes	1 per	12 months	
L2080	Yes	Yes	2 per	12 months	
L2090	Yes	Yes	2 per	12 months	
L2106	Yes	Yes	2 per	12 months	
L2108	Yes	Yes	2 per	12 months	
L2112	Yes	Yes	2 per	12 months	
L2114	Yes	Yes	2 per	12 months	
L2116	Yes	Yes	2 per	12 months	
L2126	Yes	Yes	2 per	12 months	
L2128	Yes	Yes	2 per	12 months	
L2132	Yes	Yes	2 per	12 months	
L2134	Yes	Yes	2 per	12 months	
L2136	Yes	Yes	2 per	12 months	
L2180	Yes	Yes	2 per	12 months	
L2182	Yes	Yes	2 per	12 months	
L2184	Yes	Yes	2 per	12 months	
L2186	Yes	Yes	2 per	12 months	
L2188	Yes	Yes	2 per	12 months	
L2190	Yes	Yes	1 per	12 months	
L2192	Yes	Yes	2 per	12 months	
L2200	Yes	Yes	4 per	12 months	
L2210	Yes	Yes	4 per	12 months	
L2220	Yes	Yes	4 per	12 months	
L2230	Yes	Yes	2 per	12 months			

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

		TRANSMITTAL LETTER	DATE	
			ORT-16		07/01/03	
602 Service Codes and Limitations (cont.)				
HCPCS	Covered                    Covered	Service	
Code	Under Age 21?         Age 21 and older?      Limitations	
L2240	Yes	Yes	2 per	12 months	
L2250	Yes	Yes	2 per	12 months	
L2260	Yes	Yes	2 per	12 months	
L2265	Yes	Yes	2 per	12 months	
L2270	Yes	Yes	4 per	12 months	
L2275	Yes	Yes	2 per	12 months	
L2280	Yes	Yes	2 per	12 months	
L2300	Yes	Yes	2 per	12 months	
L2310	Yes	Yes	2 per	12 months	
L2320	Yes	Yes	2 per	12 months	
L2330	Yes	Yes	2 per	12 months	
L2335	Yes	Yes	2 per	12 months	
L2340	Yes	Yes	2 per	12 months	
L2350	Yes	Yes	2 per	12 months	
L2360	Yes	No	2 per	12 months	
L2370	Yes	Yes	2 per	12 months	
L2375	Yes	Yes	4 per	12 months	
L2380	Yes	Yes	4 per	12 months	
L2385	Yes	Yes	4 per	12 months	
L2390	Yes	Yes	4 per	12 months	
L2395	Yes	Yes	4 per	12 months	
L2397	Yes	No	2 per	12 months	
L2405	Yes	Yes	4 per	12 months	
L2415	Yes	Yes	4 per	12 months	
L2425	Yes	Yes	4 per	12 months	
L2430	Yes	Yes	4 per	12 months	
L2435	Yes	Yes	4 per	12 months	
L2492	Yes	Yes	4 per	12 months	
L2500	Yes	Yes	2 per	12 months	
L2510	Yes	Yes	2 per	12 months	
L2520	Yes	Yes	2 per	12 months	
L2525	Yes	Yes	2 per	12 months	
L2526	Yes	Yes	2 per	12 months	
L2530	Yes	Yes	2 per	12 months	
L2540	Yes	Yes	2 per	12 months	
L2550	Yes	Yes	2 per	12 months	
L2570	Yes	Yes	2 per	12 months	
L2580	Yes	Yes	2 per	12 months	
L2600	Yes	Yes	2 per	12 months	
L2610	Yes	Yes	2 per	12 months	
L2620	Yes	Yes	2 per	12 months	
L2622	Yes	Yes	2 per	12 months			

Commonwealth of Massachusetts	SUBCHAPTER NUMBER AND TITLE	PAGE	
Division of Medical Assistance Provider Manual Series
ORTHOTICS MANUAL		6 SERVICE CODES	6-7	

		TRANSMITTAL LETTER	DATE	
			ORT-16		07/01/03	
602 Service Codes and Limitations (cont.)				
HCPCS	Covered                    Covered	Service	
Code	Under Age 21?         Age 21 and older?      Limitations	
L2624	Yes	Yes	2 per	12 months	
L2627	Yes	Yes	2 per	12 months	
L2628	Yes	Yes	2 per	12 months	
L2630	Yes	Yes	2 per	12 months	
L2640	Yes	Yes	2 per	12 months	
L2650	Yes	Yes	2 per	12 months	
L2660	Yes	Yes	2 per	12 months	
L2670	Yes	Yes	2 per	12 months	
L2680	Yes	Yes	2 per	12 months	
L2750	Yes	Yes	4 per	12 months	
L2755	Yes	Yes	4 per	12 months	
L2760	Yes	Yes	4 per	12 months	
L2768	Yes	Yes	4 per	12 months	
L2770	Yes	Yes	8 per	12 months	
L2780	Yes	Yes	8 per	12 months	
L2785	Yes	Yes	4 per	12 months	
L2795	Yes	Yes	2 per	12 months	
L2800	Yes	Yes	2 per	12 months	
L2810	Yes	Yes	2 per	12 months	
L2820	Yes	Yes	4 per	12 months	
L2830	Yes	Yes	4 per	12 months	
L2840	Yes	Yes	6 per	12 months	
L2850	Yes	Yes	6 per	12 months	
L2860	Yes	Yes	2 per	12 months	
L2999	Yes	Yes	~		
L3000	Yes	No	4 per	12 months	
L3001	Yes	No	4 per	12 months	
L3002	Yes	No	4 per	12 months	
L3003	Yes	No	4 per	12 months	
L3010	Yes	No	4 per	12 months	
L3020	Yes	No	4 per	12 months	
L3030	Yes	No	4 per	12 months	
L3040	Yes	No	4 per	12 months	
L3050	Yes	No	4 per	12 months	
L3060	Yes	No	4 per	12 months	
L3070	Yes	No	4 per	12 months	
L3080	Yes	No	4 per	12 months	
L3090	Yes	No	4 per	12 months	
L3100	Yes	No	2 per	12 months	
L3140	Yes	No	2 per	12 months	
L3150	Yes	No	2 per	12 months	
L3160	Yes	No	2 per	12 months			

Commonwealth of Massachusetts		SUBCHAPTER NUMBER AND TITLE	PAGE	
Division of Medical Assistance Provider Manual Series
ORTHOTICS MANUAL		6 SERVICE CODES	6-8	

		TRANSMITTAL LETTER	DATE	
			ORT-16		07/01/03	
602 Service Codes and Limitations (cont.)				
HCPCS	Covered                    Covered	Service	
Code	Under Age 21?         Age 21 and older?      Limitations	
L3170	Yes	No	2 per	12 months	
L3201	Yes	No	4 per	12 months	
L3202	Yes	No	4 per	12 months	
L3203	Yes	No	4 per	12 months	
L3204	Yes	No	4 per	12 months	
L3206	Yes	No	4 per	12 months	
L3207	Yes	No	4 per	12 months	
L3208	Yes	No	4 per	12 months	
L3209	Yes	No	4 per	12 months	
L3211	Yes	No	4 per	12 months	
L3212	Yes	No	2 per	12 months	
L3213	Yes	No	2 per	12 months	
L3214	Yes	No	2 per	12 months	
L3215	Yes	No	2 per	12 months	
L3216	Yes	No	2 per	12 months	
L3217	Yes	No	2 per	12 months	
L3219	Yes	No	2 per	12 months	
L3221	Yes	No	2 per	12 months	
L3222	Yes	No	2 per	12 months	
L3224	Yes	No	4 per	12 months	
L3225	Yes	No	4 per	12 months	
L3230	Yes	No	4 per	12 months	
L3250	Yes	No	4 per	12 months	
L3251	Yes	No	4 per	12 months	
L3252	Yes	No	4 per	12 months	
L3253	Yes	No	4 per	12 months	
L3254	Yes	No	2 per	12 months	
L3255	Yes	No	2 per	12 months	
L3257	Yes	No	2 per	12 months	
L3260	Yes	No	4 per	12 months	
L3265	Yes	No	4 per	12 months	
L3300	Yes	No	4 per	12 months	
L3310	Yes	No	4 per	12 months	
L3320	Yes	No	4 per	12 months	
L3332	Yes	No	2 per	12 months	
L3334	Yes	No	4 per	12 months	
L3350	Yes	No	4 per	12 months	
L3360	Yes	No	4 per	12 months	
L3370	Yes	No	4 per	12 months	
L3390	Yes	No	4 per	12 months	
L3400	Yes	No	4 per	12 months	
L3420	Yes	No	4 per	12 months			

Commonwealth of Massachusetts	SUBCHAPTER NUMBER AND TITLE	PAGE	
Division of Medical Assistance Provider Manual Series
ORTHOTICS MANUAL		6 SERVICE CODES	6-9	

		TRANSMITTAL LETTER	DATE	
			ORT-16		07/01/03	
602 Service Codes and Limitations (cont.)				
HCPCS	Covered                    Covered	Service	
Code	Under Age 21?         Age 21 and older?      Limitations	
L3450	Yes	No	4 per	12 months	
L3455	Yes	No	4 per	12 months	
L3460	Yes	No	4 per	12 months	
L3465	Yes	No	4 per	12 months	
L3470	Yes	No	4 per	12 months	
L3480	Yes	No	4 per	12 months	
L3485	Yes	No	4 per	12 months	
L3500	Yes	No	4 per	12 months	
L3510	Yes	No	4 per	12 months	
L3530	Yes	No	4 per	12 months	
L3540	Yes	No	4 per	12 months	
L3570	Yes	No	4 per	12 months	
L3580	Yes	No	4 per	12 months	
L3590	Yes	No	4 per	12 months	
L3595	Yes	No	4 per	12 months	
L3600	Yes	Yes	2 per	12 months	
L3610	Yes	Yes	2 per	12 months	
L3620	Yes	Yes	2 per	12 months	
L3630	Yes	Yes	2 per	12 months	
L3640	Yes	No	2 per	12 months	
L3649	Yes	No	1 per	12 months	
L3650	Yes	Yes	2 per	12 months	
L3651	Yes	No	2 per	12 months	
L3652	Yes	No	1 per	12 months	
L3660	Yes	No	2 per	12 months	
L3670	Yes	Yes	2 per	12 months	
L3675	Yes	Yes	2 per	12 months	
L3700	Yes	No	2 per	12 months	
L3701	Yes	No	2 per	12 months	
L3710	Yes	No	2 per	12 months	
L3720	Yes	Yes	2 per	12 months	
L3730	Yes	Yes	2 per	12 months	
L3740	Yes	Yes	2 per	12 months	
L3760	Yes	Yes	2 per	12 months	
L3762	Yes	Yes	2 per	12 months	
L3800	Yes	Yes	2 per	12 months	
L3805	Yes	Yes	2 per	12 months	
L3807	Yes	Yes	2 per	12 months	
L3810	Yes	Yes	2 per	12 months	
L3815	Yes	Yes	2 per	12 months	
L3820	Yes	Yes	2 per	12 months	
L3825	Yes	Yes	2 per	12 months			

Commonwealth of Massachusetts	SUBCHAPTER NUMBER AND TITLE	PAGE	
Division of Medical Assistance Provider Manual Series
ORTHOTICS MANUAL		6 SERVICE CODES	6-10	

		TRANSMITTAL LETTER	DATE	
			ORT-16		07/01/03	
602 Service Codes and Limitations (cont.)				
HCPCS	Covered                    Covered	Service	
Code	Under Age 21?         Age 21 and older?      Limitations	
L3830	Yes	Yes	2 per	12 months	
L3835	Yes	Yes	2 per	12 months	
L3840	Yes	Yes	2 per	12 months	
L3845	Yes	Yes	2 per	12 months	
L3850	Yes	Yes	2 per	12 months	
L3855	Yes	Yes	2 per	12 months	
L3860	Yes	Yes	2 per	12 months	
L3890	Yes	Yes	2 per	12 months	
L3900	Yes	Yes	2 per	12 months	
L3901	Yes	Yes	2 per	12 months	
L3902	Yes	No	2 per	12 months	
L3904	Yes	No	2 per	12 months	
L3906	Yes	Yes	2 per	12 months	
L3907	Yes	Yes	2 per	12 months	
L3908	Yes	No	2 per	12 months	
L3909	Yes	No	2 per	12 months	
L3910	Yes	Yes	2 per	12 months	
L3911	Yes	Yes	2 per	12 months	
L3912	Yes	Yes	2 per	12 months	
L3914	Yes	No	2 per	12 months	
L3916	Yes	Yes	2 per	12 months	
L3918	Yes	Yes	2 per	12 months	
L3920	Yes	Yes	2 per	12 months	
L3922	Yes	Yes	2 per	12 months	
L3923	Yes	No	2 per	12 months	
L3924	Yes	Yes	2 per	12 months	
L3926	Yes	Yes	2 per	12 months	
L3928	Yes	No	2 per	12 months	
L3930	Yes	Yes	2 per	12 months	
L3932	Yes	Yes	2 per	12 months	
L3934	Yes	Yes	2 per	12 months	
L3936	Yes	Yes	2 per	12 months	
L3938	Yes	No	2 per	12 months	
L3940	Yes	Yes	2 per	12 months	
L3942	Yes	Yes	2 per	12 months	
L3944	Yes	Yes	2 per	12 months	
L3946	Yes	Yes	2 per	12 months	
L3948	Yes	Yes	2 per	12 months	
L3950	Yes	Yes	2 per	12 months	
L3952	Yes	Yes	2 per	12 months	
L3954	Yes	Yes	2 per	12 months	
L3956	Yes	Yes	2 per	12 months			

Commonwealth of Massachusetts	SUBCHAPTER NUMBER AND TITLE	PAGE	
Division of Medical Assistance Provider Manual Series
ORTHOTICS MANUAL		6 SERVICE CODES	6-11	

		TRANSMITTAL LETTER	DATE	
			ORT-16		07/01/03	
602 Service Codes and Limitations (cont.)				
HCPCS	Covered                    Covered	Service	
Code	Under Age 21?         Age 21 and older?      Limitations	
L3960	Yes	Yes	2 per	12 months	
L3962	Yes	Yes	2 per	12 months	
L3963	Yes	Yes	2 per	12 months	
L3964	Yes	No	2 per	12 months	
L3965	Yes	No	2 per	12 months	
L3966	Yes	No	2 per	12 months	
L3968	Yes	No	2 per	12 months	
L3969	Yes	No	2 per	12 months	
L3970	Yes	No	2 per	12 months	
L3972	Yes	No	2 per	12 months	
L3974	Yes	No	2 per	12 months	
L3980	Yes	Yes	2 per	12 months	
L3982	Yes	Yes	2 per	12 months	
L3984	Yes	Yes	2 per	12 months	
L3985	Yes	Yes	2 per	12 months	
L3986	Yes	Yes	2 per	12 months	
L3995	Yes	No	2 per	12 months	
L3999	Yes	Yes	~		
L4000	Yes	No	1 per	12 months	
L4010	Yes	No	1 per	12 months	
L4020	Yes	Yes	2 per	12 months	
L4030	Yes	Yes	2 per	12 months	
L4040	Yes	Yes	2 per	12 months	
L4045	Yes	Yes	2 per	12 months	
L4050	Yes	Yes	2 per	12 months	
L4055	Yes	Yes	2 per	12 months	
L4060	Yes	Yes	2 per	12 months	
L4070	Yes	Yes	4 per	12 months	
L4080	Yes	Yes	2 per	12 months	
L4090	Yes	Yes	2 per	12 months	
L4100	Yes	Yes	2 per	12 months	
L4110	Yes	Yes	2 per	12 months	
L4130	Yes	Yes	2 per	12 months	
L4205	Yes	Yes	~		
L4210	Yes	Yes	~		
L4350	Yes	No	2 per	12 months	
L4360	Yes	No	2 per	12 months	
L4370	Yes	No	2 per	12 months	
L4380	Yes	No	2 per	12 months	
L4386	Yes	Yes	2 per	12 months	
L4392	Yes	Yes	2 per	12 months			

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ORTHOTICS MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES	PAGE
6-12	

	TRANSMITTAL LETTER
ORT-16	DATE
07/01/03	
602 Service Codes and Limitations (cont.)

HCPCS	Covered	Covered	Service	
Code	Under Age 21?	Age 21 and older?	Limitations	
L4394	Yes	Yes	2 per 12 months	
L4396	Yes	Yes	2 per 12 months	
L4398	Yes	Yes	2 per 12 months	
T2003	Yes	Yes	--