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 PRT-14
November 2002
TO:      Prosthetic Providers Participating in MassHealth FROM:      Wendy E. Warring, Commissioner
RE:      Prosthetics Manual (Revised Regulations and Subchapter 6)
Revised Regulations
The Division has revised its prosthetics regulations at 130 CMR 428.000 to add several definitions, include more specific coverage restrictions, and update the payment methodology. 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 PRT-14 November 2002 Page 2
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.
 •	All claims for prosthetic services, except labor (L7520), must contain a diagnosis name in Item 22, and an ICD-9-CM diagnosis code in Item 23, of claim form no. 9.
 •	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 prosthetic codes, except those listed below, must include modifier LT (left), RT (right), or
LTRT (left and right /bilateral).
 •	L7362
 •	L7510
 •	L7520
 •	L8000 through L8002
 •	L8015
 •	L8190 through L8230
 •	L8300 through L8330
 •	L8400
NEW MATERIAL
(The pages listed here contain new or revised language.)
Prosthetics Manual
Pages iv, vi, 4-1 through 4-12, and 6-1 through 6-16
OBSOLETE MATERIAL
(The pages listed here are no longer in effect.)
Prosthetics Manual
Pages iv and 4-1 through 4-10 — transmitted by Transmittal Letter PRT-13
Pages vi, vi-a, and 6-1 through 6-16 — transmitted by Transmittal Letter PRT-12

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

	TRANSMITTAL LETTER
PRT-14	DATE
11/22/02	
4.   PROGRAM REQUIREMENTS
428.401:	Introduction 		4-1
428.402:	Definitions 		4-1
428.403:	Eligible Members 		4-2
428.404:	Provider Eligibility 		4-3
428.405:	Provider Responsibility 		4-3
428.406:	Covered Services 		4-3
(130 CMR 428.407 Reserved)
428.408:	Noncovered Services 		4-4
428.409:	Prescription Requirements 		4-4
428.410:	Prosthetic Equipment Provided to Institutionalized Members 		4-5
428.411:	Repairs of Prosthetic Equipment 		4-5
428.412:	Prior Authorization 		4-5
428.413:	Procedure for Requesting Prior Authorization 		4-6
428.414:	Medicare Coverage 		4-7
(130 CMR 428.415 through 428.419 Reserved)
428.420:	Payment for Prosthetic Services 		4-8
428.421:	Individual Consideration 		4-8
428.422:	Adjusted Acquisition Cost 		4-9
428.423:	Recordkeeping Requirements 		4-9

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

	TRANSMITTAL LETTER
PRT-14	DATE
11/22/02	
6. SERVICE CODES AND DESCRIPTIONS
Definitions 		6-1
Service Codes and Descriptions 		6-1
Lower Limb 		6-1
Upper Limb 		6-8
Additions: Upper Limb 		6-11
Terminal Devices 		6-12
External Power 		6-13
General 		6-15
Other Prosthetic Procedures 		6-16
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
PROSTHETICS MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 428.000)	PAGE
4-1	

	TRANSMITTAL LETTER
PRT-14	DATE
11/22/02	
428.401: Introduction
130 CMR 428.000 states the requirements and procedures for the purchase and repair of prosthetic devices, customized equipment, and supplies under MassHealth. All providers of prosthetic 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 428.000 and in 130 CMR 450.000.
428.402: Definitions
The following terms used in 130 CMR 428.000 have the meanings given in 130 CMR 428.402 unless the context clearly requires a different meaning. The reimbursability of services defined in 130 CMR 428.000 is not determined by these definitions, but by application of regulations elsewhere in 130 CMR 428.000 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 prosthetic equipment and that is generally not useful in the absence of such prosthetic 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 prosthetic devices, customized equipment, or supplies, excluding all associated costs such as shipping, handling, and insurance costs in accordance with 130 CMR 428.422. Where the manufacturer is the provider, the adjusted acquisition cost is the actual cost of manufacturing such prosthetic devices, customized equipment, or supplies.
Date of Service — the date the prosthesis is delivered and fitted to the MassHealth member. If the prosthetic service involves a series of fittings and adjustments, the date of service is the date on which the final adjustment is made. If the prosthetic 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.
Discount — any remuneration or reduction of payment of any kind, whether direct or indirect, received by the provider.
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 prosthetic services.
Prosthesis (or Prosthetic Equipment) — an artificial replacement for a missing body part, such as an artificial limb or total joint replacement.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PROSTHETICS MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 428.000)	PAGE
4-2	

	TRANSMITTAL LETTER
PRT-14	DATE
11/22/02	
Prosthetic Service — the purchase, customization, fitting, repair, replacement, or adjustment of a prosthesis or component part, or other activity performed or equipment provided in accordance with 130 CMR 428.000.
Prosthetic Supplies — products that are:
 (1)	fabricated primarily and customarily to fulfill a medical or surgical purpose;
 (2)	used in conjunction with a prosthesis or prosthetic equipment;
 (3)	generally not useful in the absence of a prosthesis; and
 (4)	non-reusable and disposable.
Prosthetics — the design, fitting, and attachment of an artificial replacement of a missing body part.
Service Facility — the place of business, physically accessible to MassHealth members, where prosthetic services, especially those involving fitting, adjustment, repair, and replacement of prostheses, are performed. A service facility does not include a MassHealth member’s place of residence.
428.403: Eligible Members
(A) (1) MassHealth Members. The Division covers prosthetic services only when provided to eligible MassHealth members, subject to the restrictions and limitations in 130 CMR 428.000 and 450.000. 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.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PROSTHETICS MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 428.000)	PAGE
4-3	

	TRANSMITTAL LETTER
PRT-14	DATE
11/22/02	
428.404: Provider Eligibility
For services described in 130 CMR 428.000, the Division pays only those providers of prosthetic 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)	primarily engage in the business of providing prosthetic and repair services to the public;
 (2)	meet all state and local requirements for engaging in such business;
 (3)	be or employ a prosthetist currently certified by the American Board for Certification in Orthotics and Prosthetics, Inc. or the Board for Orthotics/Prosthetics Certification.
 (4)	be a Medicare provider;
 (5)	have a service facility that is physically accessible to MassHealth members during reasonable business hours;
 (6)	maintain a visible sign identifying the business and hours of operation; and
 (7)	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 428.404(A). Such a provider may receive payment for MassHealth services only as set
forth in 130 CMR 450.109.
428.405: Provider Responsibility
(A)	The provider must ensure that all prosthetic 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 prosthetic 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.
428.406: Covered Services
The Division pays for only those prosthetic services listed in Subchapter 6 of the Prosthetics Manual.
(130 CMR 428.407 Reserved)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PROSTHETICS MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 428.000)	PAGE
4-4	

	TRANSMITTAL LETTER
PRT-14	DATE
11/22/02	
428.408: Noncovered Services
The Division does not pay for any of the following:
 (A)	any prosthetic services for which, under comparable circumstances, the provider does not customarily bill private patients who do not have health insurance;
 (B)	nonmedical prosthetic 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 prosthetic equipment or associated items; and
 (D)	prosthetic 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.
428.409: Prescription Requirements
(A)	The purchase of prosthetic equipment requires a written prescription signed by a licensed
physician or an independent nurse practitioner. The prescription must be written on the
prescriber's prescription form and must include the following information:
 (1)	the member's name and address;
 (2)	the member’s MassHealth identification number;
 (3)	specific identification of the prescribed item;
 (4)	medical justification for the use of the item, including the member’s diagnosis;
 (5)	the prescriber's address and telephone number; and
 (6)	the date on which the prescription was signed by the prescriber.
(B)	The provider must keep the prescription on file for the period of time required by 130 CMR
450.205.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PROSTHETICS MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 428.000)	PAGE
4-5	

	TRANSMITTAL LETTER
PRT-14	DATE
11/22/02	
428.410: Prosthetic Equipment Provided to Institutionalized Members
(A)	Nursing Facilities. The Division pays prosthetic providers for:
 (1)	the purchase and repair of prosthetic equipment; and
 (2)	prosthetic 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 prosthetic providers for the purchase or repair of prosthetic equipment or for supplies provided to a hospitalized member, except for prosthetic 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 prosthetic providers or the purchase and repair of customized prosthetic 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 prosthetic providers for noncustomized equipment or supplies provided to a member residing in a state school.
(D)	Rest Homes. The Division pays prosthetic providers for the purchase and repair of prosthetic
equipment and for associated supplies provided for the personal full-time use of a member
residing in a rest home.
428.411: Repairs of Prosthetic Equipment
 (A)	The Division pays for all repair services on an individual-consideration basis as described in 130 CMR 428.422.
 (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 prosthetic equipment to the Division.
428.412: Prior Authorization
(A) Services that require prior authorization as a prerequisite for payment are identified in the Division’s regulations at 130 CMR 428.000 or are listed in Subchapter 6 of the Prosthetics 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.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PROSTHETICS MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 428.000)	PAGE
4-6	

	TRANSMITTAL LETTER
PRT-14	DATE
11/22/02	
(B)	The provider must request prior authorization in accordance with the billing instructions in
Subchapter 5 of the Prosthetics Manual. Before determining the medical necessity of an item or
service for which prior authorization is requested, 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 prosthetist to
determine whether the requested prosthetic 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.
 (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 modification or denial of a prior-authorization request 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.
428.413: 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 428.421) 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 a current prescription that must not be older than 90 days from the requested date of service (see 130 CMR 428.409 for information that must be included in the prescription);
 (3)	if requested by the Division, a current prosthetic evaluation for the equipment, performed independently of the provider by a licensed physician or prosthetist;
 (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.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PROSTHETICS MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 428.000)	PAGE
4-7	

	TRANSMITTAL LETTER
PRT-14	DATE
11/22/02	
428.414: 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 prosthetic 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 428.415 through 428.419 Reserved)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PROSTHETICS MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 428.000)	PAGE
4-8	

	TRANSMITTAL LETTER
PRT-14	DATE
11/22/02	
428.420: Payment for Prosthetic Services
(A)	Payment to a provider for prosthetic equipment and supplies is subject to the conditions and
limitations in 130 CMR 428.000 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.
(B)	Payment for the following services is included in the provider payment under
130 CMR 428.420(A). No separate payment is allowed for:
 (1)	the fitting of the prosthesis;
 (2)	instructing the member in the use of the prosthesis;
 (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 prosthesis and any prosthetic component made when fitting the prosthesis and for 90 days from the date of delivery, when the adjustments are not necessitated by changes in the member's functional abilities.
428.421: Individual Consideration
When the rate of payment for the purchase or repair of certain prosthetic 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 Prosthetics 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 428.421 and 428.422. Payment for the fitting of a prosthesis is included in the adjusted acquisition cost. Providers 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.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PROSTHETICS MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 428.000)	PAGE
4-9	

	TRANSMITTAL LETTER
PRT-14	DATE
11/22/02	
428.422: Adjusted Acquisition Cost
(A)	The provider must disclose all discounts, as defined in 130 CMR 428.402, 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 428.000, 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 428.421(B).
 (D)	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 428.434 and 450.205.
(E)	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 428.422(B).
428.423: Recordkeeping Requirements
The provider must keep a record of all prosthetic 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 prosthetic services requiring prior authorization;
 (C)	an acknowledgment 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;

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PROSTHETICS MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 428.000)	PAGE
4-10	

	TRANSMITTAL LETTER
PRT-14	DATE
11/22/02	
 (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 428.405(C) to purchase the item from
the least costly reliable source.
REGULATORY AUTHORITY
130 CMR 428.000: M.G.L. c. 118E, §§ 7 and 12.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PROSTHETICS MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-1	

	TRANSMITTAL LETTER
PRT-14	DATE
11/22/02	
601	Definitions
Custom-Fabricated Prosthesis — a prosthetic 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 prosthetist in design and fitting.
Custom-Fitted Prosthesis — a prefabricated prosthetic item sized or modified for use by one individual in accordance with a prescription that requires substantial clinical and technical judgment and alteration by a certified prosthetist. A custom-fitted prosthesis does not require casting or molding techniques.
602	Service Codes and Descriptions
Service
Code       Service Description
LOWER LIMB
The procedures 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.
Partial Foot
L5000      Partial foot, shoe insert with longitudinal arch, toe filler, each (I.C.) L5010      Partial foot, molded socket, ankle height, with toe filler L5020      Partial foot, molded socket, tibial tubercle height, with toe filler
Ankle
L5050      Ankle, Symes, molded socket, SACH foot
L5060      Ankle, Symes, metal frame, molded leather socket, articulated ankle/foot
Below Knee
L5100      Below knee, molded socket, shin, SACH foot
L5105      Below knee, plastic socket, joints and thigh lacer, SACH foot
Knee Disarticulation
L5150      Knee disarticulation (or through knee), molded socket, external knee joints, shin, SACH foot L5160      Knee disarticulation (or through knee), molded socket, bent knee configuration, external knee joints, shin, SACH foot
Above Knee
L5200      Above knee, molded socket, single axis constant friction knee, shin, SACH foot L5210      Above knee, short prosthesis, no knee joint ("stubbies"), with foot blocks, no ankle joints, each L5220      Above knee, short prosthesis, no knee joint ("stubbies"), with articulated ankle/foot, dynamically aligned, each

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

	TRANSMITTAL LETTER
PRT-14	DATE
11/22/02	
602 Service Codes and Descriptions (cont.)
Service
Code       Service Description
L5230      Above knee, for proximal femoral focal deficiency, constant friction knee, shin, SACH foot
Hip Disarticulation
L5250      Hip disarticulation, Canadian type; molded socket, hip joint, single axis constant friction knee,
shin, SACH foot L5270      Hip disarticulation, tilt-table type; molded socket, locking hip joint, single axis constant friction
knee, shin, SACH foot
Hemipelvectomy
L5280      Hemipelvectomy, Canadian type; molded socket, hip joint, single axis constant friction knee, shin, SACH foot
Endoskeletal: Below Knee
L5301      Below knee, molded socket, shin, SACH foot, endoskeletal system
Endoskeletal: Knee Disarticulation
L5311      Knee disarticulation (or through knee), molded socket, external knee joints, shin, SACH foot, endoskeletal system
Endoskeletal: Above Knee
L5321      Above knee, molded socket, open end, SACH foot, endoskeletal system, single axis knee
Endoskeletal: Hip Disarticulation
L5331      Hip disarticulation, Canadian type, molded socket, endoskeletal system, hip joint, single axis knee, SACH foot
Endoskeletal: Hemipelvectomy
L5341      Hemipelvectomy, Canadian type, molded socket, endoskeletal system, hip joint, single axis knee, SACH foot

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Division of Medical Assistance Provider
Manual Series
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	TRANSMITTAL LETTER
PRT-14	DATE
11/22/02	
602 Service Codes and Descriptions (cont.)
Service
Code       Service Description
Immediate Postsurgical or Early Fitting Procedures
L5400      Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting,
alignment, suspension, and one cast change, below knee L5410      Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting,
alignment and suspension, below knee, each additional cast change and realignment L5420      Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting,
alignment and suspension, and one cast change "AK" or knee disarticulation L5430      Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting,
alignment and suspension, "AK" or knee disarticulation, each additional cast change and
realignment L5450      Immediate postsurgical or early fitting, application of nonweight bearing rigid dressing, below
knee L5460      Immediate postsurgical or early fitting, application of nonweight bearing rigid dressing, above
knee
Initial Prosthesis
L5500      Initial, below knee "PTB" type socket, nonalignable system, pylon, no cover, SACH foot, plaster
socket, direct formed L5505      Initial, above knee—knee disarticulation, ischial level socket, nonalignable system, pylon, no
cover, SACH foot plaster socket, direct formed
Preparatory Prosthesis
L5510      Preparatory, below knee "PTB" type socket, nonalignable system, pylon, no cover, SACH foot,
plaster socket, molded to model L5520      Preparatory, below knee "PTB" type socket, nonalignable system, pylon, no cover, SACH foot,
thermoplastic or equal, direct formed L5530      Preparatory, below knee "PTB" type socket, nonalignable system, pylon, no cover, SACH foot,
thermoplastic or equal, molded to model L5535      Preparatory, below knee "PTB" type socket, nonalignable system, pylon, no cover, SACH foot,
prefabricated, adjustable open end socket L5540      Preparatory, below knee "PTB" type socket, nonalignable system, pylon, no cover, SACH foot,
laminated socket, molded to model L5560      Preparatory, above knee—knee disarticulation, ischial level socket, nonalignable system, pylon,
no cover, SACH foot, plaster socket, molded to model L5570      Preparatory, above knee—knee disarticulation, ischial level socket, nonalignable system, pylon,
no cover, SACH foot, thermoplastic or equal, direct formed L5580      Preparatory, above knee—knee disarticulation, ischial level socket, nonalignable system, pylon,
no cover, SACH foot, thermoplastic or equal, molded to model

Commonwealth of Massachusetts
Division of Medical Assistance Provider
Manual Series
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6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-4	

	TRANSMITTAL LETTER
PRT-14	DATE
11/22/02	
602 Service Codes and Descriptions (cont.)

Service Code
L5585
L5590
L5595
L5600
L5610 L5611
L5613
L5614
L5616
L5617
L5618 L5620 L5622 L5624 L5626 L5628 L5629
L5630 L5631 L5632 L5634 L5636 L5637 L5638

Service Description
Preparatory, above knee—knee disarticulation, ischial level socket, nonalignable system, pylon,
no cover, SACH foot, prefabricated, adjustable open end socket Preparatory, above knee—knee disarticulation, ischial level socket, nonalignable system, pylon,
no cover, SACH foot, laminated socket, molded to model Preparatory, hip disarticulation-hemipelvectomy, pylon, no cover, SACH foot, thermoplastic or
equal, molded to patient model Preparatory, hip disarticulation-hemipelvectomy, pylon, no cover, SACH foot, laminated socket,
molded to patient model
Additions: Lower Extremity
Addition to lower extremity, endoskeletal system, above knee, hydracadence system Addition to lower extremity, endoskeletal system, above knee—knee disarticulation, 4-bar
linkage, with friction swing phase control Addition to lower extremity, endoskeletal system, above knee—knee disarticulation, 4-bar
linkage, with hydraulic swing phase control Addition to lower extremity exoskeletal system, above knee—knee disarticulation, 4-bar linkage,
with pneumatic swing phase control Addition to lower extremity, endoskeletal system, above knee, universal multiplex system,
friction swing phase control Addition to lower extremity, quick change self-aligning unit, above knee or below knee, each
Additions: Test Sockets
Addition to lower extremity, test socket, Symes Addition to lower extremity, test socket, below knee Addition to lower extremity, test socket, knee disarticulation Addition to lower extremity, test socket, above knee Addition to lower extremity, test socket, hip disarticulation Addition to lower extremity, test socket, hemipelvectomy Addition to lower extremity, below knee, acrylic socket
Additions: Socket Variations
Addition to lower extremity, Symes type, expandable wall socket
Addition to lower extremity, above knee or knee disarticulation, acrylic socket
Addition to lower extremity, Symes type, "PTB" brim design socket
Addition to lower extremity, Symes type, posterior opening (Canadian) socket
Addition to lower extremity, Symes type, medial opening socket
Addition to lower extremity, below knee, total contact
Addition to lower extremity, below knee, leather socket

Commonwealth of Massachusetts
Division of Medical Assistance Provider
Manual Series
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6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-5	

	TRANSMITTAL LETTER
PRT-14	DATE
11/22/02	
602 Service Codes and Descriptions (cont.)
Service
Code	Service Description
L5639	Addition to lower extremity, below knee, wood socket
L5640	Addition to lower extremity, knee disarticulation, leather socket
L5642	Addition to lower extremity, above knee, leather socket
L5643	Addition to lower extremity, hip disarticulation, flexible inner socket, external frame
L5644	Addition to lower extremity, above knee, wood socket
L5645	Addition to lower extremity, below knee, flexible inner socket, external frame
L5646	Addition to lower extremity, below knee, air cushion socket
L5647	Addition to lower extremity, below knee, suction socket
L5648	Addition to lower extremity, above knee, air cushion socket
L5649	Addition to lower extremity, ischial containment/narrow M-L socket
L5650	Addition to lower extremity, total contact, above knee or knee disarticulation socket
L5651	Addition to lower extremity, above knee, flexible inner socket, external frame
L5652	Addition to lower extremity, suction suspension, above knee or knee disarticulation socket
L5653	Addition to lower extremity, knee disarticulation, expandable wall socket
Additions: Socket Insert and Suspension
L5654	Addition to lower extremity, socket insert, Symes (Kemblo, Pelite, Aliplast, Plastazote, or
equal)
L5655	Addition to lower extremity, socket insert, below knee (Kemblo, Pelite, Aliplast, Plastazote, or
equal)
L5656	Addition to lower extremity, socket insert, knee disarticulation (Kemblo, Pelite, Aliplast,
Plastazote, or equal)
L5658	Addition to lower extremity, socket insert, above knee (Kemblo, Pelite, Aliplast, Plastazote, or
equal)
L5660	Addition to lower extremity, socket insert, Symes, silicone gel or equal
L5661	Addition to lower extremity, socket insert, multidurometer, Symes
L5662	Addition to lower extremity, socket insert, below knee, silicone gel or equal
L5663	Addition to lower extremity, socket insert, knee disarticulation, silicone gel or equal
L5664	Addition to lower extremity, socket insert, above knee, silicone gel or equal
L5665	Addition to lower extremity, socket insert, multidurometer, below knee
L5666	Addition to lower extremity, below knee, cuff suspension
L5668	Addition to lower extremity, below knee, molded distal cushion
L5670	Addition to lower extremity, below knee, molded supracondylar suspension ("PTS" or similar)
L5671	Addition to lower extremity, below knee/above knee suspension locking mechanism (shuttle ,
lanyard or equal), excludes socket insert
L5672	Addition to lower extremity, below knee, removable medial brim suspension
L5674	Addition to lower extremity, below knee, suspension sleeve, any material, each
L5675	Addition to lower extremity, below knee, suspension sleeve, heavy duty, any material, each
L5676	Addition to lower extremity, below knee, knee joints, single axis, pair
L5677	Addition to lower extremity, below knee, knee joints, polycentric, pair
L5678	Addition to lower extremity, below knee, joint covers, pair

Commonwealth of Massachusetts
Division of Medical Assistance Provider
Manual Series
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6-6	

	TRANSMITTAL LETTER
PRT-14	DATE
11/22/02	
602 Service Codes and Descriptions (cont.)
Service
Code       Service Description
L5680	Addition to lower extremity, below knee, thigh lacer, nonmolded
L5682	Addition to lower extremity, below knee, thigh lacer, gluteal/ischial, molded
L5684	Addition to lower extremity, below knee, fork strap
L5686	Addition to lower extremity, below knee, back check (extension control)
L5688	Addition to lower extremity, below knee, waist belt, webbing
L5690	Addition to lower extremity, below knee, waist belt, padded and lined
L5692	Addition to lower extremity, above knee, pelvic control belt, light
L5694	Addition to lower extremity, above knee, pelvic control belt, padded and lined
L5695	Addition to lower extremity, above knee, pelvic control, sleeve suspension, neoprene or equal,
each
L5696	Addition to lower extremity, above knee or knee disarticulation, pelvic joint
L5697	Addition to lower extremity, above knee or knee disarticulation, pelvic band
L5698	Addition to lower extremity, above knee or knee disarticulation, Silesian bandage
L5699	All lower extremity prostheses, shoulder harness
Replacements
L5700	Replacement, socket, below knee, molded to patient model
L5701	Replacement, socket, above knee/knee disarticulation, including attachment plate, molded to
patient model
L5702	Replacement, socket, hip disarticulation, including hip joint, molded to patient model
L5704	Custom shaped protective cover, below knee
L5705	Custom shaped protective cover, above knee
L5706	Custom shaped protective cover, knee disarticulation
L5707	Custom shaped protective cover, hip disarticulation
Additions: Exoskeletal Knee-Shin System

L5710	Addition, exoskeletal knee-shin
L5711	Addition, exoskeletal knee-shin
L5712	Addition, exoskeletal knee-shin
knee)
L5714	Addition, exoskeletal knee-shin
L5716	Addition, exoskeletal knee-shin
L5718	Addition, exoskeletal knee-shin
L5722	Addition, exoskeletal knee-shin
L5724	Addition, exoskeletal knee-shin
L5726	Addition, exoskeletal knee-shin
L5728	Addition, exoskeletal knee-shin
L5780	Addition, exoskeletal knee-shin
control

system, single axis, manual lock
system, single axis, manual lock, ultra-light material
system, single axis, friction swing and stance phase control (safety
system, single axis, variable friction swing phase control system, polycentric, mechanical stance phase lock system, polycentric, friction swing and stance phase control system, single axis, pneumatic swing, friction stance phase control system, single axis, fluid swing phase control system, single axis, external joints fluid swing phase control system, single axis, fluid swing and stance phase control system, single axis, pneumatic/hydra pneumatic swing phase

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Division of Medical Assistance Provider
Manual Series
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6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-7	

	TRANSMITTAL LETTER
PRT-14	DATE
11/22/02	
602 Service Codes and Descriptions (cont.)
Service
Code       Service Description
Component Modifications
L5785      Addition, exoskeletal system, below knee, ultra-light material (titanium, carbon fiber, or equal) L5790      Addition, exoskeletal system, above knee, ultra-light material (titanium, carbon fiber, or equal) L5795      Addition, exoskeletal system, hip disarticulation, ultra-light material (titanium, carbon fiber, or equal)
Additions: Endoskeletal Knee-Shin System
L5810      Addition, endoskeletal knee-shin system, single axis, manual lock
L5811      Addition, endoskeletal knee-shin system, single axis, manual lock, ultra-light material
L5812      Addition, endoskeletal knee-shin system, single axis, friction swing and stance phase control
(safety knee) L5814      Addition, endoskeletal knee-shin system, polycentric, hydraulic swing phase control, mechanical
stance phase lock L5816      Addition, endoskeletal knee-shin system, polycentric, mechanical stance phase lock L5818      Addition, endoskeletal knee-shin system, polycentric, friction swing and stance phase control L5822      Addition, endoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase
control L5824      Addition, endoskeletal knee-shin system, single axis, fluid swing phase control L5826      Addition, endoskeletal knee-shin system, single axis, hydraulic swing phase control, with
miniature high activity frame L5828      Addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control L5830      Addition, endoskeletal knee-shin system, single axis, pneumatic/swing phase control L5840      Addition, endoskeletal knee-shin system, 4-bar linkage or multi-axial, pneumatic swing phase
control L5845      Addition, endoskeletal knee-shin system, stance flexion feature, adjustable L5846      Addition, endoskeletal knee-shin system, microprocessor control feature, swing phase only L5847      Addition, endoskeletal knee-shin system, microprocessor control feature, stance phase (I.C.) L5850      Addition, endoskeletal system, above knee or hip disarticulation, knee extension assist L5855      Addition, endoskeletal system, hip disarticulation, mechanical hip extension assist L5910      Addition, endoskeletal system, below knee, alignable system L5920      Addition, endoskeletal system, above knee or hip disarticulation, alignable system L5925      Addition, endoskeletal system, above knee, knee disarticulation or hip disarticulation, manual lock L5930      Addition, endoskeletal system, high activity knee control frame
L5940 Addition, endoskeletal system, below knee, ultra-light material (titanium, carbon fiber, or equal) L5950 Addition, endoskeletal system, above knee, ultra-light material (titanium, carbon fiber, or equal) L5960      Addition, endoskeletal system, hip disarticulation, ultra-light material (titanium, carbon fiber, or
equal) L5962      Addition, endoskeletal system, below knee, flexible protective outer surface covering system L5964      Addition, endoskeletal system, above knee, flexible protective outer surface covering system L5966      Addition, endoskeletal system, hip disarticulation, flexible protective outer surface covering system

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Division of Medical Assistance Provider
Manual Series
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6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-8	

	TRANSMITTAL LETTER
PRT-14	DATE
11/22/02	
602 Service Codes and Descriptions (cont.)
Service
Code       Service Description
L5968	Addition to lower-limb prosthesis, multi-axial ankle with swing phase active dorsiflexion feature
L5970	All lower extremity prostheses, foot, external keel, SACH foot
L5972	All lower extremity prostheses, flexible keel foot (Safe, Sten, Bock Dynamic, or equal)
L5974	All lower extremity prostheses, foot, single axis ankle/foot
L5975	All lower extremity prostheses, combination single axis ankle and flexible keel foot
L5976	All lower extremity prostheses, energy storing foot (Seattle Carbon Copy II or equal)
L5978	All lower extremity prostheses, foot, multiaxial ankle/foot
L5979	All lower extremity prostheses, multiaxial ankle/foot, dynamic response foot, one-piece system
L5980	All lower extremity prostheses, flex-foot system
L5981	All lower extremity prostheses, flex-walk system or equal
L5982	All exoskeletal lower extremity prostheses, axial rotation unit
L5984	All endoskeletal lower extremity prostheses, axial rotation unit
L5985	All endoskeletal lower extremity prostheses, dynamic prosthetic pylon
L5986	All lower extremity prostheses, multi-axial rotation unit ("MCP" or equal)
L5987	All lower extremity prostheses, shank foot system with vertical loading pylon
L5988	Addition to lower limb prosthesis, vertical shock-reducing pylon feature
L5989	Addition to lower extremity prosthesis, endoskeletal system, pylon with integrated electronic force
sensors
L5990	Addition to lower extremity prosthesis, user adjustable heel height
L5999	Lower extremity prosthesis, not otherwise specifed (I.C.)
UPPER LIMB
The procedures in this section are considered "base" or "basic" procedures and may be modified by listing procedures from the "Additions" section. The base procedures include only standard friction wrist and control cable system unless otherwise specified.
Partial Hand
L6000      Partial hand, Robin-Aids, thumb remaining (or equal)
L6010      Partial hand, Robin-Aids, little and/or ring finger remaining (or equal)
L6020      Partial hand, Robin-Aids, no finger remaining (or equal)
Wrist Disarticulation
L6050      Wrist disarticulation, molded socket, flexible elbow hinges, triceps pad
L6055      Wrist disarticulation, molded socket with expandable interface, flexible elbow hinges, triceps pad

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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
PRT-14	DATE
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602 Service Codes and Descriptions (cont.)
Service
Code       Service Description
Below Elbow
L6100	Below elbow, molded socket, flexible elbow hinge, triceps pad
L6110	Below elbow, molded socket (Muenster or Northwestern suspension types)
L6120	Below elbow, molded double wall split socket, step-up hinges, half cuff
L6130	Below elbow, molded double wall split socket, stump activated locking hinge, half cuff
Elbow Disarticulation
L6200      Elbow disarticulation, molded socket, outside locking hinge, forearm
L6205      Elbow disarticulation, molded socket with expandable interface, outside locking hinges, forearm
Above Elbow
L6250      Above elbow, molded double wall socket, internal locking elbow, forearm
Shoulder Disarticulation
L6300      Shoulder disarticulation, molded socket, shoulder bulkhead, humeral section, internal locking
elbow, forearm L6310      Shoulder disarticulation, passive restoration (complete prosthesis) L6320      Shoulder disarticulation, passive restoration (shoulder cap only)
Interscapular Thoracic
L6350      Interscapular thoracic, molded socket, shoulder bulkhead, humeral section, internal locking
elbow, forearm L6360      Interscapular thoracic, passive restoration (complete prosthesis) L6370      Interscapular thoracic, passive restoration (shoulder cap only)
Immediate And Early Postsurgical Procedures
L6380      Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting
alignment and suspension of components, and one cast change, wrist disarticulation or below
elbow L6382      Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting
alignment and suspension of components, and one cast change, elbow disarticulation or above
elbow L6384      Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting
alignment and suspension of components, and one cast change, shoulder disarticulation or
interscapular thoracic L6386      Immediate postsurgical or early fitting, each additional cast change and realignment L6388      Immediate postsurgical or early fitting, application of rigid dressing only

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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
PRT-14	DATE
11/22/02	
602 Service Codes and Descriptions (cont.)
Service
Code       Service Description
Endoskeletal: Below Elbow
L6400      Below elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping
Endoskeletal: Elbow Disarticulation
L6450      Elbow disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue shaping
Endoskeletal: Above Elbow
L6500      Above elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping
Endoskeletal: Shoulder Disarticulation
L6550      Shoulder disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue shaping
Endoskeletal: Interscapular Thoracic
L6570      Interscapular thoracic, molded socket, endoskeletal system, including soft prosthetic tissue
shaping L6580      Preparatory, wrist disarticulation or below elbow single wall plastic socket, friction wrist,
flexible elbow hinges, figure-of-eight harness, humeral cuff, Bowden cable control, "USMC"
or equal pylon, no cover, molded to patient model L6582      Preparatory, wrist disarticulation or below elbow, single wall plastic socket, friction wrist, flexible
elbow hinges, figure-of-eight harness, humeral cuff, Bowden cable control, "USMC" or equal
pylon, no cover, single wall socket, friction wrist, flexible elbow hinges, figure-"8" harness,
humeral cuff, Bowden cable control, "USMC" or equal pylon, no cover, direct formed L6584      Preparatory, elbow disarticulation or above elbow, single wall plastic socket, friction wrist,
locking elbow, figure-of-eight harness, fair lead cable control, "USMC" or equal pylon, no
cover, molded to patient model L6586      Preparatory, elbow disarticulation or above elbow; single wall plastic socket, friction wrist,
locking elbow, figure-of-eight harness, fair lead cable control, "USMC" or equal pylon, no
cover, direct formed L6588      Preparatory, shoulder disarticulation or interscapular thoracic, single wall plastic socket,
shoulder joint, locking elbow, friction wrist, chest strap, fair lead cable control, "USMC" or
equal pylon, no cover, molded to patient model L6590      Preparatory, shoulder disarticulation or interscapular thoracic, single wall plastic socket, shoulder
joint, locking elbow, friction wrist, chest strap, fair lead cable control, "USMC" or equal
pylon, no cover, direct formed

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Division of Medical Assistance Provider
Manual Series
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	TRANSMITTAL LETTER
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602 Service Codes and Descriptions (cont.)
Service
Code       Service Description
ADDITIONS: UPPER LIMB

The following procedures/modifications/components may be added to other base procedures. The items in this section should reflect the additional complexity of each modification procedure, in addition to the base procedure, at the time of the original order.
L6600	Upper extremity	
L6605	Upper extremity	
L6610	Upper extremity	
L6615	Upper extremity	
L6616	Upper extremity	
L6620	Upper extremity	
L6623	Upper extremity	
L6625	Upper extremity	
L6628	Upper extremity	
L6629	Upper extremity	
	equal	
L6630	Upper extremity	
L6632	Upper extremity	
L6635	Upper extremity	
L6637	Upper extremity	
L6640	Upper extremity	
L6641	Upper extremity	
L6642	Upper extremity	
L6645	Upper extremity	
L6650	Upper extremity	
L6655	Upper extremity	
L6660	Upper extremity	
L6665	Upper extremity	
L6670	Upper extremity	
L6672	Upper extremity	
L6675	Upper extremity	
L6676	Upper extremity	
L6680	Upper extremity	
L6682	Upper extremity	
L6684	Upper extremity	
L6686	Upper extremity	
L6687	Upper extremity	
L6688	Upper extremity	
L6689	Upper extremity	
additions, polycentric hinge, pair
additions, single pivot hinge, pair
additions, flexible metal hinge, pair
addition, disconnect locking wrist unit
addition, additional disconnect insert for locking wrist unit, each
addition, flexion-friction wrist unit
addition, spring assisted rotational wrist unit with latch release
addition, rotation wrist unit with cable lock
addition, quick disconnect hook adapter, Otto Bock or equal
addition, quick disconnect lamination collar with coupling piece, Otto Bock or
addition, stainless steel, any wrist
addition, latex suspension sleeve, each
addition, lift assist for elbow
addition, nudge control elbow lock
additions, shoulder abduction joint, pair
addition, excursion amplifier, pulley type
addition, excursion amplifier, lever type
addition, shoulder flexion-abduction joint, each
addition, shoulder universal joint, each
addition, standard control cable, extra
addition, heavy duty control cable
addition, Teflon or equal, cable lining
addition, hook to hand, cable adapter
addition, harness, chest or shoulder, saddle type
addition, harness, figure-of-eight type, for single control
addition, harness, figure-of-eight type, for dual control
addition, test socket, wrist disarticulation or below elbow
addition, test socket, elbow disarticulation or above elbow
addition, test socket, shoulder disarticulation or interscapular thoracic
addition, suction socket
addition, frame type socket, below elbow or wrist disarticulation
addition, frame type socket, above elbow or elbow disarticulation
addition, frame type socket, shoulder disarticulation

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Division of Medical Assistance Provider
Manual Series
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	TRANSMITTAL LETTER
PRT-14	DATE
11/22/02	
602 Service Codes and Descriptions (cont.)
Service
Code       Service Description
L6690	Upper extremity addition, frame type socket, interscapular-thoracic
L6691	Upper extremity addition, removable insert, each
L6692	Upper extremity addition, silicone gel insert or equal, each
L6693	Upper extremity addition, locking elbow, forearm counterbalance
TERMINAL DEVICES
Hooks
L6700	Terminal device, hook, Dorrance or equal, model #3
L6705	Terminal device, hook, Dorrance or equal, model #5
L6710	Terminal device, hook, Dorrance or equal, model #5X
L6715	Terminal device, hook, Dorrance or equal, model #5XA
L6720	Terminal device, hook, Dorrance or equal, model #6
L6725	Terminal device, hook, Dorrance or equal, model #7
L6730	Terminal device, hook, Dorrance or equal, model #7LO
L6735	Terminal device, hook, Dorrance or equal, model #8
L6740	Terminal device, hook, Dorrance or equal, model #8X
L6745	Terminal device, hook, Dorrance or equal, model #88X
L6750	Terminal device, hook, Dorrance or equal, model #10P
L6755	Terminal device, hook, Dorrance or equal, model #10X
L6765	Terminal device, hook, Dorrance or equal, model #12P
L6770	Terminal device, hook, Dorrance or equal, model #99X
L6775	Terminal device, hook, Dorrance or equal, model #555
L6780	Terminal device, hook, Dorrance or equal, model #SS555
L6790	Terminal device, hook, Accu-hook or equal
L6795	Terminal device, hook, 2 load or equal
L6800	Terminal device, hook, APRL VC or equal
L6805	Terminal device, modifier wrist flexion unit
L6806	Terminal device, hook, TRS Grip, Grip III, VC, or equal
L6807	Terminal device, hook, Grip I, Grip II, VC, or equal
L6808	Terminal device, hook, TRS Adept, infant or child, VC, or equal
L6809	Terminal device, hook, TRS Super Sport, passive
L6810	Terminal device, pincher tool, Otto Bock or equal
Hands
L6825	Terminal device, hand, Dorrance, VO
L6830	Terminal device, hand, Dorrance, APRL, VC
L6835	Terminal device, hand, Dorrance, Sierra, VO
L6840	Terminal device, hand, Dorrance, Becker Imperial
L6845	Terminal device, hand, Dorrance, Becker Lock Grip

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Division of Medical Assistance Provider
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602 Service Codes and Descriptions (cont.)

Service Code
L6850 L6855 L6860 L6865 L6867 L6868 L6870 L6872 L6873 L6875 L6880 L6881 L6882
L6890 L6895
L6900 L6905 L6910 L6915

Service Description
Terminal device, hand, Dorrance, Becker Plylite
Terminal device, hand, Dorrance, Robin-Aids, VO
Terminal device, hand, Dorrance, Robin-Aids, VO soft
Terminal device, hand, Dorrance, passive hand
Terminal device, hand, Dorrance, Detroit Infant Hand (mechanical)
Terminal device, hand, Dorrance, passive infant hand (Steeper, Hosmer, or equal)
Terminal device, hand, Dorrance, child mitt
Terminal device, hand, Dorrance, NYU child hand
Terminal device, hand, Dorrance, mechanical infant hand, Steeper or equal
Terminal device, hand, Dorrance, Bock, VC
Terminal device, hand, Dorrance, Bock, VO
Automatic grasp feature, addition to upper limb prosthetic terminal device
Microprocessor control feature, addition to upper limb prosthetic terminal device
Gloves For Above Hands
Terminal device, glove for above hands, production glove Terminal device, glove for above hands, custom glove
Hand Restoration
Hand restoration (casts, shading, and measurements included), partial hand, with glove, thumb
or one finger remaining Hand restoration (casts, shading, and measurements included), partial hand, with glove, multiple
fingers remaining Hand restoration (casts, shading, and measurements included), partial hand, with glove, no fingers
remaining Hand restoration (shading and measurements included), replacement glove for above
EXTERNAL POWER

Base Devices
L6920      Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, Otto
Bock or equal switch, cables, two batteries and one charger, switch control of terminal device L6925      Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, Otto
Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of
terminal device L6930      Below elbow, external power, self-suspended inner socket, removable forearm shell, Otto Bock
or equal switch, cables, two batteries and one charger, switch control of terminal device

Commonwealth of Massachusetts
Division of Medical Assistance Provider
Manual Series
PROSTHETICS MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-14	

	TRANSMITTAL LETTER
PRT-14	DATE
11/22/02	
602 Service Codes and Descriptions (cont.)

Service Code

Service Description

L6935
L6940
L6945
L6950
L6955
L6960
L6965
L6970
L6975
L7010 L7015 L7020 L7025 L7030 L7035 L7040 L7045

Below elbow, external power, self-suspended inner socket, removable forearm shell, Otto Bock or
equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal
device Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside
locking hinges, forearm, Otto Bock or equal switch, cables, two batteries and one charger,
switch control of terminal device Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside
locking hinges, forearm, Otto Bock or equal electrodes, cables, two batteries and one charger,
myoelectronic control of terminal device Above elbow, external power, molded inner socket, removable humeral shell, internal locking
elbow, forearm, Otto Bock or equal switch, cables, two batteries and one charger, switch
control of terminal device Above elbow, external power, molded inner socket, removable humeral shell, internal locking
elbow, forearm, Otto Bock or equal electrodes, cables, two batteries and one charger,
myoelectronic control of terminal device Shoulder disarticulation, external power, molded inner socket, removable shoulder shell,
shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal switch,
cables, two batteries and one charger, switch control of terminal device Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder
bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal electrodes, cables,
two batteries and one charger, myoelectronic control of terminal device Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder
bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal switch, cables,
two batteries and one charger, switch control of terminal device Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder
bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal electrodes, cables,
two batteries and one charger, myoelectronic control of terminal device Electronic hand, Otto Bock, Steeper, or equal, switch controlled Electronic hand, System Teknik, Variety Village or equal, switch controlled Electronic greifer, Otto Bock or equal, switch controlled Electronic hand, Otto Bock or equal, myoelectronically controlled Electronic hand, System Teknik, Variety Village or equal, myoelectronically controlled Electronic greifer, Otto Bock or equal, myoelectronically controlled Prehensile actuator, Hosmer or equal, switch controlled Electronic hook, child, Michigan or equal, switch controlled

Elbow
L7170	Electronic elbow, Hosmer or equal, switch controlled
L7180	Electronic elbow, Boston, Utah, or equal, myoelectronically controlled (I.C.)
L7185	Electronic elbow, adolescent, Variety Village or equal, switch controlled
L7186	Electronic elbow, child, Variety Village or equal, switch controlled

Commonwealth of Massachusetts
Division of Medical Assistance Provider
Manual Series
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6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-15	

	TRANSMITTAL LETTER
PRT-14	DATE
11/22/02	
602 Service Codes and Descriptions (cont.)

Service Code
L7190 L7191 L7260 L7261 L7266 L7272 L7274
L7360 L7362 L7364 L7366 L7499
L7510
L7520

Service Description
Electronic elbow, adolescent, Variety Village or equal, myoelectronically controlled
Electronic elbow, child, Variety Village or equal, myoelectronically controlled
Electronic wrist rotator, Otto Bock or equal
Electronic wrist rotator, for Utah arm
Servo control, Steeper or equal
Analogue control, UNB or equal
Proportional control, 6-12 volt, Liberty, Utah, or equal
Battery Components
Six-volt battery, Otto Bock or equal, each
Battery charger, six volt, Otto Bock or equal
12-volt battery, Utah or equal, each
Battery charger, 12 volt, Utah or equal
Upper extremity prosthesis, not otherwise specified (I.C.)
Repairs
Repair of prosthetic device, repair or replace minor parts (I.C.) Repair of prosthetic device, labor component, per 15 minutes

GENERAL
Prosthesis
L8000	Breast prosthesis, mastectomy bra
L8001	Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, unilateral
L8002	Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, bilateral
L8010	Breast prosthesis, mastectomy sleeve
L8015	External breast prosthesis garment, with mastectomy form, post mastectomy
L8020	Breast prosthesis, mastectomy form
L8030	Breast prosthesis, silicone or equal
L8035	Custom breast prosthesis, post mastectomy, molded to patient model
L8039	Breast prosthesis, not otherwise specified (I.C.)
Elastic Supports
L8100	Gradient compression stocking, below knee, 18-30 mmhg, each
L8110	Gradient compression stocking, below knee, 30-40 mmhg, each
L8120	Gradient compression stocking, below knee, 40-50 mmhg, each
L8130	Gradient compression stocking, thigh length, 18-30 mmhg, each
L8140	Gradient compression stocking, thigh length, 30-40 mmhg, each

Commonwealth of Massachusetts
Division of Medical Assistance Provider
Manual Series
PROSTHETICS MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-16	

	TRANSMITTAL LETTER
PRT-14	DATE
11/22/02	
602 Service Codes and Descriptions (cont.)
Service
Code	Service Description
L8150	Gradient compressioin stocking, thigh length, 40-50 mmhg, each
L8160	Gradient compression stocking, full length/chap style, 18-30 mmhg, each
L8170	Gradient compression stocking, full length/chap style, 30-40 mmhg, each
L8180	Gradient compression stocking, full length/chap style, 40-50 mmhg, each
L8190	Gradient compression stocking, waist length, 18-30 mmhg, each
L8195	Gradient compression stocking, waist length, 30-40 mmhg, each (I.C.)
L8200	Gradient compression stocking, waist length, 40-50 mmhg, each
L8210	Gradient compression stocking, custom made
L8220	Gradient compression stocking, lymphedema
L8230	Gradient compression stocking, garter belt
L8239	Gradient compression, not otherwise specified (I.C.)
Trusses
L8300	Truss, single with standard pad
L8310	Truss, double with standard pads
L8320	Truss, addition to standard pad, water pad
L8330	Truss, addition to standard pad, scrotal pad
Prosthetic Socks
L8400	Prosthetic sheath, below knee, each
L8410	Prosthetic sheath, above knee, each
L8415	Prosthetic sheath, upper limb, each
L8417	Prosthetic sheath/sock, including a gel cushion layer, below knee or above knee, each
L8420	Prosthetic sock, multiple ply, below knee, each
L8430	Prosthetic sock, multiple ply, above knee, each
L8435	Prosthetic sock, multiple ply, upper limb, each
L8440	Prosthetic shrinker, below knee, each
L8460	Prosthetic shrinker, above knee, each
L8465	Prosthetic shrinker, upper limb, each
L8470	Prosthetic sock, single ply, fitting, below knee, each
L8480	Prosthetic sock, single ply, fitting, above knee, each
L8485	Prosthetic sock, single ply, fitting, upper limb, each
L8490	Addition to prosthetic sheath/sock, air seal suction retention system
OTHER PROSTHETIC PROCEDURES
L8499      Unlisted procedure for miscellaneous prosthetic services (I.C.) Y9530     Nursing facility visit