Notification



Notification Issue Date:



Policy Attachment

Attachment to Policy # MA05.063c


Attachment:A

Policy #:MA05.063c

Description:A list of Health Care Common Procedure Coding System (HCPCS) codes with repair or replacement in the narrative.

Title:Repair or Replacement of an External Prosthetic Device


Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.


A List of Health Care Common Procedure Coding System (HCPCS) Codes with Repair or Replacement in the Narrative for an External Prosthetic Device or Orthotic.

Please note:
When there is no specific HCPCS code for the repair or replacement of an external prosthetic device, the applicable HCPCS code for the specific device should be reported with the appropriate modifier. (Refer below for specific information regarding this modifier.)

THE FOLLOWING LIST INCLUDES ONLY THOSE HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS) CODES WITH REPAIR OR REPLACEMENT IN THE NARRATIVE:

A4363 Ostomy clamp, any type, replacement only, each

A5113 Leg strap; latex, replacement only, per set

A5114 Leg strap; foam or fabric, replacement only, per set

D5926 Nasal prosthesis, replacement

D5927 Auricular prosthesis, replacement

D5928 Orbital prosthesis, replacement

D5929 Facial prosthesis, replacement

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

L5703 Ankle, Symes, molded to patient model, socket without solid ankle cushion heel (SACH) foot, replacement only

L5971 All lower extremity prosthesis, solid ankle cushion heel (SACH) foot, replacement only

L6883 Replacement socket, below elbow/wrist disarticulation, molded to patient model, for use with or without external power

L6884 Replacement docket, above elbow/elbow disarticulation, molded to patient model, for with or without external power.

L6885 Replacement socket, shoulder disarticulation/interscapular thoracic, molded to patient model, for use with or without external power

L6915 Hand restoration (shading and measurements included), replacement glove for above

L7367 Lithium ion battery, rechargeable, replacement

L7368 Lithium ion battery charger, replacement only

L7510 Repair of prosthetic device, repair or replace minor parts

L7520: Repair prosthetic device, labor component, per 15 minutes

L8048 Unspecified maxillofacial prosthesis, by report, provided by a nonphysician

L8049 Repair or modification of maxillofacial prosthesis, labor component, 15 minute increments, provided by a nonphysician

L8505 Artificial larynx replacement battery/accessory, any type

L8511 Insert for indwelling tracheoesophageal prosthesis, with or without valve, replacement only, each

L8512 Gelatin capsules or equivalent, for use with tracheoesophageal voice prosthesis, replacement only, per 10

L8513 Cleaning device used with tracheoesophageal voice prosthesis, pipet, brush, or equal, replacement only, each

L8514 Tracheoesophageal puncture dilator, replacement only, each

L8615 Headset/headpiece for use with cochlear implant device, replacement

L8616 Microphone for use with cochlear implant device, replacement

L8617 Transmitting coil for use with cochlear implant device, replacement

L8618 Transmitter cable for use with cochlear implant device or auditory osseointegrated device, replacement

L8619 Cochlear implant, external speech processor and controller, integrated system, replacement

L8621 Zinc air battery for use with cochlear implant device and auditory osseointegrated sound processors, replacement, each

L8622 Alkaline battery for use with cochlear implant device, any size, replacement, each

L8623 Lithium ion battery for use with cochlear implant device speech processor, other than ear level, replacement, each

L8624 Lithium ion battery for use with cochlear implant or auditory osseointegrated device speech processor, ear level, replacement, each

L8625 External recharging system for battery for use with cochlear implant or auditory osseointegrated device, replacement only, each

L8627 Cochlear implant, external speech processor, component, replacement

L8628 Cochlear implant, external controller component, replacement

L8629 Transmitting coil and cable, integrated, for use with cochlear implant device, replacement

L8681 Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only

L8684 Radiofrequency transmitter (external) for use with implantable sacral root neurostimulator receiver for bowel and bladder management, replacement

L8689 External recharging system for battery (internal) for use with implantable neurostimulator, replacement only

L8691 Auditory osseointegrated device, external sound processor, excludes transducer/actuator, replacement only, each

L8693 Auditory osseointegrated device abutment, any length, replacement only

L8694 Auditory osseointegrated device, transducer/actuator, replacement only, each

L8695 External recharging system for battery (external) for use with implantable neurostimulator, replacement only

Q0479 Power module for use with electric or electric/pneumatic ventricular assist device, replacement only

Q0496 Battery, other than lithium-ion, for use with electric or electric/pneumatic ventricular assist device, replacement only

Q0506 Battery, Lithium-ion, for use with electric or electric/pneumatic ventricular assist device, replacement only

V5014 Repair/modification of a hearing aid



Version Effective Date: 01/01/2018
Version Issued Date: 12/29/2017
Version Reissued Date: N/A

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