Browse HCPCS Level II 2020 Edition

HCPCS Level II Table of Contents

L3905 - L3956  Other Upper Extremity Orhtotics

L3905
Wrist hand orthosis, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment
shortWho w/nontorsion jnt(s) cf
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH2.02 Date of Service Edit: PolicyAnatomic Consideration
DME2.02 Date of Service Edit: PolicyAnatomic Consideration
L3906
Wrist hand orthosis, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment
shortWho w/o joints cf
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH2.02 Date of Service Edit: PolicyAnatomic Consideration
DME2.02 Date of Service Edit: PolicyAnatomic Consideration
L3908
Wrist hand orthosis, wrist extension control cock-up, non molded, prefabricated, off-the-shelf
shortWho cock-up nonmolde pre ots
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH2.02 Date of Service Edit: PolicyAnatomic Consideration
DME2.02 Date of Service Edit: PolicyAnatomic Consideration
L3912
Hand finger orthosis (hfo), flexion glove with elastic finger control, prefabricated, off-the-shelf
shortHfo flexion glove pre ots
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH2.03 Date of Service Edit: ClinicalAnatomic Consideration
DME2.03 Date of Service Edit: ClinicalAnatomic Consideration
L3913
Hand finger orthosis, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment
shortHfo w/o joints cf
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH2.02 Date of Service Edit: PolicyAnatomic Consideration
DME2.02 Date of Service Edit: PolicyAnatomic Consideration
L3915
Wrist hand orthosis, includes one or more nontorsion joint(s), elastic bands, turnbuckles, may include soft interface, straps, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
shortWho nontorsion jnts pre cst
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH2.02 Date of Service Edit: PolicyAnatomic Consideration
DME2.02 Date of Service Edit: PolicyAnatomic Consideration
L3916
Wrist hand orthosis, includes one or more nontorsion joint(s), elastic bands, turnbuckles, may include soft interface, straps, prefabricated, off-the-shelf
shortWho nontorsion jnts pre ots
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH2.03 Date of Service Edit: ClinicalAnatomic Consideration
DME2.03 Date of Service Edit: ClinicalAnatomic Consideration
L3917
Hand orthosis, metacarpal fracture orthosis, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
shortMetacarp fx orthosis pre cst
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH2.02 Date of Service Edit: PolicyAnatomic Consideration
DME2.02 Date of Service Edit: PolicyAnatomic Consideration
L3918
Hand orthosis, metacarpal fracture orthosis, prefabricated, off-the-shelf
shortMetacarp fx orthosis pre ots
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH2.02 Date of Service Edit: PolicyAnatomic Consideration
DME2.02 Date of Service Edit: PolicyAnatomic Consideration
L3919
Hand orthosis, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment
shortHo w/o joints cf
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH2.02 Date of Service Edit: PolicyAnatomic Consideration
DME2.02 Date of Service Edit: PolicyAnatomic Consideration
L3921
Hand finger orthosis, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment
shortHfo w/joint(s) cf
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH2.02 Date of Service Edit: PolicyAnatomic Consideration
DME2.02 Date of Service Edit: PolicyAnatomic Consideration
L3923
Hand finger orthosis, without joints, may include soft interface, straps, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
shortHfo without joints pre cst
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH2.02 Date of Service Edit: PolicyAnatomic Consideration
DME2.02 Date of Service Edit: PolicyAnatomic Consideration
L3924
Hand finger orthosis, without joints, may include soft interface, straps, prefabricated, off-the-shelf
shortHfo without joints pre ots
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH2.02 Date of Service Edit: PolicyAnatomic Consideration
DME2.02 Date of Service Edit: PolicyAnatomic Consideration
L3925
Finger orthosis, proximal interphalangeal (pip)/distal interphalangeal (dip), non torsion joint/spring, extension/flexion, may include soft interface material, prefabricated, off-the-shelf
shortFo pip dip jnt/sprng pre ots
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH4.03 Date of Service Edit: ClinicalCode Descriptor / CPT Instruction
DME4.03 Date of Service Edit: ClinicalCode Descriptor / CPT Instruction
L3927
Finger orthosis, proximal interphalangeal (pip)/distal interphalangeal (dip), without joint/spring, extension/flexion (e.g., static or ring type), may include soft interface material, prefabricated, off-the-shelf
shortFo pip dip no jt spr pre ots
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH4.03 Date of Service Edit: ClinicalClinical: Data
DME4.03 Date of Service Edit: ClinicalClinical: Data
L3929
Hand finger orthosis, includes one or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
shortHfo nontorsion jnts pre cst
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH2.02 Date of Service Edit: PolicyAnatomic Consideration
DME2.02 Date of Service Edit: PolicyAnatomic Consideration
L3930
Hand finger orthosis, includes one or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, prefabricated, off-the-shelf
shortHfo nontorsion jnts pre ots
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH2.02 Date of Service Edit: PolicyAnatomic Consideration
DME2.02 Date of Service Edit: PolicyAnatomic Consideration
L3931
Wrist hand finger orthosis, includes one or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, prefabricated, includes fitting and adjustment
shortWhfo nontorsion joint prefab
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH2.02 Date of Service Edit: PolicyAnatomic Consideration
DME2.02 Date of Service Edit: PolicyAnatomic Consideration
L3933
Finger orthosis, without joints, may include soft interface, custom fabricated, includes fitting and adjustment
shortFo w/o joints cf
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH3.03 Date of Service Edit: ClinicalClinical: Data
DME3.03 Date of Service Edit: ClinicalClinical: Data
L3935
Finger orthosis, nontorsion joint, may include soft interface, custom fabricated, includes fitting and adjustment
shortFo nontorsion joint cf
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH3.03 Date of Service Edit: ClinicalClinical: Data
DME3.03 Date of Service Edit: ClinicalClinical: Data
L3956
Addition of joint to upper extremity orthosis, any material; per joint
shortAdd joint upper ext orthosis
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH4.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
DME4.03 Date of Service Edit: ClinicalClinical: CMS Workgroup