Zimmer Surgical Products to HCPCS Code Crosswalk

Transcription

Surgical Products
NOTE #1: For Medicare Outpatient Hospital procedures, C1776 [Joint device (implantable)] and C1713 [Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable)] might be allowable for purposes of billing for Zimmer implantable devices and products. Please check with your Payer(s) for complete billing and reimbursement details.
NOTE #2: For implantable devices and products in the Zimmer Catalog, there are no separately reportable HCPCS codes for billing Inpatient Hospital Medicare procedures on the UB-04 Claim Form. These implantable devices and products are considered integral to the procedure performed, and the Medicare MS-DRG payment includes their costs in
the total facility payment. Revenue Code(s) in the 027X range could be appended on the UB-04 claim form to track facility charges for such implantable devices and products. Please check with your Payer(s) for complete billing and reimbursement details.
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Subsystem Description
2011 HCPCS Code
(If Applicable)
2011 HCPCS Code Status
Indicator for Medicare
Outpatient Prospective
Payment System
2011 Long HCPCS
Descriptior
60-3000-101-00 60300010100 ATS 3000 TOURNIQUET W/HOSES
AUTOMATIC TOURNIQUET SYSTEMS (A.T.S.)
A.T.S. 3000 TOURNIQUET SYSTEM MACHINES Tourniquets Tourniquets (Extremity)
N/A
N/A
N/A
60-3000-102-00 60300010200 ATS 3000 TOURNIQUET W/HOSES &
CUFFS
60-3000-103-00 60300010300 ATS 3000 TOURNIQUET W/HOSES,
CUFFS, STD, BSKT
STAND, BASKET
62-2100-096-00 62210009600 MANUAL, ATS3000
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
60-1200-101-00 60120010100 ATS1200 TOURNIQUET W/HOSES
N/A
N/A
N/A
60-1200-102-00 60120010200 ATS1200 TOURNIQUET W/HOSES &
CUFFS
CUFFS, STD, BSKT
STAND, BASKET
62-8000-015-00 62800001500 MANUAL, ATS1200
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
60-0750-101-00 60075010100 ATS 750 TOURNIQUET W/HOSE
60-0750-102-00 60075010200 ATS 750 TOURNIQUET W/HOSE &
CUFFS
60-0750-103-00 60075010300 ATS 750 TOURNIQUET W/HOSE,
CUFFS, STD, BSKT
60-0750-104-00 60075010400 ATS 750 TOURNIQUET W/HOSE,
STAND, BASKET
60-2000-110-00 60200011000 ATS 2000 CALIBRATION KIT
A.T.S. 750 TOURNIQUET SYSTEM MACHINES
N/A
N/A
N/A
N/A
N/A
N/A
62-2000-101-00 62200010100 ATS 2000 MANUAL W/CUFF ALERT
60-7070-053-00 60707005300 18 DPSB STER DISP CUFF LUER
LOCK W/SLEEVE
Tourniquets Tourniquets (Extremity)
Common UB-04 Revenue Codes
Comment 1
Comment 2
Comment 3
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
A.T.S. 2000 TOURNIQUET SYSTEM
ACCESSORIES
A.T.S. 2000 TOURNIQUET SYSTEM
ACCESSORIES
STERILE DISPOSABLE CUFFS W/SLEEVES
N/A
N/A
N/A
General Medical Surgical Supplies 0270, NonSterile Supplies 0271, Sterile Supplies 0272
Charges reported with UB-04 revenue codes 0270,0271 and
0272 on Medicare outpatient claims are considered packaged
services. Under Medicare OPPS, packaged services are not
separately payable.
See Pub 100-04 Medicare
Claims Processing Manual.
LOCK W/SLEEVE
N/A
N/A
N/A
separately payable.
60-7070-152-00 60707015200 12 DPSB STER DISP CUFF PLC
W/SLEEVE
N/A
N/A
N/A
separately payable.
W/SLEEVE
N/A
N/A
N/A
separately payable.
W/SLEEVE
N/A
N/A
N/A
separately payable.
W/SLEEVE
N/A
N/A
N/A
separately payable.
W/SLEEVE
N/A
N/A
N/A
separately payable.
W/SLEEVE
N/A
N/A
N/A
separately payable.
© 2011 Zimmer Surgical, Inc. | This document may not be reproduced, distributed, transmitted, displayed, published or broadcast in whole or in part without prior written permission.
PAGE 1
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
60-7075-052-00 60707505200 12 SPSB STER DISP CUFF LUER
LOCK W/SLEEVE
N/A
N/A
N/A
separately payable.
LOCK W/SLEEVE
N/A
N/A
N/A
separately payable.
LOCK W/SLEEVE
N/A
N/A
N/A
separately payable.
LOCK W/SLEEVE
N/A
N/A
N/A
separately payable.
LOCK W/SLEEVE
N/A
N/A
N/A
separately payable.
60-7075-152-00 60707515200 12 SPSB STER DISP CUFF PLC
W/SLEEVE
N/A
N/A
N/A
separately payable.
W/SLEEVE
N/A
N/A
N/A
separately payable.
W/SLEEVE
N/A
N/A
N/A
separately payable.
W/SLEEVE
N/A
N/A
N/A
separately payable.
W/SLEEVE
N/A
N/A
N/A
separately payable.
W/SLEEVE
N/A
N/A
N/A
separately payable.
60-7080-152-00 60708015200 18 DPDB STER DISP CUFF PLC
W/SLEEVE
N/A
N/A
N/A
separately payable.
WSLEEVE
N/A
N/A
N/A
separately payable.
PAGE 2
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
LOCK
STERILE DISPOSABLE CUFFS
N/A
N/A
N/A
separately payable.
LOCK
N/A
N/A
N/A
separately payable.
LOCK
N/A
N/A
N/A
separately payable.
LOCK
N/A
N/A
N/A
separately payable.
LOCK
N/A
N/A
N/A
separately payable.
LOCK
N/A
N/A
N/A
separately payable.
LOCK
N/A
N/A
N/A
separately payable.
N/A
N/A
N/A
separately payable.
N/A
N/A
N/A
separately payable.
N/A
N/A
N/A
separately payable.
N/A
N/A
N/A
separately payable.
N/A
N/A
N/A
separately payable.
N/A
N/A
N/A
separately payable.
PAGE 3
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
N/A
N/A
N/A
separately payable.
60-7075-001-00 60707500100 8 SPSB STER DISP CUFF LUER LOCK AUTOMATIC TOURNIQUET SYSTEMS (A.T.S.)
N/A
N/A
N/A
separately payable.
LOCK
N/A
N/A
N/A
separately payable.
LOCK
N/A
N/A
N/A
separately payable.
LOCK
N/A
N/A
N/A
separately payable.
LOCK
N/A
N/A
N/A
separately payable.
LOCK
N/A
N/A
N/A
separately payable.
LOCK
N/A
N/A
N/A
separately payable.
N/A
N/A
N/A
separately payable.
N/A
N/A
N/A
separately payable.
N/A
N/A
N/A
separately payable.
N/A
N/A
N/A
separately payable.
N/A
N/A
N/A
separately payable.
PAGE 4
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
N/A
N/A
N/A
separately payable.
N/A
N/A
N/A
separately payable.
60-7080-001-00 60708000100 12 DPDB STER DISP CUFF LUER
LOCK
N/A
N/A
N/A
separately payable.
LOCK
N/A
N/A
N/A
separately payable.
LOCK
N/A
N/A
N/A
separately payable.
N/A
N/A
N/A
separately payable.
N/A
N/A
N/A
separately payable.
N/A
N/A
N/A
separately payable.
60-7085-001-00 60708500100 12 SPDB STER DISP CUFF LUER
LOCK
N/A
N/A
N/A
separately payable.
LOCK
N/A
N/A
N/A
separately payable.
LOCK
N/A
N/A
N/A
separately payable.
60-7085-101-00 60708510100 12 SPDB STER DISP CUFF PLC
N/A
N/A
N/A
separately payable.
N/A
N/A
N/A
separately payable.
PAGE 5
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
N/A
N/A
N/A
separately payable.
60-7500-001-00 60750000100 8 DPSB ATS CYLINDRICAL CUFF
REUSABLE CYLINDRICAL CUFFS (NONSTERILE)
N/A
N/A
N/A
separately payable.
N/A
N/A
N/A
separately payable.
N/A
N/A
N/A
separately payable.
N/A
N/A
N/A
separately payable.
N/A
N/A
N/A
separately payable.
N/A
N/A
N/A
separately payable.
N/A
N/A
N/A
separately payable.
60-7555-001-00 60755500100 12 DPDB ATS CYLINDRICAL CUFF
N/A
N/A
N/A
separately payable.
N/A
N/A
N/A
separately payable.
N/A
N/A
N/A
separately payable.
60-7600-001-00 60760000100 8 SPSB ATS CYLINDRICAL CUFF
N/A
N/A
N/A
separately payable.
N/A
N/A
N/A
separately payable.
PAGE 6
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
N/A
N/A
N/A
separately payable.
N/A
N/A
N/A
separately payable.
N/A
N/A
N/A
separately payable.
N/A
N/A
N/A
separately payable.
N/A
N/A
N/A
separately payable.
60-7666-001-00 60766600100 12 SPDB ATS CYLINDRICAL CUFF
N/A
N/A
N/A
separately payable.
N/A
N/A
N/A
separately payable.
N/A
N/A
N/A
separately payable.
60-7350-002-00 60735000200 SPSB CONTOUR UPPER LIMB CUFF AUTOMATIC TOURNIQUET SYSTEMS (A.T.S.)
CONTOUR CUFFS W/SLEEVES (REUSABLE,
NON-STERILE)
N/A
N/A
N/A
separately payable.
60-7350-003-00 60735000300 SPSB CONTOUR THIGH CUFF
NON-STERILE)
N/A
N/A
N/A
separately payable.
60-7350-004-00 60735000400 SPSB CONTOUR LOWER LEG CUFF AUTOMATIC TOURNIQUET SYSTEMS (A.T.S.)
NON-STERILE)
N/A
N/A
N/A
separately payable.
60-7350-011-00 60735001100
SPDB CONTOUR UPPPER LIMB IVRA AUTOMATIC TOURNIQUET SYSTEMS (A.T.S.)
CUFF
NON-STERILE)
N/A
N/A
N/A
separately payable.
60-7450-002-00 60745000200 DPSB CONTOUR UPPER LIMB CUFF AUTOMATIC TOURNIQUET SYSTEMS (A.T.S.)
NON-STERILE)
N/A
N/A
N/A
separately payable.
PAGE 7
Product #
EDI Item #
Item Description
60-7450-003-00 60745000300 DPSB CONTOUR THIGH CUFF
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
NON-STERILE)
N/A
N/A
N/A
separately payable.
60-7450-004-00 60745000400 DPSB CONTOUR LOWER LEG CUFF AUTOMATIC TOURNIQUET SYSTEMS (A.T.S.)
NON-STERILE)
N/A
N/A
N/A
separately payable.
60-7450-011-00 60745001100
NON-STERILE)
N/A
N/A
N/A
separately payable.
60-7500-008-00 60750000800 DPSB CONTOUR CUFF - XL (30 IN-39 AUTOMATIC TOURNIQUET SYSTEMS (A.T.S.)
IN)
XL CONTOUR CUFFS (REUSABLE, NONSTERILE)
N/A
N/A
N/A
separately payable.
60-7600-008-00 60760000800 SPSB CONTOUR CUFF - XL (30 IN-39 AUTOMATIC TOURNIQUET SYSTEMS (A.T.S.)
IN)
XL CONTOUR CUFFS (REUSABLE, NONSTERILE)
N/A
N/A
N/A
separately payable.
60-7920-001-00 60792000100 PROT.SLEEVE/CONT.ARM CUFF
CONTOUR CUFF SLEEVES
N/A
N/A
N/A
separately payable.
60-7920-002-00 60792000200 PROT.SLEEVE/CONT.THIGHCUF
N/A
N/A
N/A
separately payable.
60-7920-003-00 60792000300 PROT.SLEEVE/CONT.LEG CUFF
N/A
N/A
N/A
separately payable.
60-8000-001-00 60800000100 SPSB EXTRA SMALL ADULT CUFF 3
IN
SMALL ADULT CUFFS W/SLEEVES
(REUSABLE, NON-STERILE)
N/A
N/A
N/A
separately payable.
60-8000-002-00 60800000200 SPSB SMALL ADULT CUFF 3.5 IN
N/A
N/A
N/A
separately payable.
60-8100-001-00 60810000100 DPSB EXTRA SMALL ADULT CUFF 3
IN
N/A
N/A
N/A
separately payable.
60-8100-002-00 60810000200 DPSB SMALL ADULT CUFF 3.5 IN
N/A
N/A
N/A
separately payable.
60-7910-001-00 60791000100 PROT. SLEEVE/ X-SM ADULT
SMALL ADULT SLEEVES
N/A
N/A
N/A
separately payable.
DPDB CONTOUR UPPER LIMB IVRA
CUFF
PAGE 8
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
60-7910-002-00 60791000200 PROT. SLEEVE/ SM ADULT 10
SMALL ADULT SLEEVES
N/A
N/A
N/A
separately payable.
60-8000-008-00 60800000800 8 INCH CUFF SLEEVE
CUFF SLEEVES - STERILE
N/A
N/A
N/A
separately payable.
60-8000-012-00 60800001200 12 INCH CUFF SLEEVE
N/A
N/A
N/A
separately payable.
60-8000-018-00 60800001800 18 INCH CUFF SLEEVE
N/A
N/A
N/A
separately payable.
60-8000-024-00 60800002400 24 INCH CUFF SLEEVE
N/A
N/A
N/A
separately payable.
60-8000-030-00 60800003000 30 INCH CUFF SLEEVE
N/A
N/A
N/A
separately payable.
60-8000-034-00 60800003400 34 INCH CUFF SLEEVE
N/A
N/A
N/A
separately payable.
60-8000-042-00 60800004200 42 INCH CUFF SLEEVE
N/A
N/A
N/A
separately payable.
60-2694-001-00 60269400100 ESMARK BANDAGES, DISP, 3IN X 9FT AUTOMATIC TOURNIQUET SYSTEMS (A.T.S.)
STER
ESMARK BANDAGES - STERILE
N/A
N/A
N/A
separately payable.
60-2694-002-00 60269400200 ESMARK BANDAGES, DISP 4INX 9FT AUTOMATIC TOURNIQUET SYSTEMS (A.T.S.)
STER
N/A
N/A
N/A
separately payable.
60-2694-003-00 60269400300 ESMARK BANDAGES, DISP, 6IN X 9FT AUTOMATIC TOURNIQUET SYSTEMS (A.T.S.)
STER
N/A
N/A
N/A
separately payable.
60-2694-004-00 60269400400 ESMARK BANDAGES, DISP, 3IN X
12FT STER
N/A
N/A
N/A
separately payable.
12FT STER
N/A
N/A
N/A
separately payable.
PAGE 9
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
12FT STER
N/A
N/A
N/A
separately payable.
60-2694-011-00 60269401100
LATEX FREE ESMARK 3IN. X 9FT.
N/A
N/A
N/A
separately payable.
60-2694-012-00 60269401200 LATEX FREE ESMARK 4IN. X 9FT.
N/A
N/A
N/A
separately payable.
60-2694-013-00 60269401300 LATEX FREE ESMARK 5.5IN X 9FT
N/A
N/A
N/A
separately payable.
N/A
N/A
N/A
separately payable.
N/A
N/A
N/A
separately payable.
60-2694-016-00 60269401600 LATEX FREE ESMARK 5.5IN X 12FT
N/A
N/A
N/A
separately payable.
60-1812-001-00 60181200100 DUAL STERILE EXTENSION HOSE
W/LUER LOCK CONNECTOR
CUFF HOSES
N/A
N/A
N/A
separately payable.
60-1812-101-00 60181210100 DUAL STERILE EXTENSION HOSE
W/PLC CONNECTOR
CUFF HOSES
N/A
N/A
N/A
separately payable.
60-2790-001-00 60279000100 ATS 500/750/1200 HOSE, RED/WE
60-2790-002-00 60279000200 ATS 500/750/1200 HOSE, BLUE/W
60-4009-001-00 60400900100 SINGLE STERILE EXTENSION HOSE AUTOMATIC TOURNIQUET SYSTEMS (A.T.S.)
W/LUER LOCK CONNECTR
CUFF HOSES
CUFF HOSES
CUFF HOSES
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
separately payable.
60-4009-101-00 60400910100 SINGLE STERILE EXTENSION HOSE AUTOMATIC TOURNIQUET SYSTEMS (A.T.S.)
W/PLC CONNECTOR
CUFF HOSES
N/A
N/A
N/A
separately payable.
60-4017-001-00
60-4018-001-00
60-7300-105-00
60-7500-100-00
60-7600-100-00
60-7600-300-00
60-7600-400-00
61-7308-000-00
06-0015-012-63
06-0020-013-70
60-0750-000-01
60-0750-000-02
60-0750-000-03
CUFF HOSES
CUFF HOSES
CUFF HOSES
CUFF HOSES
CUFF HOSES
CUFF HOSES
CUFF HOSES
CUFF HOSES
A.T.S. PARTS
A.T.S. PARTS
A.T.S. PARTS
A.T.S. PARTS
A.T.S. PARTS
Tourniquets
Tourniquets
Tourniquets
Tourniquets
Tourniquets
Tourniquets
Tourniquets
Tourniquets
Tourniquets
Tourniquets
Tourniquets
Tourniquets
Tourniquets
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
60401700100
60401800100
60730010500
60750010000
60760010000
60760030000
60760040000
61730800000
06001501263
06002001370
60075000001
60075000002
60075000003
ATS 1500/2000 DUAL HOSE, BLU/W
ATS 1500/2000 DUAL HOSE, RED/W
CPC-TO-LUER ADAPTORS
A.T.S. DUAL HOSE RETROFIT KIT
A.T.S. 500 HOSE RETROFIT KIT
RED UNIVERSAL HOSE ADAPTERS
BLUE UNIVERSAL HOSE ADAPTERS
O-RINGS FOR TOURNIQUET CUFF
CALIBRATION HOSE ATS 750
PLUMBING ASSY ATS 750
CONTROL BOARD ATS 750
BATTERY ATS 750
MEMBRANE CONTROL PANEL ATS
750
Tourniquets (Extremity)
PAGE 10
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
60-0750-000-04
60-0750-000-05
60-0750-000-06
60-0750-000-07
60-0750-000-08
60-0750-000-09
60-0750-000-10
60-0750-000-11
60-0750-000-12
60-0750-000-13
60075000004
60075000005
60075000006
60075000007
60075000008
60075000009
60075000010
60075000011
60075000012
60075000013
12 VOLT PUMP ATS 750
CASE BASE ATS 750
CASE LID ATS 750
ROTARY KNOB ATS 750
BATTERY BRACKET ATS 750
DEFLATE VALVE ATS 750
POWER ENTRY MODULE ATS 750
MAIN WIRE HARNESS ATS 750
BATTERY HARNESS ATS 750
OVERPRESSURE SWITCH HARNESS
A.T.S. PARTS
A.T.S. PARTS
A.T.S. PARTS
A.T.S. PARTS
A.T.S. PARTS
A.T.S. PARTS
A.T.S. PARTS
A.T.S. PARTS
A.T.S. PARTS
A.T.S. PARTS
Tourniquets
Tourniquets
Tourniquets
Tourniquets
Tourniquets
Tourniquets
Tourniquets
Tourniquets
Tourniquets
Tourniquets
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
60-0750-000-14
60-2000-000-03
60-2000-000-06
60-2000-000-07
60-2000-000-08
62-1131-001-00
60075000014
60200000003
60200000006
60200000007
60200000008
62113100100
OVERPRESSURE SWITCH ATS 750
PUMP W/O TUBING ATS2000
VALVE 24VOLT CLIPPARD SLOW
VALVE 24VOLT BURKERT:FAST
FUSE 1A 5X20MM
ALARM SILENCE SWITCH W/O LAMP
A.T.S. PARTS
A.T.S. PARTS
A.T.S. PARTS
A.T.S. PARTS
A.T.S. PARTS
A.T.S. PARTS
Tourniquets
Tourniquets
Tourniquets
Tourniquets
Tourniquets
Tourniquets
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
62-1132-001-00
62-1133-001-00
62-1134-001-00
62-1137-001-00
62-1138-001-00
62-1168-001-00
62-1169-001-00
62-1175-001-00
62-1179-001-00
62113200100
62113300100
62113400100
62113700100
62113800100
62116800100
62116900100
62117500100
62117900100
A.T.S. PARTS
A.T.S. PARTS
A.T.S. PARTS
A.T.S. PARTS
A.T.S. PARTS
A.T.S. PARTS
A.T.S. PARTS
A.T.S. PARTS
A.T.S. PARTS
Tourniquets
Tourniquets
Tourniquets
Tourniquets
Tourniquets
Tourniquets
Tourniquets
Tourniquets
Tourniquets
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
62-1180-001-00
62-1184-001-00
62-8000-018-00
62-8000-019-00
60-1908-001-00
60-4022-001-00
62118000100
62118400100
62800001800
62800001900
60190800100
60402200100
ALARM SILENCE LAMP
ALARM SILENCE LENS RED
FEET W/O SCREWS
FUSE DRAWER 1/4IN X 1 1/4IN
FUSE DRAWER 5X20 CM
ALARM SILENCE HARNESS
SPEAKER HARNESS
8 OHM SPEAKER
1 AMPTIME DELAY 1 1/4IN (3.2 CM)
GLASS FUSE
PUMP GASKET
GRAY POWER CORD
MAINS WIRING HARNESS, ATS
CORD CLIP, ATS1200
TOURNIQUET ACCESSORY BASKET
TOURNIQUET STAND,
TELESCOPING, W/28 BASE
PULSAVAC PLUS COMPONENT KIT
A.T.S. PARTS
A.T.S. PARTS
A.T.S. PARTS
A.T.S. PARTS
A.T.S. ACCESSORIES
A.T.S. ACCESSORIES
Tourniquets
Tourniquets
Tourniquets
Tourniquets
Tourniquets
Tourniquets
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
WOUND DEBRIDEMENT PRODUCTS
PULSAVAC PLUS
Wound
Pulsavac (Wound
Debridement Debridement)
N/A
N/A
N/A
General Medical Surgical Supplies 0270, NonSterile Supplies 0271, Sterile Supplies 0272,
separately payable.
00-5150-475-01 00515047501 PULSAVAC PLUS FAN SPRAY KIT
PULSAVAC PLUS
Wound
Pulsavac (Wound
N/A
N/A
N/A
separately payable.
00-5150-482-01 00515048201 PULSAVAC PLUS HIP KIT
PULSAVAC PLUS
Wound
Pulsavac (Wound
N/A
N/A
N/A
separately payable.
00-5150-495-01 00515049501 PULSAVAC PLUS SHOWER SPRAY
KIT
PULSAVAC PLUS
Wound
Pulsavac (Wound
N/A
N/A
N/A
separately payable.
00-5150-420-00 00515042000 PULSAVAC PLUS COMPONENT KIT
PULSAVAC PLUS
Wound
Pulsavac (Wound
N/A
N/A
N/A
separately payable.
00-5150-475-00 00515047500 PULSAVAC PLUS FAN KIT
PULSAVAC PLUS
Wound
Pulsavac (Wound
N/A
N/A
N/A
separately payable.
00-5150-482-00 00515048200 PULSAVAC PLUS HIP KIT
PULSAVAC PLUS
Wound
Pulsavac (Wound
N/A
N/A
N/A
separately payable.
00-5150-420-01 00515042001
PAGE 11
Product #
EDI Item #
Item Description
00-5150-495-00 00515049500 PULSAVAC PLUS SHOWER KIT
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
PULSAVAC PLUS
Wound
Pulsavac (Wound
N/A
N/A
N/A
separately payable.
00-5150-350-00 00515035000 PULSAVAC PLUS AC POWER SUPPLY WOUND DEBRIDEMENT PRODUCTS
US
PULSAVAC PLUS AC
Wound
Pulsavac (Wound
N/A
N/A
N/A
separately payable.
00-5150-426-01 00515042601 PULSAVAC PLUS A/C COMPONENT
KIT
PULSAVAC PLUS AC
Wound
Pulsavac (Wound
N/A
N/A
N/A
separately payable.
00-5150-476-01 00515047601 PULSAVAC PLUS AC FAN SPRAY KIT WOUND DEBRIDEMENT PRODUCTS
PULSAVAC PLUS AC
Wound
Pulsavac (Wound
N/A
N/A
N/A
separately payable.
00-5150-486-01 00515048601 PULSAVAC PLUS AC HIP KIT
PULSAVAC PLUS AC
Wound
Pulsavac (Wound
N/A
N/A
N/A
separately payable.
00-5150-496-01 00515049601 PULSAVAC PLUS AC SHOWER
SPRAY KIT
PULSAVAC PLUS AC
Wound
Pulsavac (Wound
N/A
N/A
N/A
separately payable.
00-5150-920-00 00515092000 PULSAVAC PLUS (LOW PRESSURE) WOUND DEBRIDEMENT PRODUCTS
COMPONENT KIT
PULSAVAC PLUS LOW PRESSURE
Wound
Pulsavac (Wound
N/A
N/A
N/A
separately payable.
FAN SPRAY KIT
Wound
Pulsavac (Wound
N/A
N/A
N/A
separately payable.
SHOWER SPRAY KIT
Wound
Pulsavac (Wound
N/A
N/A
N/A
separately payable.
00-5150-145-00 00515014500 ADJUSTABLE LENGTH IM TIP HI-CAP WOUND DEBRIDEMENT PRODUCTS
HIGH CAPACITY TIPS
Wound
Pulsavac (Wound
N/A
N/A
N/A
separately payable.
00-5150-155-00 00515015500 SINGLE STREAM TIP W/SPLASH
SHIELD HI-CAP
HIGH CAPACITY TIPS
Wound
Pulsavac (Wound
N/A
N/A
N/A
separately payable.
00-5150-175-00 00515017500 FAN SPRAY TIP HI-CAP
HIGH CAPACITY TIPS
Wound
Pulsavac (Wound
N/A
N/A
N/A
separately payable.
00-5150-176-00 00515017600 FAN SPRAY TIP W/FILTER HI-CAP
HIGH CAPACITY TIPS
Wound
Pulsavac (Wound
N/A
N/A
N/A
separately payable.
00-5150-181-00 00515018100 FOUR ORIFICES IM TIP HI-CAP
20.32CM X 1.27CM
HIGH CAPACITY TIPS
Wound
Pulsavac (Wound
N/A
N/A
N/A
separately payable.
PAGE 12
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
00-5150-182-00 00515018200 RADIAL SPRAY IM TIP HI-CAP
22.86CM X .89 CM
HIGH CAPACITY TIPS
Wound
Pulsavac (Wound
N/A
N/A
N/A
separately payable.
00-5150-183-00 00515018300 FEMORAL BRUSH TIP HI-CAP
HIGH CAPACITY TIPS
Wound
Pulsavac (Wound
N/A
N/A
N/A
separately payable.
00-5150-184-00 00515018400 HIP REVISION TIP HI-CAP
HIGH CAPACITY TIPS
Wound
Pulsavac (Wound
N/A
N/A
N/A
separately payable.
00-5150-185-00 00515018500 FOUR ORIFICES IM TIP HI-CAP
30.48CM X 1.27CM
HIGH CAPACITY TIPS
Wound
Pulsavac (Wound
N/A
N/A
N/A
separately payable.
00-5150-187-00 00515018700 TIBIAL PLATEAU BRUSH TIP HI-CAP
HIGH CAPACITY TIPS
Wound
Pulsavac (Wound
N/A
N/A
N/A
separately payable.
00-5150-195-00 00515019500 SHOWER SPRAY TIP HI-CAP
HIGH CAPACITY TIPS
Wound
Pulsavac (Wound
N/A
N/A
N/A
separately payable.
00-5150-188-00 00515018800 7IN SPLASH SHIELD
SPLASH SHIELDS
Wound
Pulsavac (Wound
N/A
N/A
N/A
00-5150-189-00 00515018900 9IN SPLASH SHIELD
SPLASH SHIELDS
Wound
Pulsavac (Wound
N/A
N/A
N/A
00-5150-375-00 00515037500 SHIELDLESS FAN SPRAY TIP HI-CAP WOUND DEBRIDEMENT PRODUCTS
SHIELDLESS TIPS
Wound
Pulsavac (Wound
N/A
N/A
N/A
separately payable.
00-5150-395-00 00515039500 SHIELDLESS SHOWER SPRAY TIP HI- WOUND DEBRIDEMENT PRODUCTS
CAP
SHIELDLESS TIPS
Wound
Pulsavac (Wound
N/A
N/A
N/A
separately payable.
00-5150-065-00 00515006500 WIDE SINGLE STREAM IM TIP
MISCELLANEOUS TIPS
Wound
Pulsavac (Wound
N/A
N/A
N/A
separately payable.
00-5150-186-00 00515018600 FLEXIBLE TIP
MISCELLANEOUS TIPS
Wound
Pulsavac (Wound
N/A
N/A
N/A
separately payable.
00-5150-042-00 00515004200 DUAL SPIKE Y-CONNECTOR
MISCELLANEOUS
Wound
Pulsavac (Wound
N/A
N/A
N/A
separately payable.
00-1500-050-10 00150005010 HEMOVAC INFECTION CONTROL
BAG
PVC CLOSED WOUND DRAINAGE
HEMOVAC INFECTION CONTROL KITS
Closed
Wound
Drainage
PVC
N/A
N/A
N/A
separately payable.
HEMOVAC INFECTION CONTROLKIT, PVC CLOSED WOUND DRAINAGE
3/32 PVC DRAIN
Closed
Wound
Drainage
PVC
N/A
N/A
N/A
separately payable.
00-2550-001-10 00255000110
PAGE 13
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
00-2550-002-10 00255000210 HEMOVAC INFECTION CONTROLKIT, PVC CLOSED WOUND DRAINAGE
1/8 PVC DRAIN
Closed
Wound
Drainage
PVC
N/A
N/A
N/A
separately payable.
3/16 PVC DRAIN
Closed
Wound
Drainage
PVC
N/A
N/A
N/A
separately payable.
1/4 PVC DRAIN
Closed
Wound
Drainage
PVC
N/A
N/A
N/A
separately payable.
00-2550-050-10 00255005010 400ML HEMOVAC INFECTION
CONTROL COMPONENT KIT
Closed
Wound
Drainage
PVC
N/A
N/A
N/A
separately payable.
00-2550-702-10 00255070210 BONDED HEMOVAC INF CTRL, 1/8
PVC W/TROCAR DRN CLMP
Closed
Wound
Drainage
PVC
N/A
N/A
N/A
separately payable.
PVC W/TROCR DRN CLMP
Closed
Wound
Drainage
PVC
N/A
N/A
N/A
separately payable.
PVC W/TROCAR DRN CLMP
Closed
Wound
Drainage
PVC
N/A
N/A
N/A
separately payable.
00-2500-700-10 00250070010 400ML HEMOVAC KIT 1/8 IN
HEMOVAC KITS
Closed
Wound
Drainage
PVC
N/A
N/A
N/A
separately payable.
00-2505-700-10 00250570010 400ML HEMOVAC KIT 3/16 IN
HEMOVAC KITS
Closed
Wound
Drainage
PVC
N/A
N/A
N/A
separately payable.
00-2590-700-10 00259070010 400ML HEMOVAC KIT 1/4 IN
HEMOVAC KITS
Closed
Wound
Drainage
PVC
N/A
N/A
N/A
separately payable.
00-2500-000-10 00250000010 400ML HEMOVAC KIT, 1/8 PVC DRAIN PVC CLOSED WOUND DRAINAGE
HEMOVAC KITS
Closed
Wound
Drainage
PVC
N/A
N/A
N/A
separately payable.
00-2500-004-10 00250000410 400ML HEMOVAC COMPONENT KIT
HEMOVAC KITS
Closed
Wound
Drainage
PVC
N/A
N/A
N/A
separately payable.
00-2505-000-10 00250500010 400ML HEMOVAC KIT, 3/16 SOFT PVC PVC CLOSED WOUND DRAINAGE
DRAIN
HEMOVAC KITS
Closed
Wound
Drainage
PVC
N/A
N/A
N/A
separately payable.
00-2590-000-10 00259000010 400ML HEMOVAC KIT, 1/4 PVC DRAIN, PVC CLOSED WOUND DRAINAGE
4 IN TROCAR
HEMOVAC KITS
Closed
Wound
Drainage
PVC
N/A
N/A
N/A
separately payable.
PAGE 14
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
00-2590-040-10 00259004010 400ML HEMOVAC KIT, 1/4 PVC DRAIN, PVC CLOSED WOUND DRAINAGE
5 IN TROCAR
HEMOVAC KITS
Closed
Wound
Drainage
PVC
N/A
N/A
N/A
separately payable.
00-2595-000-10 00259500010 400ML HEMOVAC KIT, 3/32 IN PVC
DRAIN
HEMOVAC KITS
Closed
Wound
Drainage
PVC
N/A
N/A
N/A
separately payable.
00-2500-900-10 00250090010 HYDROCOAT PVC KIT, 1/8 PVC
DRAIN
HEMOVAC KITS - HYDROCOAT
Closed
Wound
Drainage
PVC
N/A
N/A
N/A
separately payable.
DRAIN
Closed
Wound
Drainage
PVC
N/A
N/A
N/A
separately payable.
DRAIN
Closed
Wound
Drainage
PVC
N/A
N/A
N/A
separately payable.
00-5300-000-10 00530000010 400ML SURGIVAC KIT, 1/8 IN PVC
DRAIN
SURGIVAC KITS
Closed
Wound
Drainage
PVC
N/A
N/A
N/A
separately payable.
00-5300-004-10 00530000410 400ML SURGIVAC COMPONENT KIT
SURGIVAC KITS
Closed
Wound
Drainage
PVC
N/A
N/A
N/A
separately payable.
00-5305-000-10 00530500010 400ML SURGIVAC KIT, 3/16 IN PVC
DRAIN
SURGIVAC KITS
Closed
Wound
Drainage
PVC
N/A
N/A
N/A
separately payable.
00-5390-040-10 00539004010 400ML SURGIVAC KIT, 1/4 PVC DRAIN PVC CLOSED WOUND DRAINAGE
W/TROCAR, LARGE
SURGIVAC KITS
Closed
Wound
Drainage
PVC
N/A
N/A
N/A
separately payable.
00-1500-021-10 00150002110
MIDDLE PERFORATED PVC DRAINS
Closed
Wound
Drainage
PVC
N/A
N/A
N/A
separately payable.
00-1500-022-10 00150002210 1/8 IN PVC DRAIN, 5 IN TROCAR
Closed
Wound
Drainage
PVC
N/A
N/A
N/A
separately payable.
00-1500-023-10 00150002310 3/16 IN SOFT PVC DRAIN, 5 IN
TROCAR
Closed
Wound
Drainage
PVC
N/A
N/A
N/A
separately payable.
00-1500-024-10 00150002410 3/16 IN FIRM PVC DRAIN, 5 IN
TROCAR
Closed
Wound
Drainage
PVC
N/A
N/A
N/A
separately payable.
00-1500-025-10 00150002510 1/4 IN PVC DRAIN, 5 IN TROCAR
Closed
Wound
Drainage
PVC
N/A
N/A
N/A
separately payable.
3/32 IN PVC DRAIN, 5 IN TROCAR
PAGE 15
Product #
EDI Item #
Item Description
00-1500-032-10 00150003210 1/8 IN PVC DRAIN, DUAL TROCARS
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
Closed
Wound
Drainage
PVC
N/A
N/A
N/A
separately payable.
00-1500-033-10 00150003310 3/16 IN PVC DRAIN, DUAL TROCARS PVC CLOSED WOUND DRAINAGE
Closed
Wound
Drainage
PVC
N/A
N/A
N/A
separately payable.
00-1500-035-10 00150003510 1/4 PVC DRAIN, DUAL TROCARS
Closed
Wound
Drainage
PVC
N/A
N/A
N/A
separately payable.
00-1500-028-10 00150002810 1/8 IN PVC DRAIN, ENDPERFORATED
END PERFORATED PVC DRAINS
Closed
Wound
Drainage
PVC
N/A
N/A
N/A
separately payable.
00-1500-005-10 00150000510 5 IN TROCARS, 1/8 IN
TROCARS
Closed
Wound
Drainage
PVC
N/A
N/A
N/A
separately payable.
00-1500-011-10 00150001110
TROCARS
Closed
Wound
Drainage
PVC
N/A
N/A
N/A
separately payable.
00-1500-014-10 00150001410 4 IN TROCARS, 1/4 IN
TROCARS
Closed
Wound
Drainage
PVC
N/A
N/A
N/A
separately payable.
00-1500-020-10 00150002010 5 IN TROCARS, 1/4 IN
TROCARS
Closed
Wound
Drainage
PVC
N/A
N/A
N/A
separately payable.
00-1509-014-10 00150901410 5 IN TROCARS, 3/16 IN
TROCARS
Closed
Wound
Drainage
PVC
N/A
N/A
N/A
separately payable.
00-1500-002-10 00150000210 EVACUATOR TUBING
ACCESSORIES
Closed
Wound
Drainage
PVC
N/A
N/A
N/A
separately payable.
00-1500-015-10 00150001510 UNIVERSAL Y-CONNECTOR
ACCESSORIES
Closed
Wound
Drainage
PVC
N/A
N/A
N/A
separately payable.
00-1500-060-10 00150006010 SUCTION ADAPTER
ACCESSORIES
Closed
Wound
Drainage
PVC
N/A
N/A
N/A
separately payable.
00-1535-000-10 00153500010 DIRECTIONAL FLOW CONTROL
ACCESSORIES
Closed
Wound
Drainage
PVC
N/A
N/A
N/A
separately payable.
00-2540-000-10 00254000010 400ML HEMOVAC,1/8 SILICONE
ROUND DRAIN W/TROCAR
SILICONE CLOSED WOUND DRAINAGE
HEMOVAC KITS
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
5 IN TROCARS, 3/32 IN
PAGE 16
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
00-2541-000-10 00254100010 400ML HEMOVAC 3/16 SILICONE
HEMOVAC KITS
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
00-2545-000-10 00254500010 400ML HEMOVAC, 1/4 SILICONE
HEMOVAC KITS
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
00-2535-000-10 00253500010 100ML HEMOVAC 3/32 ROUND
W/TROCAR, SMALL STER
MINI-BULB KITS
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
00-2536-000-10 00253600010 100ML HEMOVAC, 1/8 ROUND
W/TROCAR, MEDIUM STER
MINI-BULB KITS
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
00-2537-000-10 00253700010 100ML HEMOVAC 3/16 ROUND
W/TROCAR, SOFT STER
MINI-BULB KITS
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
00-2538-000-10 00253800010 100ML MINI-BULB, 1/4 SILICONE
ROUND W/TROCAR
MINI-BULB KITS
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
00-2560-000-10 00256000010 100ML HEMOVAC FULL PERF FLAT
W/TROC 7MMX20CM STER
MINI-BULB KITS
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
00-2561-000-10 00256100010 100ML HEMOVAC FULL PERF FLT
MINI-BULB KITS
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
00-2562-000-10 00256200010 100ML HEMOVAC 3/4 PERF FLAT
MINI-BULB KITS
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
00-2563-000-10 00256300010 100ML HEMOVAC 3/4 PERF FLAT
W/TROC 10MMX20CM STR
MINI-BULB KITS
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
00-2564-000-10 00256400010 100ML HEMOVAC FULL PERF W/O
TROCAR 7MM X 20CM STER
MINI-BULB KITS
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
00-2565-000-10 00256500010 100ML HEMOVAC FULL PERF FLT
W/OTROC 10MMX20CM STR
MINI-BULB KITS
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
00-2566-000-10 00256600010 100ML HEMOVAC 3/4 PERF FLT W/O SILICONE CLOSED WOUND DRAINAGE
TROC 7MMX20CM STR
MINI-BULB KITS
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
00-2567-000-10 00256700010 100ML HEMOVAC 3/4 PERF FLT
W/OTROC 10MMX20CM STR
MINI-BULB KITS
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
PAGE 17
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
00-2568-000-10 00256800010 100ML MINI-HEMOVAC BULB
MINI-BULB KITS
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
00-2557-000-10 00255700010 100ML MINI-HEMOVAC INFECTION
CONTROL KIT
MINI-HEMOVAC INFECTION CONTROL KITS
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
00-2558-000-10 00255800010 150ML COLLECTION BAG FOR MINI- SILICONE CLOSED WOUND DRAINAGE
HEMOVAC BULB
MINI-HEMOVAC INFECTION CONTROL KITS
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
00-5340-000-10 00534000010 400ML SURGIVAC 1/8 DRAIN ROUND SILICONE CLOSED WOUND DRAINAGE
W/TROCAR
SURGIVAC KITS
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
00-5341-000-10 00534100010 400ML SURGIVAC 3/16 DRAINROUND SILICONE CLOSED WOUND DRAINAGE
W/TROCAR, SOFT
SURGIVAC KITS
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
00-5345-000-10 00534500010 400ML SURGIVAC 1/4 DRAIN ROUND SILICONE CLOSED WOUND DRAINAGE
W/TROCAR
SURGIVAC KITS
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
00-2540-069-10 00254006910 SILICONE FLAT DRAIN W/TROCAR,
FULL PERF, 7MMX20CM
FLAT SILICONE DRAINS
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
FULL PERF, 10MMX20CM
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
00-2540-071-10 00254007110
SILICONE FLAT DRAIN W/TROCAR,
3/4 PERF, 7MM X 20CM
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
3/4 PERF, 10MMX20CM
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
00-2569-000-10 00256900010 7MM X 20CM SILICONE FLAT DRAIN, SILICONE CLOSED WOUND DRAINAGE
FULL-PERFORATED
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
FULL-PERFORATED
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
3/4-PERFORATED
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
00-2572-000-10 00257200010 10MM X 20CM 3/4-PERFORATED
SILICONE FLAT DRAIN
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
PAGE 18
Product #
EDI Item #
Item Description
00-2573-000-10 00257300010 7MMX 30CM FULL PERF SILICONE
FLAT DRAIN
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
00-2574-000-10 00257400010 10MM X 30CM SILICONE FLATDRAIN, SILICONE CLOSED WOUND DRAINAGE
FULL-PERFORATED
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
00-2540-001-10 00254000110
SILICONE DRAINS
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
00-2540-002-10 00254000210 1/8 IN SILICONE ROUND DRAIN, END- SILICONE CLOSED WOUND DRAINAGE
PERFORATED
SILICONE DRAINS
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
00-2540-003-10 00254000310 1/8 IN SILICONE ROUND DRAIN,
MIDDLE-PERFORATED
SILICONE DRAINS
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
MIDDLE-PERFORATED
SILICONE DRAINS
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
END-PERFORATED
SILICONE DRAINS
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
PERFORATED
SILICONE DRAINS
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
MIDDLE-PERFORATED
SILICONE DRAINS
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
00-2540-013-10 00254001310 1/4 IN SILICIONE ROUND DRAIN,
MIDDLE-PERFORATED
SILICONE DRAINS
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
00-2540-021-10 00254002110
SILICONE DRAINS
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
00-2540-022-10 00254002210 1/8 IN SLICONE ROUND DRAIN, END- SILICONE CLOSED WOUND DRAINAGE
PERFORATED W/TROCA
SILICONE DRAINS
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
END-PERFORATED W/TRO
SILICONE DRAINS
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
PERFORATED W/TROC
SILICONE DRAINS
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
3/32 IN SILICONE ROUND DRAIN,
END-PERFORATED
3/32 IN SILICONE ROUND DRAIN,
END-PERFORATED W/TRO
PAGE 19
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
00-2540-025-10 00254002510 SILICONE DRAIN, 3/32 DRAIN
W/TROCAR MIDDLE PERF
SILICONE DRAINS
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
W/TROCAR, MIDDLE PERF
SILICONE DRAINS
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
SILICONE DRAINS
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
SILICONE DRAINS
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
00-2540-922-10 00254092210 HEMOVAC HYDROCOAT, 1/8 RND,
END PERF W/TROCAR STER
HYDROCOAT SILICONE DRAINS
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
00-2540-923-10 00254092310 HEMOVAC HYDROCOAT, 3/16
ROUND, END PERF W/TROCAR
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
00-2540-924-10 00254092410 HEMOVAC HYDROCOAT, 1/4 ROUND, SILICONE CLOSED WOUND DRAINAGE
END PERF W/TROCAR
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
MIDDLE PERF W/TROCAR
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
00-2540-927-10 00254092710 HEMOVAC HYDROCOAT, 3/16 RND,
MDL PERF W/TROCR STER
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
MIDDLE PERF W/TROCAR
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
00-2569-900-10 00256990010 HEMOVAC HYDROCOAT FLAT DRAIN SILICONE CLOSED WOUND DRAINAGE
FULL PERF 7MM X 20CM
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
00-2570-900-10 00257090010 10MM X 20CM FULLY PERF
HEMOVAC HYROCOAT FLT DRN
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
00-2571-900-10 00257190010 7MM X 20CM 3/4 PERF HEMOVAC
HYDROCOAT FLT DRN
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
00-2572-900-10 00257290010 10MM X 20CM 3/4 PERF HEMOVAC
HYDROCOAT FLT DRN
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
PAGE 20
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
00-2540-950-10 00254095010 1/8 IN HYDROCOAT QUAD-LUMEN
DRAIN W/TROCAR
HYDROCOAT QUAD-LUMEN DRAINS
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
00-2540-951-10 00254095110
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
00-2540-952-10 00254095210 1/4 IN HYDROCOAT QUAD-LUMEN
DRAIN W/TROCAR
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
00-2540-016-10 00254001610 Y-CONNECTOR (FOR 3/32 AND 1/8
ROUND DRAINS)
ACCESSORIES
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
00-2540-017-10 00254001710 Y-CONNECTORS (FOR 3/16 & 1/4
ROUND & FLAT DRAINS)
ACCESSORIES
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
00-2540-018-10 00254001810 BIFURCATED DRAIN EXTENSIONS
ACCESSORIES
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
00-2540-019-10 00254001910 SUCTION ADAPTER
ACCESSORIES
Closed
Wound
Drainage
Silicone
N/A
N/A
N/A
separately payable.
00-2555-020-05 00255502005 HEMOVAC AUTOTRANSFUSION
SYSTEM, 1/8 PVC DRAIN
SYSTEMS, 3/16 PVC DRAIN
SYSTEMS, 1/4 PVC DRAIN
00-2555-050-05 00255505005 HAS COLLECTION BOTTLE
REPLACEMENT
SYSTEM, NO DRAIN
00-2556-020-06 00255602006 ZIMMER BLOOD REINFUSION
SYSTEM 1/8
SYSTEM 3/16
SYSTEM 1/4
SYSTEM, NO DRAIN
00-1044-028-00 00104402800 ADVANCE 1115 STRAIGHT
00-1044-029-00 00104402900 ADVANCE 1115 OFFSET
00-1044-030-00 00104403000 ADVANCE 1115 4POSTER OFFSET
00-1044-031-00 00104403100 ADVANCE 1115 STRAIGHT STL
00-1044-032-00 00104403200 ADVANCE 1115 OFFSET 4POSTER ST
AUTOTRANSFUSION PRODUCTS
Autotransfusi Autotransfusion HAS
on
on
on
on
on
Autotransfusi Zimmer Blood Reinfusion
on
System
on
System
on
System
on
System
Traction
Traction Products
Traction
Traction Products
Traction
Traction Products
Traction
Traction Products
Traction
Traction Products
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
HEMOVAC AUTOTRANSFUSION SYSTEMS
(H.A.S.)
(H.A.S.)
(H.A.S.)
(H.A.S.)
(H.A.S.)
ZIMMER BLOOD REINFUSION SYSTEM
(Z.B.R.S.)
(Z.B.R.S.)
(Z.B.R.S.)
(Z.B.R.S.)
OVERHEAD FRAME KITS
OVERHEAD FRAME KITS
OVERHEAD FRAME KITS
OVERHEAD FRAME KITS
OVERHEAD FRAME KITS
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
00-1044-033-00 00104403300 STRYKER MPS STRAIGHT ABL
00-1044-034-00 00104403400 STRYKER MPS OFFSET ABS
00-1044-035-00 00104403500 STRYKER MPS OFFSET ABS
4POSTER
00-1044-036-00 00104403600 STRYKER MPS STRAIGHT STL
00-1044-037-00 00104403700 STRYKER MPS OFFSET STS
00-1044-038-00 00104403800 STRYKER MPS 4POSTER STS
00-1044-039-00 00104403900 HILL-ROM 840 4POSTER
00-2700-020-00 00270002000 TOTALCARE FRAME-BALKAN KITCOMPLETE
00-2700-026-00 00270002600 CAREASSIST FRAME -BALKAN KITCOMPLETE
00-2700-029-00 00270002900 VERSACARE FRAME-BALKAN KITCOMPLETE
00-0619-001-00 00061900100 SWIVEL BAR W/PULLEY, 9
00-0619-002-00 00061900200 DOUBLE PULLEY BAR, 18
TRACTION
TRACTION
TRACTION
OVERHEAD FRAME KITS
OVERHEAD FRAME KITS
OVERHEAD FRAME KITS
Traction
Traction
Traction
Traction Products
Traction Products
Traction Products
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
OVERHEAD FRAME KITS
OVERHEAD FRAME KITS
OVERHEAD FRAME KITS
OVERHEAD FRAME KITS
OVERHEAD FRAME KITS
Traction
Traction
Traction
Traction
Traction
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
TRACTION
OVERHEAD FRAME KITS
Traction
Traction Products
N/A
N/A
N/A
TRACTION
OVERHEAD FRAME KITS
Traction
Traction Products
N/A
N/A
N/A
TRACTION
TRACTION
TRACTION BARS & IV POSTS
Traction
Traction
Traction Products
Traction Products
N/A
N/A
N/A
N/A
N/A
N/A
3/16 IN HYDROCOAT QUAD-LUMEN
DRAIN W/TROCAR
PAGE 21
Product #
00-0640-001-00
00-0640-002-00
00-0640-004-00
00-0640-005-00
00-0640-006-00
00-0640-007-00
00-0640-011-00
00-0640-019-00
00-0640-021-00
00-0640-023-00
00-0640-023-01
00-0640-024-00
00-0640-029-00
00-0640-037-00
00-0640-038-00
00-0640-042-00
00-0640-048-00
00-0640-067-00
00-0640-086-00
00-0640-092-00
00-0640-106-00
00-0648-000-00
00-1038-002-00
00-1038-003-00
00-1038-004-00
00-1042-002-00
00-1042-003-00
00-1042-006-00
EDI Item #
00064000100
00064000200
00064000400
00064000500
00064000600
00064000700
00064001100
00064001900
00064002100
00064002300
00064002301
00064002400
00064002900
00064003700
00064003800
00064004200
00064004800
00064006700
00064008600
00064009200
00064010600
00064800000
00103800200
00103800300
00103800400
00104200200
00104200300
00104200600
Item Description
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
Traction
Traction
Traction
Traction
Traction
Traction
Traction
Traction
Traction
Traction
Traction
Traction
Traction
Traction
Traction
Traction
Traction
Traction
Traction
Traction
Traction
Traction
Traction
Traction
Traction
Traction
Traction
Traction
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
TRACTION
Traction
Traction Products
N/A
N/A
N/A
TRACTION
Traction
Traction Products
N/A
N/A
N/A
TRACTION
Traction
Traction Products
N/A
N/A
N/A
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
Traction
Traction
Traction
Traction
Traction
Traction
Traction
Traction
Traction
Traction
Traction
Traction
Traction
Traction
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
00-1238-022-00 00123802200 IV POST W/CLAMP 22 3/4 IN
TRACTION
00-1238-023-00 00123802300 ANGLED IV POST W/CLAMP, 23 3/4 IN TRACTION
Traction
Traction
Traction Products
Traction Products
N/A
N/A
N/A
N/A
N/A
N/A
00-1241-001-00
00-1241-008-00
00-1241-021-00
00-1241-044-00
00-1241-045-00
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
Traction
Traction
Traction
Traction
Traction
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
00-1241-048-00 00124104800 ANGLED IV POST W/CLAMP, 18 3/4 IN TRACTION
Traction
Traction Products
N/A
N/A
N/A
00-1242-001-00
00-1247-001-00
00-1247-003-00
00-2700-021-00
00-2700-021-01
00-2700-022-00
IV POST W/CLAMP, 5 1/2 IN
TRACTION
TRACTION
TRACTION
TOTALCARE-VERTICAL POST-61IN TRACTION
VERSACARE VERTICAL POST- 69IN TRACTION
TOTALCARE IV POST BRACKETHEAD TRACTION
Traction
Traction
Traction
Traction
Traction
Traction
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
00-2700-023-00 00270002300 TOTALCARE IV POST BRACKETFOOT TRACTION
Traction
Traction Products
N/A
N/A
N/A
00-2700-024-00
00-2700-025-00
00-2700-028-00
00-2700-040-00
00-2700-042-00
Traction
Traction
Traction
Traction
Traction
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
00-1042-007-00 00104200700
00-1042-015-00 00104201500
00-1042-090-00 00104209000
00-1044-005-00
00-1044-006-00
00-1044-007-00
00-1066-003-00
00-1066-005-00
00-1083-003-00
00-1234-001-00
00-1234-009-00
00-1236-001-00
00-1238-001-00
00-1238-002-00
00-1238-003-00
00-1238-004-00
00-1238-011-00
00104400500
00104400600
00104400700
00106600300
00106600500
00108300300
00123400100
00123400900
00123600100
00123800100
00123800200
00123800300
00123800400
00123801100
00124100100
00124100800
00124102100
00124104400
00124104500
00124200100
00124700100
00124700300
00270002100
00270002101
00270002200
00270002400
00270002500
00270002800
00270004000
00270004200
PLAIN BAR, 96
SWIVEL CLAMP BAR, 66
SINGLE CLAMP BAR, 9
SINGLE CLAMP BAR, 18
CENTER CLAMP BAR, 36
IV BAR
CURVED DOUBLE CLAMP BAR, 24
PLAIN BAR, 85
85 REINFORCED OVERHEAD BAR
OFFSET SWIVEL CLAMP BAR
HEAVY DUTY PLAIN BAR, 96
ZIMCO TRACTION PULLEY ASSY
PLASTISOL PLUG
SWIVEL CLAMP ASSEMBLY W/KNOB
KNOB-LOCK SCREW ASSY
TRAPEZE
CAP
LOCKING SLEEVE
S HOOK ONLY
SPREADER BAR, 22
DOUBLE CLAMP BAR, 27
IV POST W/CLAMP, 4 1/2
OFFSET DOUBLE CLAMP BAR, 27
PLAIN BAR, 36
SWIVEL CLAMP BAR, 48
ADJUSTABLE BAR, OVERHEAD,
LONG
SMOOTH-TRAC TRACTION BAR,
LONG
ADJUSTABLE BAR,
OVERHEAD,SHORT
SMOOTH TRAC TRACTION
BAR,SHORT
OFFSET DOUBLE CLAMP BAR, 35
SINGLE CLAMP BAR, 5
OFFSET DOUBLE CLAMP, 31
ANGLED IV POST W/CLAMP, 19 1/2 IN
Header 1
PLAIN BAR, 44
ANGLED IV POST W/CLAMP, 13 3/4 IN
CAREASSIST BRACKET HEAD
CAREASSIST BRACKET FOOT
VERSACARE BRACKET, FOOT
TOTAL CARE 40 IN PLAIN BAR
VERSACARE 42 IN PLAIN BAR
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
Comment 1
Comment 2
Comment 3
PAGE 22
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
00-0032-007-00 00003200700 VINYL PAD HALF-RING CHILD
TRACTION
TRACTION ACCESSORIES
Traction
Traction Products
E0870
Y
TRACTION FRAME, ATTACHED
TO FOOTBOARD, EXTREMITY
TRACTION, (E.G. BUCKS)
0274 Medical/Surgical Supplies and Devices Non-Implantable Durable Medical Equipment Not paid under
Prosthetic/Orthotic Devices, 0290 Durable Medical OPPS. All institutional providers other than home health
Equipment (other than renal) - General
agencies bill to DMERC.
Classification, 0291 Durable Medical Equipment
(other than renal) - Rental , 0292 Durable Medical
Equipment (other than renal) - Purchase of New
DME , 0293 Durable Medical Equipment (other
than renal) - Purchase of Used DME , 0294
Durable Medical Equipment (other than renal) Supplies/Drugs for DME ,0299 Durable Medical
Equipment (other than renal) - Other Equipment
00-0032-008-00 00003200800 VINYL PAD HALF-RING YOUTH
TRACTION
Traction
Traction Products
E0870
Y
00-0032-009-00 00003200900 VINYL PAD HALF-RING ADULT
TRACTION
Traction
Traction Products
E0870
Y
00-0032-015-00 00003201500 SLING, FULL LENGTH
TRACTION
Traction
Traction Products
A4565
N
SLINGS
0274 Medical/Surgical Supplies and Devices Prosthetic/Orthotic Devices
Packaged Item or Service. Items and Services Packaged into
APC Rates. Paid under OPPS; payment is packaged into
payment for other services. Therefore, there is no separate APC
payment.
00-0033-001-00 00003300100 PEARSON ATTACHMENT CHILD
48CM
TRACTION
Traction
Traction Products
N/A
N/A
N/A
separately payable.
00-0033-002-00 00003300200 PEARSON ATTACHMENT YOUTH
53CM
TRACTION
Traction
Traction Products
N/A
N/A
N/A
separately payable.
00-0033-003-00 00003300300 PEARSON ATTACHMENT ADULT
64CM
TRACTION
Traction
Traction Products
N/A
N/A
N/A
separately payable.
PAGE 23
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
00-0034-001-00 00003400100 FOOT SUPPORT, 26 CM
TRACTION
Traction
Traction Products
E0951 OR
E1399
Y
HEEL LOOP/HOLDER, ANY TYPE, 0274 Medical/Surgical Supplies and Devices Non-Implantable Durable Medical Equipment Not paid under
WITH OR WITHOUT ANKLE
STRAP, EACH
00-0034-002-00 00003400200 HEEL REST, 13 CM
TRACTION
Traction
Traction Products
E0951 OR
E1399
Y
HEEL LOOP/HOLDER, ANY TYPE, 0274 Medical/Surgical Supplies and Devices Non-Implantable Durable Medical Equipment Not paid under
WITH OR WITHOUT ANKLE
STRAP, EACH
00-0056-001-00 00005600100 CANVAS KNEE SLING
TRACTION
Traction
Traction Products
A4565
N
SLINGS
00-0056-002-00 00005600200 BUNKER FT PIECE W/PULLEY
TRACTION
Traction
Traction Products
E0941
Y
Gravity assisted traction device,
any type
payment.
00-0056-008-00 00005600800 POLYESTER PILE KNEE SLING
TRACTION
Traction
Traction Products
A4565
N
SLINGS
payment.
00-0056-011-00 00005601100
POLYESTER PILE KNEE SLING
TRACTION
Traction
Traction Products
A4565
N
SLINGS
payment.
00-0057-001-00
00-0057-002-00
00-0057-003-00
00-0111-003-00
00-0112-002-00
SERRATED CLIPS
ZIM CLIP
MINI-CLIPS
FOLDING BED CRADLE
BOHLER BRAUN LEG SPLINT
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
Traction
Traction
Traction
Traction
Traction
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
N/A
N/A
N/A
N/A
A4570
N/A
N/A
N/A
N/A
E
N/A
N/A
N/A
N/A
Splint
0270 – Medical surgical supplies general; 0274medical surgical;0279medical surgical supplies other supplies/devices
Not paid under OPPS. Paid by fiscal intermediaries/MACs under See Also Q4051 Splint supplies misc
a fee schedule or payment system other than OPPS.
00005700100
00005700200
00005700300
00011100300
00011200200
PAGE 24
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
00-0113-002-00 00011300200
CANVAS SLINGS
TRACTION
Traction
Traction Products
A4565
N
SLINGS
payment.
00-0114-004-00 00011400400
BOHLER-STEINMANN PIN HOLDER, 9 TRACTION
X 8CM
Traction
Traction Products
N/A
N/A
N/A
separately payable.
00-0114-005-00 00011400500
BOHLER-STEINMANN PIN HOLDER,
16 X 11CM
TRACTION
Traction
Traction Products
N/A
N/A
N/A
separately payable.
00-0114-006-00 00011400600
BOHLER-STEINMANN PIN HOLDER,
21 X 11CM
TRACTION
Traction
Traction Products
N/A
N/A
N/A
separately payable.
00-0114-054-00 00011405400 REPLACEMENT THUMB SCREW
00-0121-001-00 00012100100 KIRSCHNER WIRE TRACTOR
14X10CM
TRACTION
TRACTION
Traction
Traction
Traction Products
Traction Products
N/A
N/A
N/A
N/A
N/A
N/A
separately payable.
00-0121-002-00 00012100200 KIRSCHNER WIRE TRACTOR
19X17CM
TRACTION
Traction
Traction Products
N/A
N/A
N/A
separately payable.
00-0121-003-00 00012100300 KIRSCHNER WIRE TRACTOR 24X
17CM
TRACTION
Traction
Traction Products
N/A
N/A
N/A
separately payable.
00-0176-002-00
00-0176-003-00
00-0176-004-00
00-0183-001-00
TRACTION
TRACTION
TRACTION
TRACTION
Traction
Traction
Traction
Traction
Traction Products
Traction Products
Traction Products
Traction Products
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
00-0183-002-00 00018300200 CAST IRON TRACTION WEIGHT, 2 LB TRACTION
Traction
Traction Products
N/A
N/A
N/A
00-0183-003-00 00018300300 CAST IRON TRACTION WEIGHT, 5 LB TRACTION
Traction
Traction Products
N/A
N/A
N/A
00-0184-001-00
00-0213-000-00
00-0286-000-00
00-0311-000-00
00-0325-000-00
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
Traction
Traction
Traction
Traction
Traction
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
separately payable.
00-0325-001-00 00032500100 FINGER GRIP, SMALL
TRACTION
Traction
Traction Products
N/A
N/A
N/A
separately payable.
00-0325-002-00 00032500200 FINGER GRIP, MEDIUM
TRACTION
Traction
Traction Products
N/A
N/A
N/A
separately payable.
00-0325-003-00 00032500300 FINGER GRIP, LARGE
TRACTION
Traction
Traction Products
N/A
N/A
N/A
separately payable.
00017600200
00017600300
00017600400
00018300100
00018400100
00021300000
00028600000
00031100000
00032500000
WEIGHT CARRIER, 15 CM
CAST IRON TRACTION WEIGHT, 1 LB
NYLON CORD, 100 FEET
DICOSOLA ROPE HOLDER
S-HOOK
ST. JOSEPH BED CRADLE
TRACTION FINGER APPARATUS,
ADULT
PAGE 25
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
00-0325-004-00 00032500400 FINGER GRIP, PEDIATRIC
TRACTION
Traction
Traction Products
N/A
N/A
N/A
separately payable.
00-0325-010-00 00032501000 TRACTION FINGER
APPARATUS,PEDIATRIC
TRACTION
Traction
Traction Products
N/A
N/A
N/A
separately payable.
00-0619-003-00 00061900300 PANEL CLAMP - BUCK'S
00-0640-003-00 00064000300 TRAPEZE, HEAVY DUTY
TRACTION
TRACTION
Traction
Traction
Traction Products
Traction Products
N/A
E0911
N/A
Y
N/A
TRAPEZE BAR, HEAVY DUTY,
FOR PATIENT WEIGHT CAPACITY Prosthetic/Orthotic Devices, 0290 Durable Medical OPPS. All institutional providers other than home health
GREATER THAN 250 POUNDS, Equipment (other than renal) - General
ATTACHED TO BED, WITH GRAB Classification, 0291 Durable Medical Equipment
BAR
00-0640-008-00
00-0640-012-00
00-0640-013-00
00-0640-014-00
00-0640-018-00
00-0849-001-00
00-0849-002-00
00-0849-003-00
00-0849-004-00
00-0905-005-00
PULLEY
WALL BUMPER HORNS
PANEL CLAMP, UPPER
PANEL CLAMP, LOWER
WALL BUMPER ROLLER
SPREADER BAR, 6
SPREADER BAR, 8
SPREADER BAR, 9
SPREADER BAR, 12
SPREADER BAR, STEPHAN, 8
MINIMUM TO 16 MAXIMUM
00-0920-000-00 00092000000 NELSON FINGER EXERCISER
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
Traction
Traction
Traction
Traction
Traction
Traction
Traction
Traction
Traction
Traction
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
TRACTION
Traction
Traction Products
N/A
N/A
N/A
00-0923-002-00
00-0923-003-00
00-0923-004-00
00-0967-001-00
00-0967-002-00
00-0967-003-00
00-1015-002-00
00-1036-000-00
00-1036-017-00
00-1042-004-00
00-1231-005-00
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
Traction
Traction
Traction
Traction
Traction
Traction
Traction
Traction
Traction
Traction
Traction
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
00064000800
00064001200
00064001300
00064001400
00064001800
00084900100
00084900200
00084900300
00084900400
00090500500
00092300200
00092300300
00092300400
00096700100
00096700200
00096700300
00101500200
00103600000
00103601700
00104200400
00123100500
SPREADER BLOCK, 2
SPREADER BLOCK, 3
SPREADER BLOCK, 4
TRACTION CORD, 33 YDS
TRACTION CART HOOK KIT
MOBILE TRACTION UNIT-COMPACT
MOBILE TRACTION UNIT, X-LONG
CROSS CLAMP
BRADY SPLINT ASSEMBLY
separately payable.
separately payable.
PAGE 26
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
00-1231-009-00 00123100900 FOOT EXERCISER PAD
TRACTION
Traction
Traction Products
E1399
Y
Unlisted device
00-1231-011-00 00123101100
BRADY BALANCED SUSPENSION
SYSTEM
TRACTION
Traction
Traction Products
N/A
N/A
N/A
separately payable.
00-1231-015-00 00123101500 PEARSON ATTACHMENT, BRADY
TRACTION
Traction
Traction Products
N/A
N/A
N/A
separately payable.
00-1231-016-00
00-1231-017-00
00-1231-028-00
00-1232-000-00
TRACTION
TRACTION
TRACTION
TRACTION
Traction
Traction
Traction
Traction
Traction Products
Traction Products
Traction Products
Traction Products
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
separately payable.
00-1232-001-00 00123200100 THOMAS LEG SPLINT, PEDIATRIC
TRACTION
Traction
Traction Products
N/A
N/A
N/A
separately payable.
00-1232-002-00 00123200200 THOMAS LEG SPLINT, SMALL
TRACTION
Traction
Traction Products
N/A
N/A
N/A
separately payable.
00-1232-003-00 00123200300 THOMAS LEG SPLINT, MEDIUM
TRACTION
Traction
Traction Products
N/A
N/A
N/A
separately payable.
00-1232-004-00 00123200400 THOMAS LEG SPLINT, LARGE
TRACTION
Traction
Traction Products
N/A
N/A
N/A
separately payable.
00-1232-005-00 00123200500 THOMAS LEG SPLINT SET, SMALL
TRACTION
Traction
Traction Products
N/A
N/A
N/A
separately payable.
00-1232-006-00 00123200600 THOMAS LEG SPLINT SET, MEDIUM
TRACTION
Traction
Traction Products
N/A
N/A
N/A
separately payable.
00-1232-007-00 00123200700 SLINGS
TRACTION
Traction
Traction Products
A4565
N
SLINGS
payment.
00123101600
00123101700
00123102800
00123200000
FOOT EXERCISER ASSEMBLY
BILATERAL CLAMP ASSEMBLY
SPLINT PAD RING
THOMAS LEG SPLINT SET,
PEDIATRIC
PAGE 27
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
00-1232-008-00 00123200800 THOMAS LEG SPLINT SET, LARGE
TRACTION
Traction
Traction Products
N/A
N/A
N/A
separately payable.
00-1232-009-00 00123200900 FOOT SUPPORT SLING
TRACTION
Traction
Traction Products
E0951 OR
E1399
Y
E0951 HEEL LOOP/HOLDER, ANY 0274 Medical/Surgical Supplies and Devices Non-Implantable Durable Medical Equipment Not paid under
TYPE, WITH OR WITHOUT ANKLE Prosthetic/Orthotic Devices, 0290 Durable Medical OPPS. All institutional providers other than home health
STRAP, EACH E1399 UNLISTED Equipment (other than renal) - General
DEVICE
00-1232-010-00 00123201000 STRAP CLAMPS
00-1232-011-00 00123201100 THOMAS LEG SPLINT SET, X-WIDE
TRACTION
TRACTION
Traction
Traction
Traction Products
Traction Products
N/A
N/A
N/A
N/A
N/A
N/A
00-1232-012-00 00123201200 PEARSON ATTACHMENT, SMALL
TRACTION
Traction
Traction Products
N/A
N/A
00-1232-013-00 00123201300 PEARSON ATTACHMENT, MEDIUM
TRACTION
Traction
Traction Products
N/A
00-1232-014-00 00123201400 PEARSON ATTACHMENT, LARGE
TRACTION
Traction
Traction Products
00-1232-015-00 00123201500 PEARSON ATTACHMENT, X-WIDE
TRACTION
Traction
00-1232-016-00 00123201600 SLINGS, EXTRA WIDE
TRACTION
00-1232-017-00 00123201700 FOOT SUPPORT, SMALL
TRACTION
Comment 2
Comment 3
separately payable.
N/A
separately payable.
N/A
N/A
separately payable.
N/A
N/A
N/A
separately payable.
Traction Products
N/A
N/A
N/A
separately payable.
Traction
Traction Products
A4565
N
SLINGS
Traction
Traction Products
E0951 OR
E1399
Y
payment.
DEVICE
PAGE 28
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
00-1232-018-00 00123201800 FOOT SUPPORT, MEDIUM
TRACTION
Traction
Traction Products
E0951 OR
E1399
Y
DEVICE
00-1232-019-00 00123201900 FOOT SUPPORT, LARGE
TRACTION
Traction
Traction Products
E0951 OR
E1399
Y
DEVICE
00-1232-020-00 00123202000 FOOT SUPPORT, X-WIDE
TRACTION
Traction
Traction Products
E0951 OR
E1399
Y
DEVICE
00-1232-021-00 00123202100 HEEL REST, SMALL
TRACTION
Traction
Traction Products
E0951 OR
E1399
Y
DEVICE
00-1232-022-00 00123202200 HEEL REST, MEDIUM
TRACTION
Traction
Traction Products
E0951 OR
E1399
Y
DEVICE
00-1232-023-00 00123202300 HEEL REST, LARGE
TRACTION
Traction
Traction Products
E0951 OR
E1399
Y
DEVICE
PAGE 29
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
00-1232-024-00 00123202400 HEEL REST, X-LARGE
TRACTION
Traction
Traction Products
E0951 OR
E1399
Y
DEVICE
00-1232-025-00 00123202500 RING PAD, SMALL
TRACTION
Traction
Traction Products
E0951 OR
E1399
Y
DEVICE
00-1232-026-00 00123202600 RING PAD, MEDIUM
TRACTION
Traction
Traction Products
E0951 OR
E1399
Y
DEVICE
00-1232-027-00 00123202700 RING PAD, LARGE
TRACTION
Traction
Traction Products
E0951 OR
E1399
Y
DEVICE
00-1232-028-00 00123202800 RING PAD, X-LARGE
TRACTION
Traction
Traction Products
E0951 OR
E1399
Y
DEVICE
00-1232-030-00 00123203000 RING STRAP, SMALL
TRACTION
Traction
Traction Products
E0951 OR
E1399
Y
DEVICE
PAGE 30
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
00-1232-031-00 00123203100 RING STRAP, MEDIUM
TRACTION
Traction
Traction Products
E0951 OR
E1399
Y
DEVICE
00-1232-032-00 00123203200 RING STRAP, LARGE
TRACTION
Traction
Traction Products
E0951 OR
E1399
Y
DEVICE
00-1232-033-00 00123203300 RING STRAP, X-LARGE
TRACTION
Traction
Traction Products
E0951 OR
E1399
Y
DEVICE
00-1232-034-00 00123203400 PEARSON ATTACHMENT, PEDIATRIC TRACTION
Traction
Traction Products
N/A
N/A
N/A
separately payable.
00-1232-035-00 00123203500 FULL LENGTH SLING
TRACTION
Traction
Traction Products
A4565
N
SLINGS
payment.
00-1232-038-00 00123203800 SLINGS, PEDIATRIC
TRACTION
Traction
Traction Products
A4565
N
SLINGS
payment.
00-1232-105-00 00123210500 RADIOLUCENT SPLINT X-WIDE
TRACTION
Traction
Traction Products
N/A
N/A
N/A
separately payable.
00-1232-125-00 00123212500 KODEL RING PAD, SMALL
TRACTION
Traction
Traction Products
E1399
Y
Unlisted device
PAGE 31
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
00-1232-126-00 00123212600 KODEL RING PAD, MEDIUM
TRACTION
Traction
Traction Products
E1399
Y
Unlisted device
00-1232-127-00 00123212700 KODEL RING PAD, LARGE
TRACTION
Traction
Traction Products
E1399
Y
Unlisted device
00-1232-128-00 00123212800 KODEL THOMAS RING PAD
TRACTION
Traction
Traction Products
E1399
Y
Unlisted device
00-1232-136-00 00123213600 FOOT SUPPORT
TRACTION
Traction
Traction Products
E0951 OR
E1399
Y
DEVICE
00-1232-137-00 00123213700 HEEL REST
TRACTION
Traction
Traction Products
E0951 OR
E1399
Y
DEVICE
00-1294-001-00 00129400100 TRACTION BAR END GUARDS
TRACTION
Traction
Traction Products
N/A
N/A
N/A
00-1469-008-00 00146900800 HEAVY DUTY PULLEY
00-1600-050-00 00160005000 SINGLE BAG HOOK
00-1600-051-00 00160005100 MULTIPLE BAG HOOK
TRACTION
TRACTION
TRACTION
Traction
Traction
Traction
Traction Products
Traction Products
Traction Products
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
separately payable.
PAGE 32
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
00-1601-002-00 00160100200 ZIMCODE TRACTION WEIGHT BAG,
10 LBS
TRACTION
Traction
Traction Products
N/A
N/A
N/A
separately payable.
00-1602-001-00 00160200100 SAND WEIGHT BAG, 1 LB
TRACTION
Traction
Traction Products
N/A
N/A
N/A
separately payable.
00-1602-002-00 00160200200 SAND WEIGHT BAG, 2 LBS
TRACTION
Traction
Traction Products
N/A
N/A
N/A
separately payable.
TRACTION
Traction
Traction Products
N/A
N/A
N/A
separately payable.
TRACTION
Traction
Traction Products
N/A
N/A
N/A
separately payable.
00-3860-001-00 00386000100 FLEX-FOAM TRACTION STRIPS, 2 X
42
TRACTION
Traction
Traction Products
N/A
N/A
N/A
separately payable.
00-3860-002-00 00386000200 FLEX-FOAM TRACTION STRIPS 3X 42 TRACTION
Traction
Traction Products
N/A
N/A
N/A
separately payable.
00-3860-003-00 00386000300 FLEX-FOAM TRACTION STRIPS 4 X
42
TRACTION
Traction
Traction Products
N/A
N/A
N/A
separately payable.
00-3861-001-00 00386100100 FLEX-FOAM TRACTION STRIPS 2 IN TRACTION
X 25 YDS
Traction
Traction Products
N/A
N/A
N/A
separately payable.
00-3861-002-00 00386100200 FLEX-FOAM TRACTION STRIPS 3 IN TRACTION
X 25 YDS
Traction
Traction Products
N/A
N/A
N/A
separately payable.
00-3861-003-00 00386100300 FLEX-FOAM TRACTON STRIPS 4 IN X TRACTION
25 YDS
Traction
Traction Products
N/A
N/A
N/A
separately payable.
00-3874-001-00 00387400100 SKIN-TRAC TRACTION STRIP, 2 X 24 TRACTION
Traction
Traction Products
N/A
N/A
N/A
separately payable.
00-3874-002-00 00387400200 SKIN-TRAC TRACTION STRIP, 2-1/2 X TRACTION
30
Traction
Traction Products
N/A
N/A
N/A
separately payable.
PAGE 33
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
Traction
Traction Products
N/A
N/A
N/A
separately payable.
Traction
Traction Products
N/A
N/A
N/A
separately payable.
Traction
Traction Products
N/A
N/A
N/A
separately payable.
00-3874-011-00 00387401100
Traction
Traction Products
N/A
N/A
N/A
0274 Medical/Surgical Supplies and Devices Prosthetic/Orthotic Devices, 0290 Durable Medical
separately payable.
00-3874-012-00 00387401200
SKIN-TRAC DISPENSER CARTON,
SMALL
MEDIUM
LARGE
ADULT-LONG
LGE, X-LONG X-WIDE
WILSON CONVEX FRAME
TRACTION SET W/912 HALTER
TRACTION
TRACTION
Traction
Traction Products
N/A
N/A
N/A
TRACTION
Traction
Traction Products
N/A
N/A
N/A
TRACTION
Traction
Traction Products
N/A
N/A
N/A
TRACTION
Traction
Traction Products
N/A
N/A
N/A
TRACTION
TRACTION
MISCELLANEOUS TRACTION FRAMES
Traction
Traction
Traction Products
Traction Products
N/A
E0942
N/A
N/A
N/A
CERVICAL HEAD
HARNESS/HALTER
00-0619-000-00 00061900000 ZIMCODE BUCK'S EXTENSION
SYSTEM
TRACTION
Traction
Traction Products
E0870
Y
00-0719-010-00 00071901000 EXO-STATIC TRACTION KIT
W/WATER WEIGHT
TRACTION
Traction
Traction Products
E0942
Y
CERVICAL HEAD
HARNESS/HALTER
00-0965-000-00 00096500000 HILL-ROM PATIENT HELPER
TRACTION
Traction
Traction Products
E0910
Y
Trapeze bar, heavy duty, for patient
weight capacity greater than 250
pounds, attached to bed, with grab
bar
00-3874-013-00 00387401300
00-3874-014-00 00387401400
00-3874-015-00 00387401500
00-0551-000-00 00055100000
00-0561-912-00 00056191200
PAGE 34
Product #
EDI Item #
Item Description
00-0965-001-00 00096500100 PATIENT HELPER REINFORCED
OVERHEAD BAR
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
TRACTION
Traction
Traction Products
E0910
Y
bar
00-0965-002-01 00096500201 PAT HELPER ADAPTER(HEIGHT ADJ) TRACTION
SLEEVE
Traction
Traction Products
E0910
Y
bar
00-2700-965-00 00270096500 PATIENT HELPER, TOTAL CARE BED TRACTION
Traction
Traction Products
E0910
Y
bar
00-2700-965-01 00270096501 PATIENT HELPER STAND, TOTAL
CARE
TRACTION
Traction
Traction Products
E0910
Y
bar
00-2700-965-02 00270096502 PAT HELPER VERSACARE COMP
TRACTION
Traction
Traction Products
E0910
Y
bar
00-2700-965-03 00270096503 BED FRAME ADAPTER VERSACARE TRACTION
Traction
Traction Products
E0910
Y
bar
00-1164-000-00 00116400000
SURGICAL TRACTION PRODUCTS
Traction
Traction Products
N/A
N/A
N/A
ANKLE DISTRACTOR HARDWARE
TRACTION
separately payable.
PAGE 35
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
00-1164-001-10 00116400110
ANKLE DISTRACTOR STRAP KIT
TRACTION
Traction
Traction Products
N/A
N/A
N/A
separately payable.
00-1164-002-00 00116400200
ANKLE DISTRACTOR EXTENSION
BAR
TRACTION
Traction
Traction Products
N/A
N/A
N/A
separately payable.
00-1164-003-00 00116400300
ANKLE DISTRACTOR FORCE SCALE TRACTION
Traction
Traction Products
N/A
N/A
N/A
separately payable.
00-1164-004-00 00116400400
ANKLE DISTRACTOR TENSION BAR TRACTION
Traction
Traction Products
N/A
N/A
N/A
separately payable.
00-1320-000-00 00132000000 ALVARADO KNEE SUPPORT
ASSEMBLY
TRACTION
Traction
Traction Products
N/A
N/A
N/A
separately payable.
00-1320-011-00 00132001100
TRACTION
Traction
Traction Products
N/A
N/A
N/A
separately payable.
00-1320-012-00 00132001200 ALVARADO KNEE SUPPORT, TABLE
BUTTRESS RIGHT FOOT
TRACTION
Traction
Traction Products
N/A
N/A
N/A
separately payable.
00-1320-013-00 00132001300 ALVARADO KNEE SUPPORT, TABLE
BUTTRESS LEFT FOOT
TRACTION
Traction
Traction Products
N/A
N/A
N/A
separately payable.
00-1320-014-00 00132001400 ALVARADO SURGICAL KNEE
HOLDER STABILIZING PLATE
TRACTION
Traction
Traction Products
N/A
N/A
N/A
separately payable.
00-1320-015-10 00132001510 ALVARADO DISPOSABLE LINER
TRACTION
Traction
Traction Products
N/A
N/A
N/A
separately payable.
00-1320-200-00 00132020000 ALVARADO II KNEE SUPPORT
ASSEMBLY
TRACTION
Traction
Traction Products
N/A
N/A
N/A
separately payable.
00-1320-210-00 00132021000 ALVARADO II FOOT PIECE
TRACTION
Traction
Traction Products
N/A
N/A
N/A
separately payable.
00-1320-211-00 00132021100
TRACTION
Traction
Traction Products
N/A
N/A
N/A
separately payable.
ALVARADO KNEE SUPPORT, BASE
PLATE
ALVARADO II BASE PLATE
PAGE 36
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
00-0912-000-00 00091200000 DELUXE DISKARD HEAD HALTERS
TRACTION
TRACTION REPAIRS & WARRANTIES
Traction
Traction Products
E0942
Y
CERVICAL HEAD
HARNESS/HALTER
02-0100-000-00
02-0112-000-00
02-0114-000-00
02-0121-000-00
02010000000
02011200000
02011400000
02012100000
MISC TRACTION REPAIR
BOHLER BRAUN FRAME REPAIR
STEINMANN PIN HOLDER REPAIR
KIRSCHNER WIRE TRACTOR REPAIR
TRACTION
TRACTION
TRACTION
TRACTION
Traction
Traction
Traction
Traction
Traction Products
Traction Products
Traction Products
Traction Products
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
02-0551-000-00
02-1042-000-00
02-1232-000-00
02-1238-000-00
00-1778-001-00
02055100000
02104200000
02123200000
02123800000
00177800100
WILSON FRAME REPAIR CHG
TRACTION KNOB REPAIR CHG
BALANCED SUSP REPAIR CHG
TRACTION CLAMP REPAIR CHG
DELUXE PADDED HEAD HALTER,
SMALL
TRACTION
TRACTION
TRACTION
TRACTION
TRACTION
HEAD HALTERS
Traction
Traction
Traction
Traction
Traction
Traction Products
Traction Products
Traction Products
Traction Products
Traction Products
N/A
N/A
N/A
N/A
E0942
N/A
N/A
N/A
N/A
Y
N/A
N/A
N/A
N/A
CERVICAL HEAD
HARNESS/HALTER
00-1778-002-00 00177800200 DELUXE PADDED HEAD HALTER,
MEDIUM
TRACTION
HEAD HALTERS
Traction
Traction Products
E0942
Y
00-1778-003-00 00177800300 DELUXE PADDED HEAD HALTER,
LARGE
TRACTION
HEAD HALTERS
Traction
Traction Products
E0942
00-2700-003-00 00270000300 ZIMMER PRO HEAD HALTER
TRACTION
HEAD HALTERS
Traction
Traction Products
E0942
Comment 1
Comment 2
Comment 3
CERVICAL HEAD
HARNESS/HALTER
Y
CERVICAL HEAD
HARNESS/HALTER
Y
CERVICAL HEAD
HARNESS/HALTER
PAGE 37
Product #
EDI Item #
Item Description
00-2700-007-00 00270000700 NO.7 HEAD HALTER
Header 1
TRACTION
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
HEAD HALTERS
Traction
Traction Products
E0942
Y
CERVICAL HEAD
HARNESS/HALTER
00-0584-021-00 00058402100 COMFORT PANEL TRACTION BELT 30-TRACTION
45
PELVIC BELTS
Traction
Traction Products
E0944
Y
Pelvic belt/harness/boot
00-0584-022-00 00058402200 COMFORT PANEL TRACTION BELT 30-TRACTION
52
PELVIC BELTS
Traction
Traction Products
E0944
Y
00-0584-023-00 00058402300 COMFORT PANEL TRACTION BELT
SIZE 36-62
TRACTION
PELVIC BELTS
Traction
Traction Products
E0944
Y
00-0738-001-00 00073800100 DELUXE FOAM PADDED
PELVICBELT+C143, SMALL 26-34
TRACTION
PELVIC BELTS
Traction
Traction Products
E0944
Y
00-0738-002-00 00073800200 DELUXE FOAM PADDED PELVICBELT, TRACTION
MEDIUM 34-42
PELVIC BELTS
Traction
Traction Products
E0944
Y
PAGE 38
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
LARGE 42-50
PELVIC BELTS
Traction
Traction Products
E0944
Y
X-LARGE 50-58
PELVIC BELTS
Traction
Traction Products
E0944
Y
00-0743-001-00 00074300100 ZIMCODE PELVIC BELT, DOUBLE
STRAP VELCR,26-30
TRACTION
PELVIC BELTS
Traction
Traction Products
E0944
Y
STRAP VELCR,30-34
TRACTION
PELVIC BELTS
Traction
Traction Products
E0944
Y
STRAP VELCR,34-38
TRACTION
PELVIC BELTS
Traction
Traction Products
E0944
Y
STRAP VELCR,38-42
TRACTION
PELVIC BELTS
Traction
Traction Products
E0944
Y
PAGE 39
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
STRAP VELCR,42-46
TRACTION
PELVIC BELTS
Traction
Traction Products
E0944
Y
00-0743-006-00 00074300600 ZIMCODE PELVIC BELT, -DBL
STRAP,VELCRO, 46-50
TRACTION
PELVIC BELTS
Traction
Traction Products
E0944
Y
00-1570-001-00 00157000100 UNIVERSAL DOUBLE-STRAP PELVIC TRACTION
TRACTION BELT
PELVIC BELTS
Traction
Traction Products
E0944
Y
00-1570-002-00 00157000200 UNIVERSAL DOUBLE-STRAP PELVIC TRACTION
TRACTION BELT
PELVIC BELTS
Traction
Traction Products
E0944
Y
00-1570-011-00 00157001100
TRACTION
PELVIC BELTS
Traction
Traction Products
E0944
Y
TRACTION
PELVIC BELTS
Traction
Traction Products
E0944
Y
TRACTION STRAP KIT
00-1678-001-00 00167800100 UNIVERSAL SINGLE STRAP PELVIC
TRACTION BELT
PAGE 40
Product #
EDI Item #
Item Description
00-1774-001-00 00177400100 UNIVERSAL TRACTION BOOT
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
TRACTION
TRACTION BOOTS
Traction
Traction Products
N/A
N/A
N/A
00-2753-008-00 00275300800 DELUXE ZIM-TRAC CONV TRACTION TRACTION
SPLINT, PED
TRACTION BOOTS
Traction
Traction Products
E0870
Y
Traction frame, attached to
footboard, extremity traction, (e.g.
buck's)
SPLINT, X-SMALL
TRACTION BOOTS
Traction
Traction Products
E0870
Y
buck's)
00-2753-011-00 00275301100
DELUXE ZIM-TRAC CONV TRACTION TRACTION
SPLINT, SMALL
TRACTION BOOTS
Traction
Traction Products
E0870
Y
buck's)
SPLINT, MEDIUM
TRACTION BOOTS
Traction
Traction Products
E0870
Y
buck's)
SPLINT, LARGE
TRACTION BOOTS
Traction
Traction Products
E0870
Y
buck's)
SPLINT, X-LARGE
TRACTION BOOTS
Traction
Traction Products
E0870
Y
buck's)
00-8712-012-00 00871201200 ECONOMY LEG TRACTION SPLINT,
SMALL
TRACTION BOOTS
Traction
Traction Products
N/A
N/A
N/A
TRACTION
Comment 1
separately payable.
General Medical Surgical Supplies 0270, NonCharges reported with UB-04 revenue codes 0270,0271 and
Sterile Supplies 0271, Sterile Supplies 0272,
separately payable.
Comment 2
Comment 3
PAGE 41
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
MEDIUM
TRACTION
TRACTION BOOTS
Traction
Traction Products
N/A
N/A
N/A
separately payable.
LARGE
TRACTION
TRACTION BOOTS
Traction
Traction Products
N/A
N/A
N/A
separately payable.
00-8712-015-00 00871201500 ECONOMY LEG TRACTION SPLINT, X- TRACTION
LARGE
TRACTION BOOTS
Traction
Traction Products
N/A
N/A
N/A
separately payable.
00-0737-001-00 00073700100 SERPENTINE FOAM COLLAR, SM, X- ORTHOPAEDIC BRACES & SUPPORTS
WIDE, 4 X 18
SOFT CERVICAL COLLARS
Orthopaedic Orthopaedic Support
Supports
Products
L0120
A
CERVICAL, FLEXIBLE, NONADJUSTABLE (FOAM COLLAR)
Not paid under OPPS. Paid by fiscal intermediaries/MACs under
00-0737-002-00 00073700200 SERPENTINE FOAM COLLAR, SMALL, ORTHOPAEDIC BRACES & SUPPORTS
3 X 16-1/2
Supports
Products
L0120
A
00-0737-003-00 00073700300 SERPENTINE FOAM COLLAR,
MEDIUM, 4 X 20-1/2
ORTHOPAEDIC BRACES & SUPPORTS
Supports
Products
L0120
A
LARGE, 5 X 21-1/2
Supports
Products
L0120
A
UNIVERSAL, 3 1/2X23-1/2
Supports
Products
L0120
A
00-0737-006-00 00073700600 SERPENTINE FOAM COLLAR, SM, X- ORTHOPAEDIC BRACES & SUPPORTS
LONG, 3 X 21
Supports
Products
L0120
A
00-0737-007-00 00073700700 SERPENTINE FOAM COLLAR, SM, 2- ORTHOPAEDIC BRACES & SUPPORTS
1/2 X 16-1/2
Supports
Products
L0120
A
00-1737-001-00 00173700100 SERPENTINE FOAM COLLAR, SMALL, ORTHOPAEDIC BRACES & SUPPORTS
X-WIDE
Supports
Products
L0120
A
00-1737-002-00 00173700200 SERPENTINE FOAM COLLAR, SMALL ORTHOPAEDIC BRACES & SUPPORTS
Supports
Products
L0120
A
MEDIUM
Supports
Products
L0120
A
00-1737-004-00 00173700400 SERPENTINE FOAM COLLAR, LARGE ORTHOPAEDIC BRACES & SUPPORTS
Supports
Products
L0120
A
MEDIUM, X-LONG
Supports
Products
L0120
A
00-2739-001-00 00273900100 FOAM CERVICAL COLLAR, SMALL X- ORTHOPAEDIC BRACES & SUPPORTS
WIDE
Supports
Products
L0120
A
00-2739-002-00 00273900200 FOAM CERVICAL COLLAR, SMALL
Supports
Products
L0120
A
00-2739-003-00 00273900300 FOAM CERVICAL COLLAR, MEDIUM
Supports
Products
L0120
A
PAGE 42
Product #
EDI Item #
Item Description
00-2739-004-00 00273900400 FOAM CERVICAL COLLAR, LARGE
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
Supports
Products
L0120
A
00-2739-005-00 00273900500 FOAM CERVICAL COLLAR, MEDIUM, ORTHOPAEDIC BRACES & SUPPORTS
X-LONG
Supports
Products
L0120
A
00-2740-001-00 00274000100 FOAM CERVICAL COLLAR, SMALL, X- ORTHOPAEDIC BRACES & SUPPORTS
WIDE
Supports
Products
L0120
A
00-2740-002-00 00274000200 FOAM CERVICAL COLLAR, SMALL
Supports
Products
L0120
A
00-2740-003-00 00274000300 FOAM CERVICAL COLLAR, MEDIUM
Supports
Products
L0120
A
00-2740-004-00 00274000400 FOAM CERVICAL COLLAR, LARGE
Supports
Products
L0120
A
00-2740-005-00 00274000500 FOAM CERVICAL COLLAR, MEDIUM, ORTHOPAEDIC BRACES & SUPPORTS
X-LONG
Supports
Products
L0120
A
00-8601-380-00 00860138000 PEDIATRIC CERVICAL COLLAR
Supports
Products
L0120
A
00-8705-045-00 00870504500 FOAM CERVICAL COLLAR,
UNIVERSAL
Supports
Products
L0120
A
00-1676-001-00 00167600100 EMS EXTRICATION COLLAR,
PEDIATRIC
EMS, RIGID CERVICAL COLLARS
Supports
Products
L0120
A
00-1676-002-00 00167600200 EMS EXTRICATION COLLAR, XSMALL
Supports
Products
L0120
A
00-1676-003-00 00167600300 EMS EXTRICATION COLLAR, SHORT ORTHOPAEDIC BRACES & SUPPORTS
Supports
Products
L0120
A
00-1676-004-00 00167600400 EMS EXTRICATION COLLAR,
REGULAR
Supports
Products
L0120
A
00-1676-005-00 00167600500 EMS EXTRICATION COLLAR, TALL
Supports
Products
L0120
A
00-1676-006-00 00167600600 EMS EXTRICATION COLLAR, PED,
SHORT
Supports
Products
L0120
A
00-1741-005-00 00174100500 PHILADELPHIA CERVICAL COLLAR,
SMALL, 3-1/4
Supports
Products
L0172
A
CERVICAL, COLLAR, SEMI-RIGID 0274 Medical/Surgical Supplies and Devices THERMOPLASTIC FOAM, TWO Prosthetic/Orthotic Devices
PIECE
MEDIUM, 3-1/4
Supports
Products
L0172
A
PIECE
LARGE, 3-1/4
Supports
Products
L0172
A
PIECE
SMALL, 4-1/4
Supports
Products
L0172
A
PIECE
PAGE 43
Product #
EDI Item #
00-1741-011-00 00174101100
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
PHILADELPHIA CERVICAL COLLAR,
MEDIUM, 4-1/4
Supports
Products
L0172
A
PIECE
LARGE, 4-1/4
Supports
Products
L0172
A
PIECE
SMALL, 5-1/4
Supports
Products
L0172
A
PIECE
MEDIUM, 5-1/4
Supports
Products
L0172
A
PIECE
LARGE, 5-1/4
Supports
Products
L0172
A
PIECE
00-1741-301-00 00174130100 PADDED CERVICAL COLLAR, S
Supports
Products
L0172
A
PIECE
00-1741-302-00 00174130200 PADDED CERVICAL COLLAR, MED
Supports
Products
L0172
A
PIECE
00-1741-303-00 00174130300 PADDED CERVICAL COLLAR, STAND ORTHOPAEDIC BRACES & SUPPORTS
Supports
Products
L0172
A
PIECE
00-1741-304-00 00174130400 PADDED CERVICAL COLLAR, T
Supports
Products
L0172
A
PIECE
00-1741-309-00 00174130900 REPLACEMENT PAD SET
Supports
Products
L0172
A
PIECE
00-1742-001-00 00174200100 Philly Patriot Collar, Pe
Supports
Products
L0172
A
PIECE
00-1742-002-00 00174200200 PHILLY PATRIOT ADJUSTABLE
EXTRICATION COLLAR ADULT
Supports
Products
L0172
A
PIECE
00-1750-001-00 00175000100 PHILLY ONE-PIECE EXTRICATION
COLLAR, INFANT
Supports
Products
L0172
A
PIECE
COLLAR, PED
Supports
Products
L0172
A
PIECE
COLLAR, LOW
Supports
Products
L0172
A
PIECE
COLLAR, SHORT
Supports
Products
L0172
A
PIECE
COLLAR, REG
Supports
Products
L0172
A
PIECE
COLLAR, TALL
Supports
Products
L0172
A
PIECE
00-1751-005-00 00175100500 COOLBRACE COLLAR, SMALL
Supports
Products
L0172
A
PIECE
PAGE 44
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
00-1751-006-00 00175100600 COOLBRACE COLLAR, MEDIUM
Supports
Products
L0172
A
PIECE
00-1751-007-00 00175100700 COOLBRACE COLLAR, LARGE
Supports
Products
L0172
A
PIECE
PED, 2-1/2
Supports
Products
L0172
A
PIECE
00-0764-001-10 00076400110
ZIMMER ARM SLING MULTI-PAK
ARM SLINGS
Supports
Products
A4565
N
SLINGS
payment.
00-0764-002-10 00076400210 ZIMMER ARM SLING MULTI-PAK
ARM SLINGS
Supports
Products
A4565
N
SLINGS
payment.
ARM SLINGS
Supports
Products
A4565
N
SLINGS
payment.
ARM SLINGS
Supports
Products
A4565
N
SLINGS
payment.
00-0764-010-00 00076401000 PEDIATRIC ARM SLING, XX-SMALL
ARM SLINGS
Supports
Products
A4565
N
SLINGS
payment.
00-0764-011-00 00076401100
PEDIATRIC ARM SLING, X-SMALL
ARM SLINGS
Supports
Products
A4565
N
SLINGS
payment.
00-1796-011-00 00179601100
FASHION ARM SLING, SMALL
ARM SLINGS
Supports
Products
A4565
N
SLINGS
payment.
00-1796-011-10 00179601110
FASHION ARM SLING SMALL, BOX 10 ORTHOPAEDIC BRACES & SUPPORTS
ARM SLINGS
Supports
Products
A4565
N
SLINGS
payment.
ARM SLINGS
Supports
Products
A4565
N
SLINGS
payment.
00-1796-012-10 00179601210 FASHION ARM SLING, MEDIUM, BOX ORTHOPAEDIC BRACES & SUPPORTS
10
ARM SLINGS
Supports
Products
A4565
N
SLINGS
payment.
00-1796-013-00 00179601300 FASHION ARM SLING, LARGE
ARM SLINGS
Supports
Products
A4565
N
SLINGS
payment.
00-1796-013-10 00179601310 FASHION ARM SLING, LARGE, BOX
10
ARM SLINGS
Supports
Products
A4565
N
SLINGS
payment.
00-1796-012-00 00179601200 FASHION ARM SLING, MEDIUM
PAGE 45
Product #
EDI Item #
Item Description
00-1796-014-00 00179601400 FASHION ARM SLING, X-LARGE
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
ARM SLINGS
Supports
Products
A4565
N
SLINGS
payment.
00-1796-014-10 00179601410 FASHION ARM SLING, X-LARGE, BOX ORTHOPAEDIC BRACES & SUPPORTS
10
ARM SLINGS
Supports
Products
A4565
N
SLINGS
payment.
00-1798-001-00 00179800100 UNIVERSAL MULTI-SLING
ARM SLINGS
Supports
Products
A4565
N
SLINGS
payment.
00-1892-001-00 00189200100 PADDED STRAP ARM SLING, SMALL ORTHOPAEDIC BRACES & SUPPORTS
ARM SLINGS
Supports
Products
A4565
N
SLINGS
payment.
00-1892-002-00 00189200200 PADDED STRAP ARM SLING,
MEDIUM
ARM SLINGS
Supports
Products
A4565
N
SLINGS
payment.
00-1892-003-00 00189200300 PADDED STRAP ARM SLING, LARGE ORTHOPAEDIC BRACES & SUPPORTS
ARM SLINGS
Supports
Products
A4565
N
SLINGS
payment.
00-1892-004-00 00189200400 PADDED STRAP ARM SLING, XLARGE
ARM SLINGS
Supports
Products
A4565
N
SLINGS
payment.
00-1898-001-00 00189800100 American Way Arm Sling
ARM SLINGS
Supports
Products
A4565
N
SLINGS
payment.
00-1978-001-00 00197800100 UNIVERSAL ARM ELEVATOR/SLING
ARM SLINGS
Supports
Products
A4565
N
SLINGS
payment.
00-8600-194-00 00860019400 GARDNER ARM ELEVATOR,
PEDIATRIC
ARM SLINGS
Supports
Products
A4565
N
SLINGS
payment.
00-8600-195-00 00860019500 GARDNER ARM ELEVATOR, YOUTH
ARM SLINGS
Supports
Products
A4565
N
SLINGS
payment.
00-8601-377-00 00860137700 PEDIATRIC FASHION ARM SLING,
NAVY
ARM SLINGS
Supports
Products
A4565
N
SLINGS
payment.
00-8601-377-50 00860137750 PEDIATRIC FASHION ARM SLING,
CHILD PRINT
ARM SLINGS
Supports
Products
A4565
N
SLINGS
payment.
66-0576-001-00 66057600100 STRAP ARM SLING W/PAD, SMALL
ARM SLINGS
Supports
Products
A4565
N
SLINGS
payment.
PAGE 46
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
66-0576-002-00 66057600200 STRAP ARM SLING W/PAD, MEDIUM ORTHOPAEDIC BRACES & SUPPORTS
ARM SLINGS
Supports
Products
A4565
N
SLINGS
payment.
66-0576-003-00 66057600300 STRAP ARM SLING W/PAD, LARGE
ARM SLINGS
Supports
Products
A4565
N
SLINGS
payment.
00-0763-001-00 00076300100 SHOULDER IMMOBILIZER/VELPEAU ORTHOPAEDIC BRACES & SUPPORTS
DRESSING, SMALL
SHOULDER IMMOBILIZERS
Supports
Products
L3670
A
SHOULDER ORTHOSIS,
0274 Medical/Surgical Supplies and Devices ACROMIO/CLAVICULAR (CANVAS Prosthetic/Orthotic Devices
AND WEBBING TYPE),
PREFABRICATED, INCLUDES
FITTING AND ADJUSTMENT
Not paid under OPPS. Paid by fiscal intermediaries/MACs under When hospital outpatient staff provide a prosthetic See Pub 100-04 Medicare
or orthotic device, and the HCPCS code that
describes that device includes the fitting,
adjustment, or other services necessary for the
patient’s use of the item, the hospital should not bill
a visit or procedure HCPCS code to report the
charges associated with the fitting, adjustment, or
other related services. Instead, the HCPCS code
for the device already includes the fitting,
adjustment or other similar services.
DRESSING, MEDIUM
Supports
Products
L3670
A
SHOULDER ORTHOSIS,
AND WEBBING TYPE),
DRESSING, LARGE
Supports
Products
L3670
A
SHOULDER ORTHOSIS,
AND WEBBING TYPE),
DRESSING, X-LARGE
Supports
Products
L3670
A
SHOULDER ORTHOSIS,
AND WEBBING TYPE),
00-0763-011-00 00076301100
Supports
Products
L3670
A
SHOULDER ORTHOSIS,
AND WEBBING TYPE),
SHOULDER IMMOBILIZER/VELPEAU ORTHOPAEDIC BRACES & SUPPORTS
DRESSING, PED
PAGE 47
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
00-0783-001-00 00078300100 MEN ELASTIC SHOULDER
IMOBILIZER, CHEST, 24-30
Supports
Products
L3670
A
SHOULDER ORTHOSIS,
AND WEBBING TYPE),
Supports
Products
L3670
A
SHOULDER ORTHOSIS,
AND WEBBING TYPE),
IMOBILIZER, CHEST 36-42
Supports
Products
L3670
A
SHOULDER ORTHOSIS,
AND WEBBING TYPE),
Supports
Products
L3670
A
SHOULDER ORTHOSIS,
AND WEBBING TYPE),
00-0784-001-00 00078400100 WOMEN ELASTIC SHOULDER
Supports
Products
L3670
A
SHOULDER ORTHOSIS,
AND WEBBING TYPE),
Supports
Products
L3670
A
SHOULDER ORTHOSIS,
AND WEBBING TYPE),
PAGE 48
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
Supports
Products
L3670
A
SHOULDER ORTHOSIS,
AND WEBBING TYPE),
Supports
Products
L3670
A
SHOULDER ORTHOSIS,
AND WEBBING TYPE),
00-0784-005-00 00078400500 ELASTIC SHOULDER IMMOBILIZER
XX-LARGE
Supports
Products
L3670
A
SHOULDER ORTHOSIS,
AND WEBBING TYPE),
00-1785-001-00 00178500100 UNIVERSAL SHOULDER
IMMOBILIZER
Supports
Products
A4466
E
GARMENT, BELT, SLEEVE OR
0270 – Medical surgical supplies general; 0274OTHER COVERING, ELASTIC OR medical surgical;0279SIMILAR STRETCHABLE
medical surgical supplies other supplies/devices
MATERIAL, ANY TYPE, EACH
00-1893-001-00 00189300100 PADDED ARM/SHOULDER
IMMOBILIZER, SMALL
Supports
Products
L3670
A
SHOULDER ORTHOSIS,
supplies prosthetic/orthotic devices; 0279- medical Not paid under OPPS. Paid by fiscal intermediaries/MACs under
ACROMIO/CLAVICULAR (CANVAS surgical supplies other supplies/devices
AND WEBBING TYPE),
When hospital outpatient staff provide a prosthetic See Pub 100-04 Medicare
IMMOBILIZER, MEDIUM
Supports
Products
L3670
A
SHOULDER ORTHOSIS,
General Medical Surgical Supplies 0270, NonACROMIO/CLAVICULAR (CANVAS Sterile Supplies 0271, Sterile Supplies 0272,
AND WEBBING TYPE),
IMMOBILIZER, LARGE
Supports
Products
L3670
A
SHOULDER ORTHOSIS,
ACROMIO/CLAVICULAR (CANVAS
AND WEBBING TYPE),
PAGE 49
Product #
EDI Item #
Item Description
IMMOBILIZER, X-LARGE
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
Supports
Products
L3670
A
SHOULDER ORTHOSIS,
AND WEBBING TYPE),
00-3898-005-00 00389800500 DELUXE SLING AND SWATHE, SMALL ORTHOPAEDIC BRACES & SUPPORTS
Supports
Products
A4565
N
SLINGS
payment.
00-3898-006-00 00389800600 DELUXE SLING AND SWATHE,
MEDIUM
Supports
Products
A4565
N
SLINGS
payment.
00-3898-007-00 00389800700 DELUXE SLING AND SWATHE,
LARGE
Supports
Products
A4565
N
SLINGS
payment.
00-3898-008-00 00389800800 DELUXE SLING AND SWATHE, XLARGE
Supports
Products
A4565
N
SLINGS
payment.
00-3899-001-00 00389900100 UNIVERSAL SLING AND SWATHE
Supports
Products
A4565
N
SLINGS
payment.
00-8601-796-00 00860179600 DELUXE SLING AND SWATHE, XSMALL
Supports
Products
A4565
N
SLINGS
payment.
00-0735-001-00 00073500100 MCLEOD CLAVICLE SPLINT, BUCKLE, ORTHOPAEDIC BRACES & SUPPORTS
X-SMALL
CLAVICLE SPLINTS
Supports
Products
L3650
A
SHOULDER ORTHOSIS, FIGURE 0274 Medical/Surgical Supplies and Devices OF EIGHT DESIGN ABDUCTION Prosthetic/Orthotic Devices
RESTRAINER, PREFABRICATED,
INCLUDES FITTING AND
ADJUSTMENT
SMALL
CLAVICLE SPLINTS
Supports
Products
L3650
A
ADJUSTMENT
PAGE 50
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
MEDIUM
CLAVICLE SPLINTS
Supports
Products
L3650
A
ADJUSTMENT
LARGE
CLAVICLE SPLINTS
Supports
Products
L3650
A
ADJUSTMENT
X-LARGE
CLAVICLE SPLINTS
Supports
Products
L3650
A
ADJUSTMENT
00-0735-011-00 00073501100
CLAVICLE SPLINTS
Supports
Products
L3650
A
ADJUSTMENT
00-0735-012-00 00073501200 MCLEOD CLAVICLE SPLINT,
CONTACT CLOSURE, SMALL
CLAVICLE SPLINTS
Supports
Products
L3650
A
ADJUSTMENT
CONTACT CLOSURE, MEDIUM
CLAVICLE SPLINTS
Supports
Products
L3650
A
ADJUSTMENT
MCLEOD CLAVICLE SPLINT,
CONTACT CLOSURE, X-SMALL
PAGE 51
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
CONTACT CLOSURE, LARGE
CLAVICLE SPLINTS
Supports
Products
L3650
A
ADJUSTMENT
CONTACT CLOSURE, X-LARGE
CLAVICLE SPLINTS
Supports
Products
L3650
A
ADJUSTMENT
00-8600-282-00 00860028200 MCCLEOD CLAVICLE STRAP, XSMALL
CLAVICLE SPLINTS
Supports
Products
L3650
A
ADJUSTMENT
00-0799-001-00 00079900100 WRIST SPLINT, SMALL, LEFT
WRIST SPLINTS
Supports
Products
S8451
N/A
Splint, prefabricated, wrist or ankle General Medical Surgical Supplies 0270, NonSterile Supplies 0271, Sterile Supplies 0272,
separately payable.
00-0799-002-00 00079900200 WRIST SPLINT, SMALL, RIGHT
WRIST SPLINTS
Supports
Products
S8451
N/A
separately payable.
00-0799-003-00 00079900300 WRIST SPLINT, MEDIUM, LEFT
WRIST SPLINTS
Supports
Products
S8451
N/A
separately payable.
00-0799-004-00 00079900400 WRIST SPLINT, MEDIUM, RIGHT
WRIST SPLINTS
Supports
Products
S8451
N/A
separately payable.
00-0799-005-00 00079900500 WRIST SPLINT, LARGE, LEFT
WRIST SPLINTS
Supports
Products
S8451
N/A
separately payable.
00-0799-006-00 00079900600 WRIST SPLINT, LARGE, RIGHT
WRIST SPLINTS
Supports
Products
S8451
N/A
separately payable.
00-0799-007-00 00079900700 WRIST SPLINT, X-LARGE, LEFT
WRIST SPLINTS
Supports
Products
S8451
N/A
separately payable.
PAGE 52
Product #
EDI Item #
Item Description
00-0799-008-00 00079900800 WRIST SPLINT, X-LARGE, RIGHT
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
WRIST SPLINTS
Supports
Products
S8451
N/A
separately payable.
00-1476-001-00 00147600100 ZIMMER PREMIUM WRIST BRACE, X- ORTHOPAEDIC BRACES & SUPPORTS
SMALL, LEFT
WRIST SPLINTS
Supports
Products
L3807
A
WRIST HAND FINGER
0274 Medical/Surgical Supplies and Devices ORTHOSIS, WITHOUT JOINT(S), Prosthetic/Orthotic Devices
FITTING AND ADJUSTMENTS,
ANY TYPE
SMALL, RIGHT
WRIST SPLINTS
Supports
Products
L3807
A
WRIST HAND FINGER
ANY TYPE
00-1476-003-00 00147600300 ZIMMER PREMIUM WRIST BRACE,
SMALL, LEFT
WRIST SPLINTS
Supports
Products
L3807
A
WRIST HAND FINGER
ANY TYPE
SMALL, RIGHT
WRIST SPLINTS
Supports
Products
L3807
A
WRIST HAND FINGER
ANY TYPE
MEDIUM, LEFT
WRIST SPLINTS
Supports
Products
L3807
A
WRIST HAND FINGER
ANY TYPE
PAGE 53
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
MEDIUM, RIGHT
WRIST SPLINTS
Supports
Products
L3807
A
WRIST HAND FINGER
ANY TYPE
LARGE, LEFT
WRIST SPLINTS
Supports
Products
L3807
A
WRIST HAND FINGER
ANY TYPE
LARGE, RIGHT
WRIST SPLINTS
Supports
Products
L3807
A
WRIST HAND FINGER
ANY TYPE
LARGE, LEFT
WRIST SPLINTS
Supports
Products
L3807
A
WRIST HAND FINGER
ANY TYPE
LARGE, RIGHT
WRIST SPLINTS
Supports
Products
L3807
A
WRIST HAND FINGER
ANY TYPE
00-1477-001-00 00147700100 ZIMMER PREMIUM THUMB SPICA, X- ORTHOPAEDIC BRACES & SUPPORTS
SMALL, LEFT
WRIST SPLINTS
Supports
Products
L3931
A
WRIST HAND FINGER
0274 Medical/Surgical Supplies and Devices ORTHOSIS, INCLUDES ONE OR Prosthetic/Orthotic Devices
MORE NONTORSION JOINT(S),
TURNBUCKLES, ELASTIC
BANDS/SPRINGS, MAY INCLUDE
SOFT INTERFACE MATERIAL,
STRAPS, PREFABRICATED,
ADJUSTMENT
PAGE 54
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
SMALL, RIGHT
WRIST SPLINTS
Supports
Products
L3931
A
WRIST HAND FINGER
ADJUSTMENT
00-1477-003-00 00147700300 ZIMMER PREMIUM THUMB SPICA,
SMALL, LEFT
WRIST SPLINTS
Supports
Products
L3931
A
WRIST HAND FINGER
ADJUSTMENT
SMALL, RIGHT
WRIST SPLINTS
Supports
Products
L3931
A
WRIST HAND FINGER
ADJUSTMENT
MEDIUM, LEFT
WRIST SPLINTS
Supports
Products
L3931
A
WRIST HAND FINGER
ADJUSTMENT
MEDIUM, RIGHT
WRIST SPLINTS
Supports
Products
L3931
A
WRIST HAND FINGER
ADJUSTMENT
LARGE, LEFT
WRIST SPLINTS
Supports
Products
L3931
A
WRIST HAND FINGER
ADJUSTMENT
PAGE 55
Product #
EDI Item #
Item Description
LARGE, RIGHT
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
WRIST SPLINTS
Supports
Products
L3931
A
WRIST HAND FINGER
ADJUSTMENT
LARGE, LEFT
WRIST SPLINTS
Supports
Products
L3931
A
WRIST HAND FINGER
ADJUSTMENT
LARGE, RIGHT
WRIST SPLINTS
Supports
Products
L3931
A
WRIST HAND FINGER
ADJUSTMENT
00-1478-001-00 00147800100 Exo-Wrist Brace, Small, L
WRIST SPLINTS
Supports
Products
L3807
A
WRIST HAND FINGER
ANY TYPE
00-1478-002-00 00147800200 Exo-Wrist Brace, Small, R
WRIST SPLINTS
Supports
Products
L3807
A
WRIST HAND FINGER
ANY TYPE
00-1478-003-00 00147800300 EXO-WRIST BRACE, MEDIUM, L
WRIST SPLINTS
Supports
Products
L3807
A
WRIST HAND FINGER
ANY TYPE
PAGE 56
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
00-1478-004-00 00147800400 EXO-WRIST BRACE, MEDIUM, R
WRIST SPLINTS
Supports
Products
L3807
A
WRIST HAND FINGER
ANY TYPE
00-1478-005-00 00147800500 EXO-WRIST BRACE, LARGE, L
WRIST SPLINTS
Supports
Products
L3807
A
WRIST HAND FINGER
ANY TYPE
00-1478-006-00 00147800600 EXO-WRIST BRACE, LARGE, R
WRIST SPLINTS
Supports
Products
L3807
A
WRIST HAND FINGER
ANY TYPE
00-1759-001-00 00175900100 DELUXE COCKUP WRIST SPLINT,
SMALL, LEFT
WRIST SPLINTS
Supports
Products
L3908
A
WRIST HAND ORTHOSIS, WRIST 0274 Medical/Surgical Supplies and Devices EXTENSION CONTROL COCKProsthetic/Orthotic Devices
UP, NON MOLDED,
SMALL, RIGHT
WRIST SPLINTS
Supports
Products
L3908
A
UP, NON MOLDED,
MEDIUM, LEFT
WRIST SPLINTS
Supports
Products
L3908
A
UP, NON MOLDED,
PAGE 57
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
MEDIUM, RIGHT
WRIST SPLINTS
Supports
Products
L3908
A
UP, NON MOLDED,
LARGE, LEFT
WRIST SPLINTS
Supports
Products
L3908
A
UP, NON MOLDED,
LARGE, RIGHT
WRIST SPLINTS
Supports
Products
L3908
A
UP, NON MOLDED,
00-1759-007-00 00175900700 DELUXE COCKUP WRIST SPLINT, X- ORTHOPAEDIC BRACES & SUPPORTS
LARGE, LEFT
WRIST SPLINTS
Supports
Products
L3908
A
UP, NON MOLDED,
LARGE, RIGHT
WRIST SPLINTS
Supports
Products
L3908
A
UP, NON MOLDED,
00-1769-002-00 00176900200 UNIVERSAL COCK-UP WRIST SPLINT, ORTHOPAEDIC BRACES & SUPPORTS
RIGHT
WRIST SPLINTS
Supports
Products
L3908
A
UP, NON MOLDED,
PAGE 58
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
00-1769-003-00 00176900300 UNIVERSAL COCK-UP WRIST,
SPLINT, LEFT
WRIST SPLINTS
Supports
Products
L3908
A
UP, NON MOLDED,
00-1799-001-00 00179900100 ADJUSTABLE WRIST BRACE, XSMALL, LEFT
WRIST SPLINTS
Supports
Products
L3807
A
WRIST HAND FINGER
ANY TYPE
00-1799-002-00 00179900200 ADJUSTABLE WRIST BRACE, XSMALL, RIGHT
WRIST SPLINTS
Supports
Products
L3807
A
WRIST HAND FINGER
ANY TYPE
00-1799-003-00 00179900300 ADJUSTABLE WRIST BRACE, SMALL, ORTHOPAEDIC BRACES & SUPPORTS
LEFT
WRIST SPLINTS
Supports
Products
L3807
A
WRIST HAND FINGER
ANY TYPE
00-1799-004-00 00179900400 ADJUSTABLE WRIST BRACE, SMALL, ORTHOPAEDIC BRACES & SUPPORTS
RIGHT
WRIST SPLINTS
Supports
Products
L3807
A
WRIST HAND FINGER
ANY TYPE
00-1799-005-00 00179900500 ADJUSTABLE WRIST BRACE,
MEDIUM, LEFT
WRIST SPLINTS
Supports
Products
L3807
A
WRIST HAND FINGER
ANY TYPE
PAGE 59
Product #
EDI Item #
Item Description
00-1799-006-00 00179900600 ADJUSTABLE WRIST BRACE,
MEDIUM, RIGHT
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
WRIST SPLINTS
Supports
Products
L3807
A
WRIST HAND FINGER
ANY TYPE
00-1799-007-00 00179900700 ADJUSTABLE WRIST BRACE, LARGE, ORTHOPAEDIC BRACES & SUPPORTS
LEFT
WRIST SPLINTS
Supports
Products
L3807
A
WRIST HAND FINGER
ANY TYPE
00-1799-008-00 00179900800 ADJUSTABLE WRIST BRACE, LARGE, ORTHOPAEDIC BRACES & SUPPORTS
RIGHT
WRIST SPLINTS
Supports
Products
L3807
A
WRIST HAND FINGER
ANY TYPE
00-1799-009-00 00179900900 ADJUSTABLE WRIST BRACE, XLARGE, LEFT
WRIST SPLINTS
Supports
Products
L3807
A
WRIST HAND FINGER
ANY TYPE
00-1799-010-00 00179901000 ADJUSTABLE WRIST BRACE, XLARGE, RIGHT
WRIST SPLINTS
Supports
Products
L3807
A
WRIST HAND FINGER
ANY TYPE
00-3447-303-00 00344730300 WRISTLET WITH STRAP, SMALL
RIGHT
WRIST SPLINTS
Supports
Products
A4466
E
00-3447-304-00 00344730400 WRISTLET WITH STRAP, MEDIUM
RIGHT
WRIST SPLINTS
Supports
Products
A4466
E
00-3447-305-00 00344730500 WRISTLET WITH STRAP, LARGE
RIGHT
WRIST SPLINTS
Supports
Products
A4466
E
PAGE 60
Product #
EDI Item #
Item Description
00-3447-306-00 00344730600 WRISTLET WITH STRAP, X-LARGE
RIGHT
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
WRIST SPLINTS
Supports
Products
A4466
E
00-3447-403-00 00344740300 WRISTLET WITH STRAP, SMALL LEFT ORTHOPAEDIC BRACES & SUPPORTS
WRIST SPLINTS
Supports
Products
A4466
E
00-3447-404-00 00344740400 WRISTLET WITH STRAP, MEDIUM
LEFT
WRIST SPLINTS
Supports
Products
A4466
E
00-3447-405-00 00344740500 WRISTLET WITH STRAP, LARGE
LEFT
WRIST SPLINTS
Supports
Products
A4466
E
00-3447-406-00 00344740600 WRISTLET WITH STRAP, X-LARGE
LEFT
WRIST SPLINTS
Supports
Products
A4466
E
SMALL, LEFT
WRIST SPLINTS
Supports
Products
L3908
A
UP, NON MOLDED,
SMALL, RIGHT
WRIST SPLINTS
Supports
Products
L3908
A
UP, NON MOLDED,
00-8601-887-02 00860188702 UNIVERSAL COCK-UP WRIST SPLINT ORTHOPAEDIC BRACES & SUPPORTS
6 RIGHT
WRIST SPLINTS
Supports
Products
L3908
A
UP, NON MOLDED,
00-8601-887-03 00860188703 UNIVERSAL COCK-UP WRIST SPLINT ORTHOPAEDIC BRACES & SUPPORTS
6 LEFT
WRIST SPLINTS
Supports
Products
L3908
A
UP, NON MOLDED,
PAGE 61
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
00-1479-001-00 00147900100 ZIMMER AIRFORM BACK SUPPORT
SMALL
BACK SUPPORTS
Supports
Products
L0625
A
Lumbar orthosis, flexible, provides 0274 Medical/Surgical Supplies and Devices lumbar support, posterior extends Prosthetic/Orthotic Devices
from l-1 to below l-5 vertebra,
produces intracavitary pressure to
reduce load on the intervertebral
discs, includes straps, closures,
may include pendulous abdomen
design, shoulder straps, stays,
prefabricated, includes fitting and
adjustment
MEDIUM
BACK SUPPORTS
Supports
Products
L0625
A
adjustment
LARGE
BACK SUPPORTS
Supports
Products
L0625
A
adjustment
00-1479-004-00 00147900400 ZIMMER AIRFORM BACK SUPPORT X- ORTHOPAEDIC BRACES & SUPPORTS
LARGE
BACK SUPPORTS
Supports
Products
L0625
A
adjustment
XX-LARGE
BACK SUPPORTS
Supports
Products
L0625
A
adjustment
00-1730-001-00 00173000100 UNIVERSAL SACROLUMBAR
SUPPORT
BACK SUPPORTS
Supports
Products
L0626 or L0627 A
Lumbar orthosis, sagittal control, 0274 Medical/Surgical Supplies and Devices with rigid posterior panel(s),
Prosthetic/Orthotic Devices
posterior extends from l-1 to below l5 vertebra, produces intracavitary
pressure to reduce load on the
intervertebral discs, includes straps,
closures, may include padding,
stays, shoulder straps, pendulous
abdomen design, prefabricated,
includes fitting and adjustment
PAGE 62
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
00-1735-021-00 00173502100 SPS III, LUMBAR SUPPORT, X-SMALL, ORTHOPAEDIC BRACES & SUPPORTS
28-32
BACK SUPPORTS
Supports
Products
L0627
A
Lumbar orthosis, sagittal control,
with rigid anterior and posterior
panels, posterior extends from l-1
to below l-5 vertebra, produces
intracavitary pressure to reduce
load on the intervertebral discs,
includes straps, closures, may
include padding, shoulder straps,
pendulous abdomen design,
adjustment
00-1735-022-00 00173502200 SPS III, LUMBAR SUPPORT, SMALL,
32-36
BACK SUPPORTS
Supports
Products
L0627
A
adjustment
00-1735-023-00 00173502300 SPS III, LUMBAR SUPPORT, MEDIUM, ORTHOPAEDIC BRACES & SUPPORTS
36-40
BACK SUPPORTS
Supports
Products
L0627
A
adjustment
00-1735-024-00 00173502400 SPS III, LUMBAR SUPPORT, LARGE,
40-44
BACK SUPPORTS
Supports
Products
L0627
A
adjustment
00-1735-025-00 00173502500 SPS III, LUMBAR SUPPORT, XLARGE, 44-48
BACK SUPPORTS
Supports
Products
L0627
A
adjustment
00-2735-022-00 00273502200 ELASTIC BACK SUPPORT, SMALL
BACK SUPPORTS
Supports
Products
L0625
A
adjustment
PAGE 63
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
00-2735-023-00 00273502300 ELASTIC BACK SUPPORT, MEDIUM
BACK SUPPORTS
Supports
Products
L0625
A
adjustment
00-2735-024-00 00273502400 ELASTIC BACK SUPPORT, LARGE
BACK SUPPORTS
Supports
Products
L0625
A
adjustment
00-2735-025-00 00273502500 ELASTIC BACK SUPPORT, X-LARGE ORTHOPAEDIC BRACES & SUPPORTS
BACK SUPPORTS
Supports
Products
L0625
A
adjustment
00-3449-001-00 00344900100 UNIVERSAL LUMBAR SUPPORT,
SMALL/MEDIUM
BACK SUPPORTS
Supports
Products
L0625
A
adjustment
00-3449-002-00 00344900200 UNIVERSAL LUMBAR SUPPORT,
LARGE/X-LARGE
BACK SUPPORTS
Supports
Products
L0625
A
adjustment
00-0584-011-00 00058401100
RIB BELTS
Supports
Products
A4466
E
00-0584-012-00 00058401200 COMFORT PANEL RIB BELT, FEMALE ORTHOPAEDIC BRACES & SUPPORTS
RIB BELTS
Supports
Products
A4466
E
00-2721-006-00 00272100600 UNIVERSAL RIB BELT, MALE, 6 IN
RIB BELTS
Supports
Products
A4466
E
00-2721-008-00 00272100800 UNIVERSAL RIB BELT, MALE, 8 IN
RIB BELTS
Supports
Products
A4466
E
OTHER COVERING, ELASTIC OR
SIMILAR STRETCHABLE
SIMILAR STRETCHABLE
SIMILAR STRETCHABLE
SIMILAR STRETCHABLE
COMFORT PANEL RIB BELT, MALE
PAGE 64
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
00-2722-006-00 00272200600 UNIVERSAL RIB BELT, FEMALE, 6 IN ORTHOPAEDIC BRACES & SUPPORTS
RIB BELTS
Supports
Products
A4466
E
00-2722-008-00 00272200800 UNIVERSAL RIB BELT, FEMALE, 8 IN ORTHOPAEDIC BRACES & SUPPORTS
RIB BELTS
Supports
Products
A4466
E
00-0584-031-00 00058403100 COMFORT PANEL 9 IN ABDOMINAL
BINDER
ABDOMINAL SUPPORTS
Supports
Products
N/A
N/A
SIMILAR STRETCHABLE
SIMILAR STRETCHABLE
N/A
00-0584-032-00 00058403200 COMFORT PANEL 9 IN ABDOMINAL
BINDER
ABDOMINAL SUPPORTS
Supports
Products
N/A
N/A
00-0584-041-00 00058404100 COMFORT PANEL 12 IN ABDOMINAL ORTHOPAEDIC BRACES & SUPPORTS
BINDER
ABDOMINAL SUPPORTS
Supports
Products
N/A
00-0584-042-00 00058404200 COMFORT PANEL 12 IN ABDOMINAL ORTHOPAEDIC BRACES & SUPPORTS
BINDER
ABDOMINAL SUPPORTS
Supports
Products
00-0584-043-00 00058404300 COMFORT PANEL ABDOMINAL S
ABDOMINAL SUPPORTS
00-0584-044-00 00058404400 COMFORT PANEL ABDOMINAL S
00-2732-010-00 00273201000 UNIVERSAL ABDOMINAL SUPPORT,
10 IN
Comment 1
Comment 2
Comment 3
separately payable.
N/A
separately payable.
N/A
N/A
separately payable.
N/A
N/A
N/A
separately payable.
Supports
Products
N/A
N/A
N/A
separately payable.
ABDOMINAL SUPPORTS
Supports
Products
N/A
N/A
N/A
separately payable.
ABDOMINAL SUPPORTS
Supports
Products
N/A
N/A
N/A
separately payable.
00-2732-012-00 00273201200 UNIVERSAL ABDOMINAL SUPPORT,
12 IN
ABDOMINAL SUPPORTS
Supports
Products
N/A
N/A
N/A
separately payable.
00-1876-503-12 00187650312 KNEE IMMOBILIZER FOAM
CONTOURED, SMALL, 12
SIZED KNEE IMMOBILIZERS
Knee
Knee Support Products
Immobilizers
L1830
A
KNEE ORTHOSIS, IMMOBILIZER, 0274 Medical/Surgical Supplies and Devices CANVAS LONGITUDINAL,
Knee
Immobilizers
L1830
A
PAGE 65
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
Knee
Immobilizers
L1830
A
Knee
Immobilizers
L1830
A
Knee
Immobilizers
L1830
A
CONTOURED, MEDIUM, 12
Knee
Immobilizers
L1830
A
Knee
Immobilizers
L1830
A
Knee
Immobilizers
L1830
A
PAGE 66
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
Knee
Immobilizers
L1830
A
Knee
Immobilizers
L1830
A
CONTOURED, LARGE, 12
Knee
Immobilizers
L1830
A
Knee
Immobilizers
L1830
A
Knee
Immobilizers
L1830
A
Knee
Immobilizers
L1830
A
PAGE 67
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
Knee
Immobilizers
L1830
A
CONTOURED, X-LARGE, 12
Knee
Immobilizers
L1830
A
Knee
Immobilizers
L1830
A
Knee
Immobilizers
L1830
A
Knee
Immobilizers
L1830
A
Knee
Immobilizers
L1830
A
PAGE 68
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
CONTOURED, XX-LARGE, 19
Knee
Immobilizers
L1830
A
CONTOURED, XX-LARGE, 22
Knee
Immobilizers
L1830
A
STRAIGHT, SMALL, 12
Knee
Immobilizers
L1830
A
STRAIGHT, SMALL, 19
Knee
Immobilizers
L1830
A
STRAIGHT, SMALL, 22
Knee
Immobilizers
L1830
A
STRAIGHT, SMALL, 24
Knee
Immobilizers
L1830
A
PAGE 69
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
STRAIGHT, MEDIUM, 12
Knee
Immobilizers
L1830
A
Knee
Immobilizers
L1830
A
Knee
Immobilizers
L1830
A
Knee
Immobilizers
L1830
A
Knee
Immobilizers
L1830
A
STRAIGHT, LARGE, 12
Knee
Immobilizers
L1830
A
PAGE 70
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
STRAIGHT, LARGE, 16
Knee
Immobilizers
L1830
A
STRAIGHT, LARGE, 19
Knee
Immobilizers
L1830
A
STRAIGHT, LARGE, 22
Knee
Immobilizers
L1830
A
STRAIGHT, LARGE, 24
Knee
Immobilizers
L1830
A
STRAIGHT, X-LARGE, 12
Knee
Immobilizers
L1830
A
Knee
Immobilizers
L1830
A
PAGE 71
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
Knee
Immobilizers
L1830
A
Knee
Immobilizers
L1830
A
STRAIGHT, XX-LARGE, 19
Knee
Immobilizers
L1830
A
00-1877-503-12 00187750312 KNEE IMMOBILIZER FOAM/TRICOT,
SMALL, 12
Knee
Immobilizers
L1830
A
SMALL, 16
Knee
Immobilizers
L1830
A
SMALL, 19
Knee
Immobilizers
L1830
A
PAGE 72
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
SMALL, 22
Knee
Immobilizers
L1830
A
SMALL, 24
Knee
Immobilizers
L1830
A
MEDIUM, 12
Knee
Immobilizers
L1830
A
MEDIUM, 16
Knee
Immobilizers
L1830
A
MEDIUM, 19
Knee
Immobilizers
L1830
A
MEDIUM, 22
Knee
Immobilizers
L1830
A
PAGE 73
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
MEDIUM, 24
Knee
Immobilizers
L1830
A
LARGE, 12
Knee
Immobilizers
L1830
A
LARGE, 16
Knee
Immobilizers
L1830
A
LARGE, 19
Knee
Immobilizers
L1830
A
LARGE, 22
Knee
Immobilizers
L1830
A
LARGE, 24
Knee
Immobilizers
L1830
A
PAGE 74
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
00-1877-506-12 00187750612 KNEE IMMOBILIZER FOAM/TRICOT, X- ORTHOPAEDIC BRACES & SUPPORTS
LARGE, 12
Knee
Immobilizers
L1830
A
LARGE, 16
Knee
Immobilizers
L1830
A
LARGE, 19
Knee
Immobilizers
L1830
A
LARGE, 22
Knee
Immobilizers
L1830
A
LARGE, 24
Knee
Immobilizers
L1830
A
XX-LARGE, 19
Knee
Immobilizers
L1830
A
PAGE 75
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
XX-LARGE, 22
Knee
Immobilizers
L1830
A
00-1880-500-12 00188050012 KNEE IMMOBILIZER WITH
MEDIAL/LATERAL STAYS, 12
UNIVERSAL KNEE IMMOBILIZERS
Knee
Immobilizers
L1830
A
Knee
Immobilizers
L1830
A
Knee
Immobilizers
L1830
A
Knee
Immobilizers
L1830
A
Knee
Immobilizers
L1830
A
PAGE 76
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
Knee
Immobilizers
L1830
A
Knee
Immobilizers
L1830
A
00-1882-500-12 00188250012 KNEE IMMOBILIZER TRIM FOAM,
CONTOURED STAYS, 12
Knee
Immobilizers
L1830
A
00-1882-500-16 00188250016 KNEE IMMOBILIZER TRIM
FOAM,CONTOURED STAYS 16
Knee
Immobilizers
L1830
A
CONTOURED STAYS, 19
Knee
Immobilizers
L1830
A
CONTOURED STAYS, 22
Knee
Immobilizers
L1830
A
PAGE 77
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
CONTOURED STAYS, 24
Knee
Immobilizers
L1830
A
CONTOURED STAYS, 26
Knee
Immobilizers
L1830
A
CONTOURED STAYS, 28
Knee
Immobilizers
L1830
A
STRAIGHT STAYS, 12
Knee
Immobilizers
L1830
A
STRAIGHT STAYS, 16
Knee
Immobilizers
L1830
A
STRAIGHT STAYS, 19
Knee
Immobilizers
L1830
A
PAGE 78
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
STRAIGHT STAYS, 22
Knee
Immobilizers
L1830
A
STRAIGHT STAYS, 24
Knee
Immobilizers
L1830
A
00-1883-500-12 00188350012 KNEE IMMOBILIZER TRI-PANEL,
CONTOURED STAYS, 12
Knee
Immobilizers
L1830
A
CONTOURED STAYS, 16
Knee
Immobilizers
L1830
A
CONTOURED STAYS, 19
Knee
Immobilizers
L1830
A
CONTOURED STAYS, 22
Knee
Immobilizers
L1830
A
PAGE 79
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
CONTOURED STAYS, 24
Knee
Immobilizers
L1830
A
CONTOURED STAYS, 26
Knee
Immobilizers
L1830
A
CONTOURED STAYS, 28
Knee
Immobilizers
L1830
A
00-1885-500-12 00188550012 KNEE IMMOBILIZER, UNIV
W/PATELLA STRAP, 12
Knee
Immobilizers
L1830
A
W/PATELLA STRAP, 16
Knee
Immobilizers
L1830
A
W/PATELLA STRAP, 19
Knee
Immobilizers
L1830
A
PAGE 80
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
W/PATELLA STRAP, 22
Knee
Immobilizers
L1830
A
W/PATELLA STRAP, 24
Knee
Immobilizers
L1830
A
W/PATELLA STRAP, 26
Knee
Immobilizers
L1830
A
W/PATELLA STRAP, 28
Knee
Immobilizers
L1830
A
00-1888-500-12 00188850012 UNIV ELASTIC STRAP KNEE
IMMOBILIZER, 12
Knee
Immobilizers
L1830
A
IMMOBILIZER, 16
Knee
Immobilizers
L1830
A
PAGE 81
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
IMMOBILIZER, 19
Knee
Immobilizers
L1830
A
IMMOBILIZER, 22
Knee
Immobilizers
L1830
A
IMMOBILIZER, 24
Knee
Immobilizers
L1830
A
IMMOBILIZER, 26
Knee
Immobilizers
L1830
A
IMMOBILIZER, 28
Knee
Immobilizers
L1830
A
00-1889-000-10 00188900010 POPLITEAL FOAM INSERT
Knee
Immobilizers
N/A
N/A
N/A
separately payable.
00-1444-001-00 00144400100 FORMFIT NIGHT SPLINT, SMALL
NIGHT SPLINTS
Supports
Products
L1930
A
ANKLE FOOT ORTHOSIS,
0274 Medical/Surgical Supplies and Devices PLASTIC OR OTHER MATERIAL, Prosthetic/Orthotic Devices
PAGE 82
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
00-1444-002-00 00144400200 FORMFIT NIGHT SPLINT, MEDIUM
NIGHT SPLINTS
Supports
Products
L1930
A
00-1444-003-00 00144400300 FORMFIT NIGHT SPLINT, LARGE
NIGHT SPLINTS
Supports
Products
L1930
A
00-1716-010-00 00171601000 PAVLIK HARNESS, SMALL
PAVLIK HARNESSES
Supports
Products
E0944
Y
00-1716-011-00 00171601100
PAVLIK HARNESSES
Supports
Products
E0944
Y
00-1716-012-00 00171601200 PAVLIK HARNESS, LARGE
PAVLIK HARNESSES
Supports
Products
E0944
Y
00-8601-416-00 00860141600 PAVLIK HARNESS, X-SMALL
PAVLIK HARNESSES
Supports
Products
E0944
Y
PAVLIK HARNESS, MEDIUM
PAGE 83
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
00-0766-001-00 00076600100 ANKLE BR W/ELASTIC STRAP,XSMALL LEFT
ANKLE BRACES
Supports
Products
L1902
A
Ankle foot orthosis, ankle gauntlet, 0274 Medical/Surgical Supplies and Devices prefabricated, includes fitting and Prosthetic/Orthotic Devices
adjustment
00-0766-002-00 00076600200 ANKLE BR W/ELASTIC STRAP,XSMALL, RIGHT
ANKLE BRACES
Supports
Products
L1902
A
adjustment
00-0766-003-00 00076600300 ANKLE BR W/ELASTIC STRAP,
SMALL, LEFT
ANKLE BRACES
Supports
Products
L1902
A
adjustment
00-0766-004-00 00076600400 ANKLE BR W/ELASTIC STRAP,SMALL, ORTHOPAEDIC BRACES & SUPPORTS
RIGHT
ANKLE BRACES
Supports
Products
L1902
A
adjustment
MEDIUM, LEFT
ANKLE BRACES
Supports
Products
L1902
A
adjustment
MEDIUM, RIGHT
ANKLE BRACES
Supports
Products
L1902
A
adjustment
PAGE 84
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
LARGE, LEFT
ANKLE BRACES
Supports
Products
L1902
A
adjustment
LARGE, RIGHT
ANKLE BRACES
Supports
Products
L1902
A
adjustment
00-0766-009-00 00076600900 ANKLE BR W/ELASTIC STRAP, XLARGE, LEFT
ANKLE BRACES
Supports
Products
L1902
A
adjustment
00-0766-010-00 00076601000 ANKLE BR W/ELASTIC STRAP, XLARGE, RIGHT
ANKLE BRACES
Supports
Products
L1902
A
adjustment
00-1421-001-00 00142100100 50/50 GEL ANKLE BRACE, LEFT
ANKLE BRACES
Supports
Products
L1930
A
00-1421-002-00 00142100200 50/50 GEL ANKLE BRACE, RIGHT
ANKLE BRACES
Supports
Products
L1930
A
PAGE 85
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
00-1422-001-00 00142200100 80/20 GEL ANKLE BRACE, LEFT
ANKLE BRACES
Supports
Products
L1930
A
00-1422-002-00 00142200200 80/20 GEL ANKLE BRACE, RIGHT
ANKLE BRACES
Supports
Products
L1930
A
00-1423-001-00 00142300100 50/50 PONY GEL ANKLE, LEFT
ANKLE BRACES
Supports
Products
L1930
A
00-1423-002-00 00142300200 50/50 PONY GEL ANKLE, RIGHT
ANKLE BRACES
Supports
Products
L1930
A
00-1424-001-00 00142400100 LACE LOCK ANKLE BRACE, LEFT
ANKLE BRACES
Supports
Products
L1930
A
00-1424-002-00 00142400200 LACE LOCK ANKLE BRACE, RIGHT
ANKLE BRACES
Supports
Products
L1930
A
PAGE 86
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
00-1425-001-00 00142500100 PONY LACE LOCK ANKLE, LEFT
ANKLE BRACES
Supports
Products
L1930
A
00-1425-002-00 00142500200 PONY LACE LOCK ANKLE, RIGHT
ANKLE BRACES
Supports
Products
L1930
A
00-1435-001-00 00143500100 ZIMMER HONEYCONE ANKLE
STIRRUP, LEFT
ANKLE BRACES
Supports
Products
L1902
A
adjustment
00-1435-002-00 00143500200 ZIMMER HONEYCOMB ANKLE
STIRRUP, RIGHT
ANKLE BRACES
Supports
Products
L1902
A
adjustment
00-1435-021-00 00143502100 ZIMMER AIR ANKLE STIRRUP, LEFT
ANKLE BRACES
Supports
Products
L1902
A
adjustment
00-1435-022-00 00143502200 ZIMMER AIR ANKLE STIRRUP, RIGHT ORTHOPAEDIC BRACES & SUPPORTS
ANKLE BRACES
Supports
Products
L1902
A
adjustment
PAGE 87
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
00-1436-001-00 00143600100 ZIMMER LACE ANKLE W/O STRAPS, ORTHOPAEDIC BRACES & SUPPORTS
SMALL
ANKLE BRACES
Supports
Products
L1902
A
adjustment
MEDIUM
ANKLE BRACES
Supports
Products
L1902
A
adjustment
LARGE
ANKLE BRACES
Supports
Products
L1902
A
adjustment
X-LARGE
ANKLE BRACES
Supports
Products
L1902
A
adjustment
00-1436-005-00 00143600500 ZIMMER LACE ANKLE W/ STRAPS,
SMALL
ANKLE BRACES
Supports
Products
L1902
A
adjustment
00-1436-006-00 00143600600 ZIMMER LACE ANKLE W/ STRAPS,
MEDIUM
ANKLE BRACES
Supports
Products
L1902
A
adjustment
PAGE 88
Product #
EDI Item #
Item Description
00-1436-007-00 00143600700 ZIMMER LACE ANKLE W/STRAPS,
LARGE
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
ANKLE BRACES
Supports
Products
L1902
A
adjustment
00-1436-008-00 00143600800 ZIMMER LACE ANKLE W/ STRAPS, X- ORTHOPAEDIC BRACES & SUPPORTS
LARGE
ANKLE BRACES
Supports
Products
L1902
A
adjustment
00-1767-003-00 00176700300 DELUXE ANKLE BRACE, SMALL
ANKLE BRACES
Supports
Products
L1902
A
adjustment
00-1767-004-00 00176700400 DELUXE ANKLE BRACE, MEDIUM
ANKLE BRACES
Supports
Products
L1902
A
adjustment
00-1767-005-00 00176700500 DELUXE ANKLE BRACE, LARGE
ANKLE BRACES
Supports
Products
L1902
A
adjustment
00-1767-006-00 00176700600 DELUXE ANKLE BRACE, X-LARGE
ANKLE BRACES
Supports
Products
L1902
A
adjustment
PAGE 89
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
00-3453-003-00 00345300300 ANKLE SUPPORT W/CONTACT
CLOSURE, SMALL
ANKLE BRACES
Supports
Products
L1902
A
adjustment
CLOSURE, MEDIUM
ANKLE BRACES
Supports
Products
L1902
A
adjustment
CLOSURE, LARGE
ANKLE BRACES
Supports
Products
L1902
A
adjustment
CLOSURE, X-LARGE
ANKLE BRACES
Supports
Products
L1902
A
adjustment
00-8916-031-00 00891603100 DH PRESSURE RELIEF WALKER,
SMALL
PRESSURE RELIEF WALKERS
Supports
Products
L2116
A
FRACTURE ORTHOSIS, TIBIAL
FRACTURE ORTHOSIS, RIGID,
MEDIUM
Supports
Products
L2116
A
PAGE 90
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
LARGE
Supports
Products
L2116
A
00-8916-004-00 00891600400 FIXED HINGE LEG WALKER, SMALL
LOWER LEG WALKERS
Supports
Products
L2116
A
00-8916-004-01 00891600401 REPLACEMENT LINER FOR 8916-04
LOWER LEG WALKERS
Supports
Products
L2116
A
00-8916-005-00 00891600500 FIXED HINGE LEG WALKER, MEDIUM ORTHOPAEDIC BRACES & SUPPORTS
LOWER LEG WALKERS
Supports
Products
L2116
A
LOWER LEG WALKERS
Supports
Products
L2116
A
00-8916-006-00 00891600600 FIXED HINGE LEG WALKER, LARGE ORTHOPAEDIC BRACES & SUPPORTS
LOWER LEG WALKERS
Supports
Products
L2116
A
00-8916-006-01 00891600601 REPLACMENT LINER FOR 8916-06
LOWER LEG WALKERS
Supports
Products
N/A
N/A
N/A
separately payable.
PAGE 91
Product #
EDI Item #
00-8916-011-00 00891601100
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
REPLACEMENT LINER FOR 8916-14
LOWER LEG WALKERS
Supports
Products
N/A
N/A
N/A
separately payable.
LOWER LEG WALKERS
Supports
Products
N/A
N/A
N/A
separately payable.
LOWER LEG WALKERS
Supports
Products
N/A
N/A
N/A
separately payable.
00-8916-014-00 00891601400 LOWER LEG ORTHOSIS II, SMALL
LOWER LEG WALKERS
Supports
Products
L2116
A
00-8916-015-00 00891601500 LOWER LEG ORTHOSIS II, MEDIUM
LOWER LEG WALKERS
Supports
Products
L2116
A
00-8916-016-00 00891601600 LOWER LEG ORTHOSIS II, LARGE
LOWER LEG WALKERS
Supports
Products
L2116
A
00-8916-024-00 00891602400 ZIMMER AIR WALKER, SMALL
LOWER LEG WALKERS
Supports
Products
L2116
A
00-8916-025-00 00891602500 ZIMMER AIR WALKER, MEDIUM
LOWER LEG WALKERS
Supports
Products
L2116
A
PAGE 92
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
00-8916-026-00 00891602600 ZIMMER AIR WALKER, LARGE
LOWER LEG WALKERS
Supports
Products
L2116
A
00-8916-041-00 00891604100 ZIMMER ANKLE TOP WALKER,
SMALL
LOWER LEG WALKERS
Supports
Products
L2116
A
MEDIUM
LOWER LEG WALKERS
Supports
Products
L2116
A
LARGE
LOWER LEG WALKERS
Supports
Products
L2116
A
00-1995-009-00 00199500900 CUSHION ROCKER CAST SHOE,PED ORTHOPAEDIC BRACES & SUPPORTS
CAST SHOES & BOOTS
Supports
Products
L3260
A
Surgical boot/shoe, each
00-1995-010-00 00199501000 CUSHION ROCKER CAST SHOE, XX- ORTHOPAEDIC BRACES & SUPPORTS
SMALL
CAST SHOES & BOOTS
Supports
Products
L3260
A
00-1995-011-00 00199501100
CAST SHOES & BOOTS
Supports
Products
L3260
A
00-1995-012-00 00199501200 CUSHION ROCKER CAST SHOE,
SMALL
CAST SHOES & BOOTS
Supports
Products
L3260
A
MEDIUM
CAST SHOES & BOOTS
Supports
Products
L3260
A
LARGE
CAST SHOES & BOOTS
Supports
Products
L3260
A
00-1995-015-00 00199501500 CUSHION ROCKER CAST SHOE, XLARGE
CAST SHOES & BOOTS
Supports
Products
L3260
A
CUSHION ROCKER CAST SHOE, XSMALL
PAGE 93
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
00-1995-021-00 00199502100 CUSHION ROCKER CAST BOOT, XSMALL
CAST SHOES & BOOTS
Supports
Products
L3260
A
00-1995-022-00 00199502200 CUSHION ROCKER CAST BOOT,
SMALL
CAST SHOES & BOOTS
Supports
Products
L3260
A
MEDIUM
CAST SHOES & BOOTS
Supports
Products
L3260
A
LARGE
CAST SHOES & BOOTS
Supports
Products
L3260
A
00-1995-025-00 00199502500 CUSHION ROCKER CAST BOOT, XLARGE
CAST SHOES & BOOTS
Supports
Products
L3260
A
00-1997-001-00 00199700100 DARCO CAST SHOE NAVY, X-SMALL ORTHOPAEDIC BRACES & SUPPORTS
CAST SHOES & BOOTS
Supports
Products
L3260
A
00-1997-002-00 00199700200 DARCO CAST SHOE NAVY, SMALL
CAST SHOES & BOOTS
Supports
Products
L3260
A
00-1997-003-00 00199700300 DARCO CAST SHOE NAVY, MEDIUM ORTHOPAEDIC BRACES & SUPPORTS
CAST SHOES & BOOTS
Supports
Products
L3260
A
00-1997-004-00 00199700400 DARCO CAST SHOE NAVY, LARGE
CAST SHOES & BOOTS
Supports
Products
L3260
A
00-1997-005-00 00199700500 DARCO CAST SHOE NAVY, X-LARGE ORTHOPAEDIC BRACES & SUPPORTS
CAST SHOES & BOOTS
Supports
Products
L3260
A
00-8716-011-00 00871601100
CAST SHOES & BOOTS
Supports
Products
L3260
A
00-8716-012-00 00871601200 ROCKER SOLE CAST SHOE, SMALL ORTHOPAEDIC BRACES & SUPPORTS
CAST SHOES & BOOTS
Supports
Products
L3260
A
00-8716-013-00 00871601300 ROCKER SOLE CAST SHOE, MEDIUM ORTHOPAEDIC BRACES & SUPPORTS
CAST SHOES & BOOTS
Supports
Products
L3260
A
00-8716-014-00 00871601400 ROCKER SOLE CAST SHOE, LARGE ORTHOPAEDIC BRACES & SUPPORTS
CAST SHOES & BOOTS
Supports
Products
L3260
A
00-8716-015-00 00871601500 ROCKER SOLE CAST SHOE, XLARGE
CAST SHOES & BOOTS
Supports
Products
L3260
A
00-1443-001-00 00144300100 DARCO ORTHOWEDGE HEALING
SHOE, X-SMALL
HEALING SHOES
Supports
Products
L3260
A
SURGICAL BOOT/SHOE, EACH
SHOE, SMALL
HEALING SHOES
Supports
Products
L3260
A
SHOE, MEDIUM
HEALING SHOES
Supports
Products
L3260
A
SHOE, LARGE
HEALING SHOES
Supports
Products
L3260
A
ROCKER SOLE CAST SHOE, XSMALL
PAGE 94
Product #
EDI Item #
Item Description
00-1443-005-00 00144300500 DARCO ORTHOWEDGE SHOE, XLARGE
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
HEALING SHOES
Supports
Products
L3260
A
00-1433-001-00 00143300100 DH PRESSURE RELIEF SHOE SMALL ORTHOPAEDIC BRACES & SUPPORTS
POST-OP SHOES
Supports
Products
L3260
A
00-1433-002-00 00143300200 DH PRESSURE RELIEF SHOE
MEDIUM
POST-OP SHOES
Supports
Products
L3260
A
00-1433-003-00 00143300300 DH PRESSURE RELIEF SHOE LARGE ORTHOPAEDIC BRACES & SUPPORTS
POST-OP SHOES
Supports
Products
L3260
A
00-1433-004-00 00143300400 DH PRESSURE RELIEF SHOE, XLARGE
POST-OP SHOES
Supports
Products
L3260
A
00-1611-021-00 00161102100
PADDED POST-OP SHOE, MEN,
SMALL, W/VELCRO
POST-OP SHOES
Supports
Products
L3260
A
00-1611-022-00 00161102200
MEDIUM, W/VELCRO
POST-OP SHOES
Supports
Products
L3260
A
00-1611-023-00 00161102300
LARGE, W/VELCRO
POST-OP SHOES
Supports
Products
L3260
A
00-1611-024-00 00161102400
PADDED POST-OP SHOE, WOMEN,
SMALL W/VELCRO
POST-OP SHOES
Supports
Products
L3260
A
00-1611-025-00 00161102500
MEDIUM W/VELCRO
POST-OP SHOES
Supports
Products
L3260
A
00-1611-026-00 00161102600
LARGE, W/VELCRO
POST-OP SHOES
Supports
Products
L3260
A
00-1711-004-00 00171100400
DARCO POST-OP SHOE, WOMEN,
SMALL
POST-OP SHOES
Supports
Products
L3260
A
00-1711-005-00 00171100500
MEDIUM
POST-OP SHOES
Supports
Products
L3260
A
00-1711-006-00 00171100600
LARGE
POST-OP SHOES
Supports
Products
L3260
A
00-1711-011-00 00171101100
DARCO POST-OP SHOE, MEN,
SMALL
POST-OP SHOES
Supports
Products
L3260
A
00-1711-012-00 00171101200
MEDIUM
POST-OP SHOES
Supports
Products
L3260
A
00-1711-013-00 00171101300
LARGE
POST-OP SHOES
Supports
Products
L3260
A
00-1711-014-00 00171101400
DARCO POST-OP SHOE, MEN, XLARGE
POST-OP SHOES
Supports
Products
L3260
A
00-1811-001-00 00181100100
DARCO MED/SURG BLACK VELCRO, ORTHOPAEDIC BRACES & SUPPORTS
XS
POST-OP SHOES
Supports
Products
L3260
A
PAGE 95
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
00-1811-002-00 00181100200
SM
POST-OP SHOES
Supports
Products
L3260
A
00-1811-003-00 00181100300
MD
POST-OP SHOES
Supports
Products
L3260
A
00-1811-004-00 00181100400
LG
POST-OP SHOES
Supports
Products
L3260
A
00-1811-005-00 00181100500
XL
POST-OP SHOES
Supports
Products
L3260
A
00-1991-001-00 00199100100 POST-OPERATIVE SHOE, MEN'S,
SMALL
POST-OP SHOES
Supports
Products
L3260
A
MEDIUM
POST-OP SHOES
Supports
Products
L3260
A
LARGE
POST-OP SHOES
Supports
Products
L3260
A
00-1991-004-00 00199100400 POST-OPERATIVE SHOE, WOMEN'S, ORTHOPAEDIC BRACES & SUPPORTS
SMALL
POST-OP SHOES
Supports
Products
L3260
A
MEDIUM
POST-OP SHOES
Supports
Products
L3260
A
LARGE
POST-OP SHOES
Supports
Products
L3260
A
00-8601-697-01 00860169701 PADDED POST-OP SHOE,
PEDIATRIC, LACE-UP
POST-OP SHOES
Supports
Products
L3260
A
00-8601-697-02 00860169702 PADDED POST-OP SHOE, YOUTH,
W/VELCRO
POST-OP SHOES
Supports
Products
L3260
A
00-0754-006-00 00075400600 FROIMSON TENNIS ELBOW
SUPPORT, UNIVERSAL
FOREARM & ELBOW SUPPORTS
Supports
Products
L3999
A
Upper limb orthosis, not otherwise 0274 Medical/Surgical Supplies and Devices specified
00-1295-002-00 00129500200 ZIMMER FOREARM SUPPORT,
SMALL
Supports
Products
L3999
A
MEDIUM
Supports
Products
L3999
A
LARGE
Supports
Products
L3999
A
00-1295-005-00 00129500500 ZIMMER FOREARM SUPPORT, XLARGE
Supports
Products
L3999
A
SMALL
Supports
Products
L3999
A
MEDIUM
Supports
Products
L3999
A
PAGE 96
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
LARGE
Supports
Products
L3999
A
00-1295-011-00 00129501100
Supports
Products
L3999
A
00-1445-001-00 00144500100 TENNIS ELBOW SPT W/GEL
Supports
Products
L3999
A
00-3448-003-00 00344800300 NEOPRENE ELBOW SUPPORT,
SMALL
Supports
Products
L3999
A
MEDIUM
Supports
Products
L3999
A
LARGE
Supports
Products
L3999
A
00-3448-006-00 00344800600 NEOPRENE ELBOW SUPPORT, XLARGE
Supports
Products
L3999
A
00-0774-001-00 00077400100 ELASTIC KNEE SUPPORT, SMALL
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
00-0774-002-00 00077400200 ELASTIC KNEE SUPPORT, MEDIUM
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
00-0774-003-00 00077400300 ELASTIC KNEE SUPPORT, LARGE
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
00-0774-004-00 00077400400 ELASTIC KNEE SUPPORT, X-LARGE ORTHOPAEDIC BRACES & SUPPORTS
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
00-3455-003-00 00345500300 KNEE SLEEVE W/CLOSED PATELLA, ORTHOPAEDIC BRACES & SUPPORTS
BEIGE, SMALL
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
BEIGE, MEDIUM
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
BEIGE, LARGE
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
BEIGE, X-LARGE
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
BEIGE, XX-LARGE
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
BLUE, SMALL
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
ZIMMER FOREARM SUPPORT, XLARGE
PAGE 97
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
BLUE, MEDIUM
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
BLUE, LARGE
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
BLUE, X-LARGE
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
BLUE, XX-LARGE
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
00-3456-003-00 00345600300 KNEE SLEEVE W/OPEN PATELLA,
BEIGE, SMALL
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
BEIGE, MEDIUM
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
BEIGE, LARGE
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
BEIGE, X-LARGE
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
BEIGE, XX-LARGE
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
BLUE, SMALL
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
BLUE, MEDIUM
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
BLUE, LARGE
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
BLUE, X-LARGE
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
BLUE, XX-LARGE
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
00-3457-000-00 00345700000 NEOPRENE UNIVERSAL KNEE
SUPPORT, BEIGE
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
00-3458-103-00 00345810300 NEOPRENE KNEE SPRT INFERIOR
BUTTRESS, BEIGE, SML
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
PAGE 98
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
BUTTRESS, BEIGE, MED
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
BUTTRESS, BEIGE, LGE
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
BUTTRESS, BEIGE, X-LGE
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
BUTTRESS BEIGE, XX-LGE
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
BUTTRESS, BEIGE, XXXLG
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
BUTTRESS, BEIGE, XXXXL
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
BUTTRESS, BLUE, SML
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
BUTTRESS, BLUE, MED
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
BUTTRESS, BLUE, LGE
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
BUTTRESS, BLUE, X-LGE
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
BUTTRESS, BLUE, XX-LGE
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
00-3458-203-00 00345820300 NEOPRENE KNEE SPRT SUPERIOR
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
BUTTRESS BEIGE, XX-LGE
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
PAGE 99
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
BTRSS BGE XXX-L
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
BTRSS BG XXXXLGE
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
BUTTRESS, BLUE, SML
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
BUTTRESS, BLUE, MED
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
BUTTRESS, BLUE, LGE
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
00-3458-303-00 00345830300 NEOPRENE KNEE SPRT RIGHT
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
BUTTRESS, BEIGE, XX-LGE
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
BUTTRESS, BLUE, SML
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
BUTTRESS, BLUE, MED
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
BUTTRESS, BLUE, LGE
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
PAGE 100
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
00-3458-403-00 00345840300 NEOPRENE KNEE SPRT LEFT
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
BUTTRESS, BEIGE, XX-LGE
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
BUTTRESS, BLUE, SML
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
BUTTRESS, BLUE, MED
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
BUTTRESS, BLUE, LGE
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
00-3459-003-00 00345900300 NEOPRENE PATELLAR STABILIZER, ORTHOPAEDIC BRACES & SUPPORTS
BEIGE, SMALL
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
BEIGE, MEDIUM
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
BEIGE, LARGE
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
BEIGE, X-LARGE
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
BEIGE, XX-LARGE
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
PAGE 101
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
BLUE, SMALL
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
BLUE, MEDIUM
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
BLUE, LARGE
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
BLUE, X-LARGE
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
BLUE, XX-LARGE
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
00-3460-003-00 00346000300 NEOPRENE HINGED KNEE
SUPPORT, BEIGE, SMALL
KNEE SUPPORTS
Knee
Immobilizers
L1810
A
Knee orthosis, elastic with joints,
adjustment
SUPPORT, BEIGE, MEDIUM
KNEE SUPPORTS
Knee
Immobilizers
L1810
A
adjustment
SUPPORT, BEIGE, LARGE
KNEE SUPPORTS
Knee
Immobilizers
L1810
A
adjustment
SUPPORT, BEIGE, X-LARGE
KNEE SUPPORTS
Knee
Immobilizers
L1810
A
adjustment
PAGE 102
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
SUPPORT, BEIGE, XX-LARGE
KNEE SUPPORTS
Knee
Immobilizers
L1810
A
adjustment
SUPPORT, BLUE, SMALL
KNEE SUPPORTS
Knee
Immobilizers
L1810
A
adjustment
SUPPORT, BLUE, MEDIUM
KNEE SUPPORTS
Knee
Immobilizers
L1810
A
adjustment
SUPPORT, BLUE, LARGE
KNEE SUPPORTS
Knee
Immobilizers
L1810
A
adjustment
SUPPORT, BLUE, X-LARGE
KNEE SUPPORTS
Knee
Immobilizers
L1810
A
adjustment
SUPPORT, BLUE, XX-LARGE
KNEE SUPPORTS
Knee
Immobilizers
L1810
A
adjustment
00-3461-003-00 00346100300 NEOPRENE POST-ARTHROSCOPY
KNEE SUPPORT, BEIGE, SML
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
KNEE SUPPORT, BEIGE, MED
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
PAGE 103
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
KNEE SUPPORT, BEIGE, LGE
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
KNEE SUPPORT, BEIGE, XLG
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
KNEE SUPPORT, BEIGE, XXL
KNEE SUPPORTS
Knee
Immobilizers
A4466
E
00-1558-001-00 00155800100 FLEXION/EXTENSION KNEE BRACE, ORTHOPAEDIC BRACES & SUPPORTS
REGULAR
HINGED KNEE SUPPORTS
Knee
Immobilizers
E1812
Y
DYNAMIC KNEE,
EXTENSION/FLEXION DEVICE
WITH ACTIVE RESISTANCE
CONTROL
Non-Implantable Durable Medical Equipment Not paid under
OPPS. All institutional providers other than home health
00-1558-002-00 00155800200 FLEXION/EXTENSION KNEE BRACE, ORTHOPAEDIC BRACES & SUPPORTS
SHORT
Knee
Immobilizers
E1812
Y
Non-Implantable Durable Medical Equipment Not paid under
OPPS. All institutional providers other than home health
00-1746-001-00 00174600100 DROP-LOK KNEE BRACE, X-SMALL
Knee
Immobilizers
L1832
A
00-1746-002-00 00174600200 DROP-LOK KNEE BRACE, SMALL
Knee
Immobilizers
L1832
A
0274 Medical/Surgical Supplies and Devices Prosthetic/Orthotic Devices, 0290 Durable Medical
DYNAMIC KNEE,
0274 Medical/Surgical Supplies and Devices EXTENSION/FLEXION DEVICE
Prosthetic/Orthotic Devices, 0290 Durable Medical
WITH ACTIVE RESISTANCE
CONTROL
Knee orthosis, locking knee joint(s), 0274 Medical/Surgical Supplies and Devices positional orthosis, prefabricated, Prosthetic/Orthotic Devices
PAGE 104
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
00-1746-003-00 00174600300 DROP-LOK KNEE BRACE, MEDIUM
Knee
Immobilizers
L1832
A
00-1746-004-00 00174600400 DROP-LOK KNEE BRACE, LARGE
Knee
Immobilizers
L1832
A
00-1746-005-00 00174600500 DROP-LOK KNEE BRACE, X-LARGE
Knee
Immobilizers
L1832
A
00-1747-001-00 00174700100 CARTILAGE KNEE BRACE, X-SMALL ORTHOPAEDIC BRACES & SUPPORTS
Knee
Immobilizers
A4466
E
00-1747-002-00 00174700200 CARTILAGE KNEE BRACE, SMALL
Knee
Immobilizers
A4466
E
00-1747-003-00 00174700300 CARTILAGE KNEE BRACE, MEDIUM
Knee
Immobilizers
A4466
E
00-1747-004-00 00174700400 CARTILAGE KNEE BRACE, LARGE
Knee
Immobilizers
A4466
E
00-1747-005-00 00174700500 CARTILAGE KNEE BRACE, X-LARGE ORTHOPAEDIC BRACES & SUPPORTS
Knee
Immobilizers
A4466
E
PAGE 105
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
00-1773-002-00 00177300200 HINGED KNEE SUPPORT, SMALL
Knee
Immobilizers
L1810
A
adjustment
00-1773-003-00 00177300300 HINGED KNEE SUPPORT, MEDIUM
Knee
Immobilizers
L1810
A
adjustment
00-1773-004-00 00177300400 HINGED KNEE SUPPORT, LARGE
Knee
Immobilizers
L1810
A
adjustment
00-1773-005-00 00177300500 HINGED KNEE SUPPORT, X-LARGE
Knee
Immobilizers
L1810
A
adjustment
SUPPORT, SMALL
Knee
Immobilizers
L1810
A
adjustment
PAGE 106
Product #
EDI Item #
00-3475-011-00 00347501100
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
NEOPRENE HINGED KNEE
SUPPPORT, MEDIUM
Knee
Immobilizers
L1810
A
adjustment
SUPPORT, LARGE
Knee
Immobilizers
L1810
A
adjustment
SUPPORT, X-LARGE
Knee
Immobilizers
L1810
A
adjustment
00-3475-014-00 00347501400 NEOPRENE HINGED KNEE SPT, XXL ORTHOPAEDIC BRACES & SUPPORTS
Knee
Immobilizers
L1810
A
adjustment
00-4444-002-00 00444400200 STANDARD ORTHOPAEDIC WRAP,
2IN X 5YD
ELASTIC BANDAGES
Supports
Products
S8431
N/A
Compression bandage, roll
separately payable.
3IN X 5YD
ELASTIC BANDAGES
Supports
Products
S8431
N/A
separately payable.
4IN X 5YD
ELASTIC BANDAGES
Supports
Products
S8431
N/A
separately payable.
PAGE 107
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
6IN X 5YD
ELASTIC BANDAGES
Supports
Products
S8431
N/A
separately payable.
2IN X 5YD
ELASTIC BANDAGES
Supports
Products
S8431
N/A
separately payable.
3IN X 5YD
ELASTIC BANDAGES
Supports
Products
S8431
N/A
separately payable.
4IN X 5YD
ELASTIC BANDAGES
Supports
Products
S8431
N/A
separately payable.
6IN X 5YD
ELASTIC BANDAGES
Supports
Products
S8431
N/A
separately payable.
4IN X 10YD
ELASTIC BANDAGES
Supports
Products
S8431
N/A
separately payable.
6IN X 10YD
ELASTIC BANDAGES
Supports
Products
S8431
N/A
separately payable.
00-5555-002-00 00555500200 PREMIUM ORTHOPAEDIC WRAP, 2IN ORTHOPAEDIC BRACES & SUPPORTS
X 5.5YD
ELASTIC BANDAGES
Supports
Products
S8431
N/A
separately payable.
X 5.5YD
ELASTIC BANDAGES
Supports
Products
S8431
N/A
separately payable.
X 5.5YD
ELASTIC BANDAGES
Supports
Products
S8431
N/A
separately payable.
X 5.5 YDS
ELASTIC BANDAGES
Supports
Products
S8431
N/A
separately payable.
X 10YD
ELASTIC BANDAGES
Supports
Products
S8431
N/A
separately payable.
X 11YD
ELASTIC BANDAGES
Supports
Products
S8431
N/A
separately payable.
PAGE 108
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
00-5555-032-00 00555503200 STERILE PREMIUM ORTHOPAEDIC
WRAP, 2IN X 5.5YD
ELASTIC BANDAGES
Supports
Products
S8431
N/A
separately payable.
WRAP, 3IN X 5.5YD
ELASTIC BANDAGES
Supports
Products
S8431
N/A
separately payable.
WRAP, 4IN X 5.5YD
ELASTIC BANDAGES
Supports
Products
S8431
N/A
separately payable.
WRAP, 6IN X 5.5YD
ELASTIC BANDAGES
Supports
Products
S8431
N/A
separately payable.
WRAP, 4IN X 11YD
ELASTIC BANDAGES
Supports
Products
S8431
N/A
separately payable.
WRAP, 6IN X 11YD
ELASTIC BANDAGES
Supports
Products
S8431
N/A
separately payable.
00-4444-102-00 00444410200 STANDARD ORTHOPAEDIC WRAP
NON-LATEK 2IN X 5YD
ELASTIC BANDAGES - NON-LATEX
Supports
Products
S8431
N/A
separately payable.
NON-LATEKX 3IN X 5YD
Supports
Products
S8431
N/A
separately payable.
NON-LATEX 4IN X 5YD
Supports
Products
S8431
N/A
separately payable.
NON-LATEX 6IN X 5YD
Supports
Products
S8431
N/A
separately payable.
00-4444-112-00 00444411200
STANDARD ORTHOPAEDIC WRAP
NON-LATEX 2IN X 5YD
Supports
Products
S8431
N/A
separately payable.
00-4444-113-00 00444411300
NON-LATEX 3IN X 5YD
Supports
Products
S8431
N/A
separately payable.
00-4444-114-00 00444411400
NON-LATEX 4IN X 5YD
Supports
Products
S8431
N/A
separately payable.
PAGE 109
Product #
EDI Item #
00-4444-116-00 00444411600
Item Description
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
NON-LATEX 6IN X 5YD
Supports
Products
S8431
N/A
separately payable.
NON-LATEX 4IN X 10YD
Supports
Products
S8431
N/A
separately payable.
Supports
Products
S8431
N/A
separately payable.
00-5555-102-00 00555510200 PREMIUM ORTHOPAEDIC WRAP
NON-LATEX 2IN X 5.5YD
Supports
Products
S8431
N/A
separately payable.
NON-LATEX 3IN X 5.5 YD
Supports
Products
S8431
N/A
separately payable.
Supports
Products
S8431
N/A
separately payable.
Supports
Products
S8431
N/A
separately payable.
Supports
Products
S8431
N/A
separately payable.
Supports
Products
S8431
N/A
separately payable.
00-5555-232-00 00555523200 STERILE PREMIUM ORTHO WRAP
Supports
Products
S8431
N/A
separately payable.
Supports
Products
S8431
N/A
separately payable.
Supports
Products
S8431
N/A
separately payable.
Supports
Products
S8431
N/A
separately payable.
PAGE 110
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
Supports
Products
S8431
N/A
separately payable.
Supports
Products
S8431
N/A
separately payable.
00-1610-014-00 00161001400 INSTANT COLD PACK, SMALL
COLD PACKS
Supports
Products
N/A
N/A
N/A
separately payable.
00-1610-015-00 00161001500 INSTANT COLD PACK, LARGE
COLD PACKS
Supports
Products
N/A
N/A
N/A
separately payable.
00-2761-022-12 00276102212 COLD THERAPY WRAP, X-SMALL
COLD THERAPY WRAPS
Supports
Products
N/A
N/A
N/A
separately payable.
00-2761-023-12 00276102312 COLD THERAPY WRAP, SMALL
COLD THERAPY WRAPS
Supports
Products
N/A
N/A
N/A
separately payable.
00-2761-024-12 00276102412 COLD THERAPY WRAP, MEDIUM
COLD THERAPY WRAPS
Supports
Products
N/A
N/A
N/A
separately payable.
00-2761-025-12 00276102512 COLD THERAPY WRAP, LARGE
COLD THERAPY WRAPS
Supports
Products
N/A
N/A
N/A
separately payable.
00-2761-026-12 00276102612 COLD THERAPY WRAP, X-LARGE
COLD THERAPY WRAPS
Supports
Products
N/A
N/A
N/A
separately payable.
00-2761-027-12 00276102712 COLD THERAPY WRAP, SHOULDER
COLD THERAPY WRAPS
Supports
Products
N/A
N/A
N/A
separately payable.
00-2763-025-12 00276302512 COLD THERAPY WRAP, X-LONG
COLD THERAPY WRAPS
Supports
Products
N/A
N/A
N/A
separately payable.
00-1702-005-00 00170200500 PLASTIC FOREARM SPLINT, CHILD,
LEFT
SPLINTS
FOREARM SPLINTS
Splints
Splint Products
S8451
N/A
separately payable.
00-1702-006-00 00170200600 PLASTIC FOREARM SPLINT, CHILD,
RIGHT
SPLINTS
FOREARM SPLINTS
Splints
Splint Products
S8451
N/A
separately payable.
PAGE 111
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
00-1702-007-00 00170200700 PLASTIC FOREARM SPLINT, YOUTH, SPLINTS
LEFT
FOREARM SPLINTS
Splints
Splint Products
S8451
N/A
separately payable.
00-1702-008-00 00170200800 PLASTIC FOREARM SPLINT, YOUTH, SPLINTS
RIGHT
FOREARM SPLINTS
Splints
Splint Products
S8451
N/A
separately payable.
00-1702-009-00 00170200900 PLASTIC FOREARM SPLINT, ADULT,
LEFT
SPLINTS
FOREARM SPLINTS
Splints
Splint Products
S8451
N/A
separately payable.
00-1702-010-00 00170201000 PLASTIC FOREARM SPLINT, ADULT,
RIGHT
SPLINTS
FOREARM SPLINTS
Splints
Splint Products
S8451
N/A
separately payable.
00-1704-005-00 00170400500 PLASTIC COLLES SPLINT, SMALL
CHILD, LEFT
SPLINTS
FOREARM SPLINTS
Splints
Splint Products
S8451
N/A
separately payable.
00-1704-006-00 00170400600 PLASTIC COLLES SPLINT, SMALL
CHILD, RIGHT
SPLINTS
FOREARM SPLINTS
Splints
Splint Products
S8451
N/A
separately payable.
00-1704-007-00 00170400700 PLASTIC COLLES SPLINT, CHILD,
LEFT
SPLINTS
FOREARM SPLINTS
Splints
Splint Products
S8451
N/A
separately payable.
00-1704-008-00 00170400800 PLASTIC COLLES SPLINT, CHILD,
RIGHT
SPLINTS
FOREARM SPLINTS
Splints
Splint Products
S8451
N/A
separately payable.
00-1704-009-00 00170400900 PLASTIC COLLES SPLINT,
YOUTH/SMALL ADULT, LEFT
SPLINTS
FOREARM SPLINTS
Splints
Splint Products
S8451
N/A
Service not separately priced by part B
00-1704-010-00 00170401000 PLASTIC COLLES SPLINT,
YOUTH/SMALL ADULT, RIGHT
SPLINTS
FOREARM SPLINTS
Splints
Splint Products
S8451
N/A
separately payable.
00-1704-011-00 00170401100
PLASTIC COLLES SPLINT, ADULT,
LEFT
SPLINTS
FOREARM SPLINTS
Splints
Splint Products
S8451
N/A
separately payable.
00-1704-012-00 00170401200 PLASTIC COLLES SPLINT, ADULT,
RIGHT
SPLINTS
FOREARM SPLINTS
Splints
Splint Products
S8451
N/A
separately payable.
66-0012-001-00 66001200100 FOREARM SPLINT, LEFT, CHILD,
PADDED, 7-1/2
SPLINTS
FOREARM SPLINTS
Splints
Splint Products
S8451
N/A
separately payable.
PAGE 112
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
66-0012-002-00 66001200200 FOREARM SPLINT, RIGHT, CHILD,
PADDED, 7-1/2
SPLINTS
FOREARM SPLINTS
Splints
Splint Products
S8451
N/A
separately payable.
66-0012-003-00 66001200300 FOREARM SPLINT, LEFT, YOUTH,
PADDED, 10
SPLINTS
FOREARM SPLINTS
Splints
Splint Products
S8451
N/A
separately payable.
66-0012-004-00 66001200400 FOREARM SPLINT, RIGHT, YOUTH,
PADDED, 10
SPLINTS
FOREARM SPLINTS
Splints
Splint Products
S8451
N/A
separately payable.
66-0012-005-00 66001200500 FOREARM SPLINT, LEFT, ADULT,
PADDED, 11-1/2
SPLINTS
FOREARM SPLINTS
Splints
Splint Products
S8451
N/A
separately payable.
66-0012-006-00 66001200600 FOREARM SPLINT, RIGHT, ADULT,
PADDED, 11-1/2
SPLINTS
FOREARM SPLINTS
Splints
Splint Products
S8451
N/A
separately payable.
66-0020-001-00 66002000100 COLLES SPLINT PADDED
LEFTSMALL CHILD
SPLINTS
FOREARM SPLINTS
Splints
Splint Products
S8451
N/A
separately payable.
66-0020-002-00 66002000200 COLLES SPLINT, PADDED, RIGHT,
SMALL CHILD
SPLINTS
FOREARM SPLINTS
Splints
Splint Products
S8451
N/A
separately payable.
66-0020-003-00 66002000300 COLLES SPLINT, PADDED, LEFT,
CHILD, 8 1/4 X 2 3/4
SPLINTS
FOREARM SPLINTS
Splints
Splint Products
S8451
N/A
separately payable.
CHILD, 8 1/4 X 2 3/4
SPLINTS
FOREARM SPLINTS
Splints
Splint Products
S8451
N/A
separately payable.
YOUTH, 10 X 3 1/4
SPLINTS
FOREARM SPLINTS
Splints
Splint Products
S8451
N/A
separately payable.
YOUTH, 10 X 3 1/4
SPLINTS
FOREARM SPLINTS
Splints
Splint Products
S8451
N/A
separately payable.
ADULT, 11 X 4
SPLINTS
FOREARM SPLINTS
Splints
Splint Products
S8451
N/A
separately payable.
ADULT, 11 X 4
SPLINTS
FOREARM SPLINTS
Splints
Splint Products
S8451
N/A
separately payable.
PAGE 113
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
00-0016-001-00 00001600100 METACARPAL SPLINT, LEFT, YOUTH, SPLINTS
ANTERIOR 9 X 8CM
WRIST & FINGER SPLINTS
Splints
Splint Products
A4570
E
Splint
00-0016-002-00 00001600200 METACARPAL SPLINT, RIGHT,
YOUTH, ANTERIOR 9 X 8CM
SPLINTS
Splints
Splint Products
A4570
E
Splint
00-0016-003-00 00001600300 METACARPAL SPLINT, LEFT, ADULT,
ANTERIOR 10 X 9CM
SPLINTS
Splints
Splint Products
A4570
E
Splint
00-0016-004-00 00001600400 METACARPAL SPLINT, RIGHT,ADULT, SPLINTS
ANTERIOR 10 X 9CM
Splints
Splint Products
A4570
E
Splint
00-0025-001-00 00002500100 FINGER PROTECTORS NONPADDED SPLINTS
4 CM
Splints
Splint Products
S8450
N/A
lint, prefabricated, digit (specify digit General Medical Surgical Supplies 0270, Nonby use of modifier)
See Also Q4049 Finger splint, static; Q4051 Splint supplies misc
8 CM
Splints
Splint Products
S8450
N/A
9 CM
Splints
Splint Products
S8450
N/A
00-0376-001-00 00037600100 MASON-ALLEN SPLINT
SPLINTS
Splints
Splint Products
A4570
E
Splint
00-0376-002-00 00037600200 MASON-ALLEN SPLINT
SPLINTS
Splints
Splint Products
A4570
E
Splint
00-0548-001-00 00054800100 ZIMFOAM FINGER SPLINTS, 46 X 2
CM
SPLINTS
Splints
Splint Products
A4570
E
Splint
Not paid under OPPS. Paid by fiscal intermediaries/MACs under See Also Q4049 Finger splint, static; Q4051 Splint See Pub 100-04 Medicare
supplies misc
CM
SPLINTS
Splints
Splint Products
A4570
E
Splint
supplies misc
CM
SPLINTS
Splints
Splint Products
A4570
E
Splint
supplies misc
00-0756-001-00 00075600100 ZIMFOAM BASEBALL SPLINTS, 2-3/4 SPLINTS
Splints
Splint Products
A4570
E
Splint
00-0756-002-00 00075600200 ZIMFOAM BASEBALL SPLINTS, 213/16
SPLINTS
Splints
Splint Products
A4570
E
Splint
ZIMFOAM BASEBALL SPLINTS, 2-1/4 SPLINTS
Splints
Splint Products
A4570
E
Splint
supplies misc
00-0756-011-00 00075601100
00-1756-001-00 00175600100 ZIMFOAM FINGER SPLINT KIT
SPLINTS
Splints
Splint Products
A4570
E
Splint
00-2548-001-00 00254800100 FINGER SPLINT KITS, ASSORTED
SIZES
SPLINTS
Splints
Splint Products
S8450
N/A
00-2548-011-00 00254801100
FINGER SPLINT KITS, 1-1/4
SPLINTS
Splints
Splint Products
S8450
N/A
00-2548-012-00 00254801200 FINGER SPLINT KITS, 2-1/4
SPLINTS
Splints
Splint Products
S8450
N/A
SPLINTS
Splints
Splint Products
S8450
N/A
SPLINTS
Splints
Splint Products
S8450
N/A
PAGE 114
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
00-2548-015-00 00254801500 FINGER SPLINT KIT, W/BULB, 3-1/4
SPLINTS
Splints
Splint Products
S8450
N/A
SPLINTS
Splints
Splint Products
S8450
N/A
SPLINTS
Splints
Splint Products
S8450
N/A
SPLINTS
Splints
Splint Products
S8450
N/A
SPLINTS
Splints
Splint Products
S8450
N/A
00-2549-001-00 00254900100 STAX FINGER SPLINT KIT
SPLINTS
Splints
Splint Products
S8450
N/A
00-2549-011-00 00254901100
REPLACEMENT SPLINTS, 1
SPLINTS
Splints
Splint Products
S8450
N/A
separately payable.
00-2549-012-00 00254901200 REPLACEMENT SPLINTS, 2
SPLINTS
Splints
Splint Products
S8450
N/A
separately payable.
SPLINTS
Splints
Splint Products
S8450
N/A
separately payable.
SPLINTS
Splints
Splint Products
S8450
N/A
separately payable.
SPLINTS
Splints
Splint Products
S8450
N/A
separately payable.
00-2549-016-00 00254901600 REPLACEMENT SPLINTS, 5-1/2
SPLINTS
Splints
Splint Products
S8450
N/A
separately payable.
SPLINTS
Splints
Splint Products
S8450
N/A
separately payable.
SPLINTS
Splints
Splint Products
S8450
N/A
separately payable.
66-0017-001-00 66001700100 PADDED FINGER SPLINTS, 1-5/8
SPLINTS
Splints
Splint Products
S8450
N/A
66-0017-002-00 66001700200 PADDED FINGER SPLINTS, 2-5/8
SPLINTS
Splints
Splint Products
S8450
N/A
66-0017-003-00 66001700300 PADDED FINGER SPLINTS, 6
SPLINTS
Splints
Splint Products
S8450
N/A
PAGE 115
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
66-0017-004-00 66001700400 FINGER COTS, PADDED, 1-1/4
SPLINTS
Splints
Splint Products
S8450
N/A
66-0017-005-00 66001700500 FINGER COTS, PADDED, 2
SPLINTS
Splints
Splint Products
S8450
N/A
66-0017-006-00 66001700600 FINGER COTS, PADDED, 3
SPLINTS
Splints
Splint Products
S8450
N/A
66-0017-007-00 66001700700 FINGER COTS, PADDED, 3-1/2
SPLINTS
Splints
Splint Products
S8450
N/A
66-0017-008-00 66001700800 ZIMFOAM FINGER SPLINTS,
PADDED, 3-5/8
SPLINTS
Splints
Splint Products
S8450
N/A
66-0017-009-00 66001700900 ZIMFOAM FINGER SPLINTS,
PADDED, 4-5/8
SPLINTS
Splints
Splint Products
S8450
N/A
66-0017-013-00 66001701300 NARROW FINGER SPLINTS,
PADDED, 6
SPLINTS
Splints
Splint Products
S8450
N/A
66-0025-001-00 66002500100 FINGER PROTECTORS, PADDED, 1- SPLINTS
1/2
Splints
Splint Products
S8450
N/A
66-0025-002-00 66002500200 FINGER PROTECTORS, PADDED, 3
SPLINTS
Splints
Splint Products
S8450
N/A
66-0025-003-00 66002500300 FINGER PROTECTORS, PADDED, 3- SPLINTS
1/2
Splints
Splint Products
S8450
N/A
66-0080-001-00 66008000100 LEWIN STERN THUMB SPLINT,6
SPLINTS
Splints
Splint Products
S8450
N/A
separately payable.
66-0080-002-00 66008000200 LEWIN STERN FINGER SPLINT8-7/16 SPLINTS
Splints
Splint Products
S8450
N/A
SPLINTS
Splints
Splint Products
S8450
N/A
66-0081-000-00 66008100000 LEWIN BASEBALL SPLINTS, 3
SPLINTS
Splints
Splint Products
S8450
N/A
separately payable.
SPLINTS
Splints
Splint Products
S8450
N/A
separately payable.
00-8905-002-00 00890500200 UNIVERSAL PLASTER SPLINTING,
7.2 YD
SPLINTS
UNIVERSAL SPLINTS
Splints
Splint Products
A4580
E
t supplies (e.g. plaster)
7.2 YD
SPLINTS
UNIVERSAL SPLINTS
Splints
Splint Products
A4580
E
7.2 YD
SPLINTS
UNIVERSAL SPLINTS
Splints
Splint Products
A4580
E
separately payable.
PAGE 116
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
7.2 YD
SPLINTS
UNIVERSAL SPLINTS
Splints
Splint Products
A4580
E
7.2 YD
SPLINTS
UNIVERSAL SPLINTS
Splints
Splint Products
A4580
E
00-8906-013-00 00890601300 FIBERGLASS SPLINTING, 3 X 12
SPLINTS
UNIVERSAL SPLINTS
Splints
Splint Products
A4590
E
Special casting material (e.g.
fiberglass)
SPLINTS
UNIVERSAL SPLINTS
Splints
Splint Products
A4590
E
fiberglass)
SPLINTS
UNIVERSAL SPLINTS
Splints
Splint Products
A4590
E
fiberglass)
00-1706-005-00 00170600500 PLASTIC TIBIA/FIBULA SPLINT SML
CHILD, KNEE LENGTH
SPLINTS
LEG SPLINTS
Splints
Splint Products
A4570
E
Splint
00-1706-006-00 00170600600 PLASTIC TIBIA/FIBULA SPLINT,
CHILD, KNEE LENGTH
SPLINTS
LEG SPLINTS
Splints
Splint Products
A4570
E
Splint
YOUTH, KNEE LENGTH
SPLINTS
LEG SPLINTS
Splints
Splint Products
A4570
E
Splint
ADULT, KNEE LENGTH
SPLINTS
LEG SPLINTS
Splints
Splint Products
A4570
E
Splint
00-1706-009-00 00170600900 PLASTIC TIBIA/FIBULA SPLINT SML
CHILD, HIP LENGTH
SPLINTS
LEG SPLINTS
Splints
Splint Products
A4570
E
Splint
CHILD, HIP LENGTH
SPLINTS
LEG SPLINTS
Splints
Splint Products
A4570
E
Splint
00-1706-011-00 00170601100
PLASTIC TIBIA/FIBULA SPLINT,
YOUTH, HIP LENGTH
SPLINTS
LEG SPLINTS
Splints
Splint Products
A4570
E
Splint
ADULT, HIP LENGTH
SPLINTS
LEG SPLINTS
Splints
Splint Products
A4570
E
Splint
66-0040-001-00 66004000100 TIBIA/FIBULA SPLINT, PAD,SMALL
CHILD, 8-3/4
SPLINTS
LEG SPLINTS
Splints
Splint Products
A4570
E
Splint
66-0040-002-00 66004000200 TIBIA/FIBULA SPLINT, PAD,CHILD, 11- SPLINTS
3/4
LEG SPLINTS
Splints
Splint Products
A4570
E
Splint
66-0040-003-00 66004000300 TIBIA/FIBULA SPLINT,
PAD,YOUTH/SMALL ADULT, 14
LEG SPLINTS
Splints
Splint Products
A4570
E
Splint
SPLINTS
PAGE 117
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
66-0040-004-00 66004000400 TIBIA/FIBULA SPLINT, PAD,ADULT, 15- SPLINTS
3/4
LEG SPLINTS
Splints
Splint Products
A4570
E
Splint
66-0040-005-00 66004000500 TIBIA/FIBULA SPLINT, PAD,HIP,
SMALL CHILD, 14
SPLINTS
LEG SPLINTS
Splints
Splint Products
A4570
E
Splint
CHILD, 19-1/2
SPLINTS
LEG SPLINTS
Splints
Splint Products
A4570
E
Splint
66-0040-007-00 66004000700 TIBIA/FIBULA SPLINT, PAD, HIP,
Y/SML ADULT
SPLINTS
LEG SPLINTS
Splints
Splint Products
A4570
E
Splint
ADULT, 31
SPLINTS
LEG SPLINTS
Splints
Splint Products
A4570
E
Splint
00-1632-010-00 00163201000 HUMERAL FRACTURE BRACE,
SMALL
SPLINTS
FRACTURE BRACES
Cast
Products
Cast Products
L3980
A
Upper extremity fracture orthosis,
humeral, prefabricated, includes
fitting and adjustment
00-1632-011-00 00163201100
SPLINTS
FRACTURE BRACES
Cast
Products
Cast Products
L3980
A
Upper extremity fracture orthosis,
humeral, prefabricated, includes
fitting and adjustment
00-8915-043-00 00891504300 THUMB/WRIST IMMOBILIZER, SMALL, SPLINTS
LEFT
FRACTURE BRACES
Cast
Products
Cast Products
L3807
A
Wrist hand finger orthosis, without 0274 Medical/Surgical Supplies and Devices joint(s), prefabricated, includes
fitting and adjustments, any type
00-8915-044-00 00891504400 THUMB/WRIST IMMOBILIZER, SMALL, SPLINTS
RIGHT
FRACTURE BRACES
Cast
Products
Cast Products
L3807
A
HUMERAL FRACTURE BRACE,
LARGE
PAGE 118
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
00-8915-045-00 00891504500 THUMB/WRIST IMMOBILIZER,
MEDIUM, LEFT
SPLINTS
FRACTURE BRACES
Cast
Products
Cast Products
L3807
A
MEDIUM, RIGHT
SPLINTS
FRACTURE BRACES
Cast
Products
Cast Products
L3807
A
LARGE, LEFT
SPLINTS
FRACTURE BRACES
Cast
Products
Cast Products
L3807
A
LARGE, RIGHT
SPLINTS
FRACTURE BRACES
Cast
Products
Cast Products
L3807
A
00-1086-002-00 00108600200 ABDUCTION PILLOW SET, SMALL
FOAM PRODUCTS
ABDUCTION PILLOWS
Foam
Products
Foam Products
E0190
E
POSITIONING
0270 – Medical surgical supplies general; 0274CUSHION/PILLOW/WEDGE, ANY medical surgical;0279SHAPE OR SIZE, INCLUDES ALL medical surgical supplies other supplies/devices
COMPONENTS AND
ACCESSORIES
00-1086-003-00 00108600300 ABDUCTION PILLOW SET, MEDIUM
FOAM PRODUCTS
ABDUCTION PILLOWS
Foam
Products
Foam Products
E0190
E
POSITIONING
COMPONENTS AND
ACCESSORIES
00-1086-004-00 00108600400 ABDUCTION PILLOW SET, LARGE
FOAM PRODUCTS
ABDUCTION PILLOWS
Foam
Products
Foam Products
E0190
E
POSITIONING
COMPONENTS AND
ACCESSORIES
00-1086-012-00 00108601200 ABDUCTION PILLOW BAND, SMALL
FOAM PRODUCTS
ABDUCTION PILLOWS
Foam
Products
Foam Products
E0190
E
POSITIONING
COMPONENTS AND
ACCESSORIES
00-1086-013-00 00108601300 ABDUCTION PILLOW BAND, MEDIUM FOAM PRODUCTS
ABDUCTION PILLOWS
Foam
Products
Foam Products
E0190
E
POSITIONING
COMPONENTS AND
ACCESSORIES
PAGE 119
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
00-1086-014-00 00108601400 ABDUCTION PILLOW BAND, LARGE
FOAM PRODUCTS
ABDUCTION PILLOWS
Foam
Products
Foam Products
E0190
E
POSITIONING
COMPONENTS AND
ACCESSORIES
00-1086-022-00 00108602200 TUBULAR ZIMFOAM PADS, SMALL
FOAM PRODUCTS
ABDUCTION PILLOWS
Foam
Products
Foam Products
E0190
E
POSITIONING
COMPONENTS AND
ACCESSORIES
00-1086-023-00 00108602300 TUBULAR ZIMFOAM PADS, MEDIUM FOAM PRODUCTS
ABDUCTION PILLOWS
Foam
Products
Foam Products
E0190
E
POSITIONING
COMPONENTS AND
ACCESSORIES
00-1086-024-00 00108602400 TUBULAR ZIMFOAM PADS, LARGE
FOAM PRODUCTS
ABDUCTION PILLOWS
Foam
Products
Foam Products
E0190
E
POSITIONING
COMPONENTS AND
ACCESSORIES
00-1086-032-00 00108603200 ABDUCTION PILLOW STRAPS,
SMALL
FOAM PRODUCTS
ABDUCTION PILLOWS
Foam
Products
Foam Products
E0190
E
POSITIONING
COMPONENTS AND
ACCESSORIES
MEDIUM
FOAM PRODUCTS
ABDUCTION PILLOWS
Foam
Products
Foam Products
E0190
E
POSITIONING
COMPONENTS AND
ACCESSORIES
LARGE
FOAM PRODUCTS
ABDUCTION PILLOWS
Foam
Products
Foam Products
E0190
E
POSITIONING
COMPONENTS AND
ACCESSORIES
00-2671-001-00 00267100100 ABDUCTION PILLOWS
FOAM PRODUCTS
ABDUCTION PILLOWS
Foam
Products
Foam Products
E0190
E
POSITIONING
COMPONENTS AND
ACCESSORIES
FOAM PRODUCTS
ABDUCTION PILLOWS
Foam
Products
Foam Products
E0190
E
POSITIONING
COMPONENTS AND
ACCESSORIES
FOAM PRODUCTS
ABDUCTION PILLOWS
Foam
Products
Foam Products
E0190
E
POSITIONING
COMPONENTS AND
ACCESSORIES
00-0658-001-00 00065800100 HEEL PROTECTORS, ZIMMER
FOAM PRODUCTS
HEEL & ELBOW PROTECTORS
Foam
Products
Foam Products
E0191
Y
HEEL OR ELBOW PROTECTOR, 0274 Medical/Surgical Supplies and Devices Non-Implantable Durable Medical Equipment Not paid under
EACH
PAGE 120
Product #
EDI Item #
Item Description
00-1761-001-00 00176100100 HEEL PROTECTOR, ECONOMY
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
FOAM PRODUCTS
Foam
Products
Foam Products
E0191
Y
EACH
00-1782-001-00 00178200100 HEEL/ELBOW PROTECTORS, ULTRA- FOAM PRODUCTS
CARE
Foam
Products
Foam Products
E0191
Y
EACH
00-2790-010-00 00279001000 HEEL/ELBOW PROTECTORS,
SLEEVE KNIT
FOAM PRODUCTS
Foam
Products
Foam Products
E0191
Y
EACH
00-8713-001-00 00871300100 HEEL/ELBOW PROTECTORS
FOAM PRODUCTS
Foam
Products
Foam Products
E0191
Y
EACH
00-2656-000-00 00265600000 OR DONUTS
FOAM PRODUCTS
POSITIONERS
Foam
Products
Foam Products
E0190
E
00-2658-000-00 00265800000 MULTI-CRADLE POSITIONER
FOAM PRODUCTS
POSITIONERS
Foam
Products
Foam Products
E0190
E
00-2663-000-00 00266300000 LAMINECTOMY ARM CRADLES
FOAM PRODUCTS
POSITIONERS
Foam
Products
Foam Products
E0190
E
00-2664-000-00 00266400000 ULNAR NERVE PROTECTORS
FOAM PRODUCTS
POSITIONERS
Foam
Products
Foam Products
E0190
E
POSITIONING
CUSHION/PILLOW/WEDGE, ANY
SHAPE OR SIZE, INCLUDES ALL
COMPONENTS AND
ACCESSORIES
POSITIONING
COMPONENTS AND
ACCESSORIES
POSITIONING
COMPONENTS AND
ACCESSORIES
POSITIONING
COMPONENTS AND
ACCESSORIES
PAGE 121
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
00-2665-000-00 00266500000 BODY ALIGNERS
FOAM PRODUCTS
POSITIONERS
Foam
Products
Foam Products
E0190
E
00-2666-000-00 00266600000 CAST ELEVATORS
FOAM PRODUCTS
POSITIONERS
Foam
Products
Foam Products
E0190
E
00-2669-000-00 00266900000 FOOT DROP STOPS
FOAM PRODUCTS
POSITIONERS
Foam
Products
Foam Products
E0190
E
00-2670-000-00 00267000000 CRADLE BOOTS
FOAM PRODUCTS
POSITIONERS
Foam
Products
Foam Products
E0190
E
00-2675-000-00 00267500000 SHOULDER ABDUCTION
POSITIONER
FOAM PRODUCTS
POSITIONERS
Foam
Products
Foam Products
E0190
E
00-2678-000-00 00267800000 L-P ULNAR NERVE PROTECTORS
FOAM PRODUCTS
POSITIONERS
Foam
Products
Foam Products
E0190
E
00-2679-000-00 00267900000 OR HEAD POSITIONER
FOAM PRODUCTS
POSITIONERS
Foam
Products
Foam Products
E0190
E
00-2680-000-00 00268000000 DEROTATION BOOT, COMPLETE
FOAM PRODUCTS
POSITIONERS
Foam
Products
Foam Products
E0190
E
00-2680-001-00 00268000100 DEROTATION BOOT LINER
FOAM PRODUCTS
POSITIONERS
Foam
Products
Foam Products
E0190
E
00-2040-003-00 00204000300 PCS KNEE ANTI-EMBOLISM
STOCKINGS, SMALL, SHORT
ANTI-EMBOLISM STOCKINGS
KNEE-HIGH
Compressio Compression Products
n Products
A4500
E
STOCKINGS, MEDIUM, SHORT
KNEE-HIGH
n Products
A4500
STOCKINGS, LARGE, SHORT
KNEE-HIGH
n Products
STOCKINGS, SMALL, REGULAR
KNEE-HIGH
STOCKINGS, MEDIUM, REGULAR
STOCKINGS, LARGE, REGULAR
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
POSITIONING
COMPONENTS AND
ACCESSORIES
POSITIONING
COMPONENTS AND
ACCESSORIES
POSITIONING
COMPONENTS AND
ACCESSORIES
POSITIONING
COMPONENTS AND
ACCESSORIES
POSITIONING
COMPONENTS AND
ACCESSORIES
POSITIONING
COMPONENTS AND
ACCESSORIES
POSITIONING
COMPONENTS AND
ACCESSORIES
POSITIONING
COMPONENTS AND
ACCESSORIES
POSITIONING
COMPONENTS AND
ACCESSORIES
Surgical stockings below knee
length, each
E
length, each
A4500
E
length, each
n Products
A4500
E
length, each
KNEE-HIGH
n Products
A4500
E
length, each
KNEE-HIGH
n Products
A4500
E
length, each
PAGE 122
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
STOCKINGS, X-LARGE, REGULAR
KNEE-HIGH
n Products
A4500
E
length, each
00-2040-011-00 00204001100
KNEE-HIGH
n Products
A4500
E
length, each
STOCKINGS, MEDIUM, LONG
KNEE-HIGH
n Products
A4500
E
length, each
STOCKINGS, LARGE, LONG
KNEE-HIGH
n Products
A4500
E
length, each
STOCKINGS, X-LARGE, LONG
KNEE-HIGH
n Products
A4500
E
length, each
00-2040-023-00 00204002300 PCS THIGH ANTI-EMBOLISM
STOCKINGS, SMALL, SHORT
THIGH-HIGH
n Products
A4495
E
Surgical stockings thigh length,
each
STOCKINGS, MEDIUM, SHORT
THIGH-HIGH
n Products
A4495
E
each
STOCKINGS, LARGE, SHORT
THIGH-HIGH
n Products
A4495
E
each
STOCKINGS, SMALL, REGULAR
THIGH-HIGH
n Products
A4495
E
each
STOCKINGS, MEDIUM, REGULAR
THIGH-HIGH
n Products
A4495
E
each
STOCKINGS, LARGE, REGULAR
THIGH-HIGH
n Products
A4495
E
each
STOCKINGS, X-LGE, REGULAR
THIGH-HIGH
n Products
A4495
E
each
STOCKINGS, SMALL, LONG
THIGH-HIGH
n Products
A4495
E
each
STOCKINGS, MEDIUM, LONG
THIGH-HIGH
n Products
A4495
E
each
STOCKINGS, LARGE, LONG
THIGH-HIGH
n Products
A4495
E
each
STOCKINGS, X-LARGE, LONG
THIGH-HIGH
n Products
A4495
E
each
CAST PADDING
Cast
Products
A4580
E
00-0211-001-00 00021100100
PCS KNEE ANTI-EMBOLISM
STOCKINGS, SMALL, LONG
WHITE FELT PADDING, 3/8 X 36 X 21 CASTING PRODUCTS
Cast Products
PAGE 123
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
00-0217-005-00 00021700500 WHITE FELT PADDING, 1/8 X 36 X 21 CASTING PRODUCTS
CAST PADDING
Cast
Products
Cast Products
A4580
E
CAST PADDING
Cast
Products
Cast Products
A4580
E
CAST PADDING
Cast
Products
Cast Products
A4580
E
00-8890-002-00 00889000200 ORTHO CAST PADDING, 2
CASTING PRODUCTS
CAST PADDING
Cast
Products
Cast Products
A4580
E
CASTING PRODUCTS
CAST PADDING
Cast
Products
Cast Products
A4580
E
CASTING PRODUCTS
CAST PADDING
Cast
Products
Cast Products
A4580
E
CASTING PRODUCTS
CAST PADDING
Cast
Products
Cast Products
A4580
E
00-8899-002-00 00889900200 CAST VACUUM
CASTING PRODUCTS
CAST REMOVAL PRODUCTS
N/A
N/A
N/A
CASTING PRODUCTS
Cast
Products
Cast
Products
Cast Products
00-8899-019-00 00889901900 BAGS FILTER REPLACEMENT
Cast Products
N/A
N/A
N/A
separately payable.
00-8899-026-00 00889902600 CAST VAC WIREFORM
CASTING PRODUCTS
Cast Products
N/A
N/A
N/A
00-8909-001-00 00890900100 ZIMMER CAST SAW
CASTING PRODUCTS
Cast Products
N/A
N/A
N/A
00-8909-007-00 00890900700 ZIMMER CAST REMOVAL SYSTEM
CASTING PRODUCTS
Cast Products
N/A
N/A
N/A
00-8909-011-00 00890901100
CASTING PRODUCTS
Cast
Products
Cast
Products
Cast
Products
Cast
Products
Cast Products
N/A
N/A
N/A
separately payable.
00-8909-012-00 00890901200 UNIVERSAL CAST SAW BLADE,2-1/2 CASTING PRODUCTS
Cast
Products
Cast Products
N/A
N/A
N/A
separately payable.
00-8909-015-00 00890901500 CUTTER II SHROUD ASSEMBLY, 90
DEG
00-8909-016-00 00890901600 CUTTER II SHROUD ASSEMBLY,
STRAIGHT
00-8909-065-00 00890906500 VACUUM CONNECTOR KIT, 90 DEG
CASTING PRODUCTS
N/A
N/A
N/A
Cast Products
N/A
N/A
N/A
CASTING PRODUCTS
Cast Products
N/A
N/A
N/A
00-8909-066-00 00890906600 VACUUM CONNECTOR KIT,
STRAIGHT
02-8909-000-00 02890900000 CAST CUTTER REPAIR
CASTING PRODUCTS
Cast Products
N/A
N/A
N/A
CASTING PRODUCTS
Cast Products
N/A
N/A
N/A
00-8896-013-00 00889601300 CASTING SPLINTS, 3 X 15
CASTING PRODUCTS
CAST TAPE
Cast
Products
Cast
Products
Cast
Products
Cast
Products
Cast
Products
Cast
Products
Cast Products
CASTING PRODUCTS
Cast Products
A4590
E
fiberglass)
CASTING PRODUCTS
CAST TAPE
Cast
Products
Cast Products
A4590
E
fiberglass)
SUPER UNIVERSAL SAW BLADE
PAGE 124
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
CASTING PRODUCTS
CAST TAPE
Cast
Products
Cast Products
A4590
E
fiberglass)
CASTING PRODUCTS
CAST TAPE
Cast
Products
Cast Products
A4590
E
fiberglass)
CASTING PRODUCTS
CAST TAPE
Cast
Products
Cast Products
A4590
E
fiberglass)
00-8897-002-00 00889700200 ZIM-FLEX CAST TAPE 2
CASTING PRODUCTS
CAST TAPE
Cast
Products
Cast Products
A4590
E
fiberglass)
00-8897-002-01 00889700201 ZIM-FLEX CAST TAPE, RED 2
CASTING PRODUCTS
CAST TAPE
Cast
Products
Cast Products
A4590
E
fiberglass)
00-8897-002-02 00889700202 ZIM-FLEX CAST TAPE, PINK,2
CASTING PRODUCTS
CAST TAPE
Cast
Products
Cast Products
A4590
E
fiberglass)
00-8897-002-03 00889700203 ZIM-FLEX CAST TAPE, LIGHTBLUE, 2 CASTING PRODUCTS
CAST TAPE
Cast
Products
Cast Products
A4590
E
fiberglass)
00-8897-002-04 00889700204 ZIM-FLEX CAST TAPE, BLUE,2
CASTING PRODUCTS
CAST TAPE
Cast
Products
Cast Products
A4590
E
fiberglass)
00-8897-002-06 00889700206 ZIM-FLEX CAST TAPE, GREEN, 2
CASTING PRODUCTS
CAST TAPE
Cast
Products
Cast Products
A4590
E
fiberglass)
00-8897-003-00 00889700300 ZIM-FLEX CAST TAPE, 3
CASTING PRODUCTS
CAST TAPE
Cast
Products
Cast Products
A4590
E
fiberglass)
00-8897-003-01 00889700301 ZIM-FLEX CAST TAPE, RED, 3
CASTING PRODUCTS
CAST TAPE
Cast
Products
Cast Products
A4590
E
fiberglass)
CASTING PRODUCTS
CAST TAPE
Cast
Products
Cast Products
A4590
E
fiberglass)
00-8897-003-03 00889700303 ZIM-FLEX CAST TAPE, LIGHTBLUE, 3 CASTING PRODUCTS
CAST TAPE
Cast
Products
Cast Products
A4590
E
fiberglass)
CASTING PRODUCTS
CAST TAPE
Cast
Products
Cast Products
A4590
E
fiberglass)
CASTING PRODUCTS
CAST TAPE
Cast
Products
Cast Products
A4590
E
fiberglass)
CASTING PRODUCTS
CAST TAPE
Cast
Products
Cast Products
A4590
E
fiberglass)
00-8897-004-01 00889700401 ZIM-FLEX CAST TAPE, RED, 4
CASTING PRODUCTS
CAST TAPE
Cast
Products
Cast Products
A4590
E
fiberglass)
PAGE 125
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
Payment System
2011 HCPCS Code
(If Applicable)
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
CASTING PRODUCTS
CAST TAPE
Cast
Products
Cast Products
A4590
E
fiberglass)
00-8897-004-03 00889700403 ZIM-FLEX CAST TAPE, LT BLU, 4
CASTING PRODUCTS
CAST TAPE
Cast
Products
Cast Products
A4590
E
fiberglass)
CASTING PRODUCTS
CAST TAPE
Cast
Products
Cast Products
A4590
E
fiberglass)
CASTING PRODUCTS
CAST TAPE
Cast
Products
Cast Products
A4590
E
fiberglass)
CASTING PRODUCTS
CAST TAPE
Cast
Products
Cast Products
A4590
E
fiberglass)
00-1720-000-00 00172000000 ESMARCH PLASTER SHEARS
CASTING PRODUCTS
CAST INSTRUMENTS
N/A
N/A
N/A
CASTING PRODUCTS
CAST INSTRUMENTS
Cast Products
N/A
N/A
N/A
00-3809-000-00 00380900000 UTILITY FELT SHEARS
CASTING PRODUCTS
CAST INSTRUMENTS
00-3812-000-00 00381200000 BRUN PLASTER SHEARS
CASTING PRODUCTS
CAST INSTRUMENTS
Cast
Products
Cast
Products
Cast
Products
Cast
Products
Cast
Products
Cast
Products
Cast Products
00-3807-002-00 00380700200 UNIVERSAL SCISSORS, 18CM
separately payable.
Cast
Products
Cast
Products
Cast
Products
Cast Products
N/A
N/A
N/A
Cast Products
N/A
N/A
N/A
Cast Products
A4580
E
Cast Products
N/A
N/A
N/A
Cast Products
N/A
N/A
N/A
Cast Products
N/A
N/A
N/A
Cast Products
N/A
N/A
N/A
00-3820-000-00 00382000000 CAST CART
CASTING PRODUCTS
CAST INSTRUMENTS
00-3820-054-00 00382005400 DISPOSABLE BUCKETS
CASTING PRODUCTS
CAST INSTRUMENTS
00-3826-000-00 00382600000 CAST SPREADER
CASTING PRODUCTS
CAST INSTRUMENTS
00-3835-000-00 00383500000 BOEHLER CAST BREAKER
CASTING PRODUCTS
CAST INSTRUMENTS
00-8889-002-00 00888900200 STOCKINETTE, 2
CASTING PRODUCTS
STOCKINETTE
00-8889-003-00 00888900300 STOCKINETTE, 3
CASTING PRODUCTS
STOCKINETTE
Cast
Products
Cast Products
A4580
E
00-8889-004-00 00888900400 STOCKINETTE, 4
CASTING PRODUCTS
STOCKINETTE
Cast
Products
Cast Products
A4580
E
00-8889-005-00 00888900500 STOCKINETTE, 5
CASTING PRODUCTS
STOCKINETTE
Cast
Products
Cast Products
A4580
E
00-8801-000-00 00880100000 ZIMMER AIR DERMATOME
COMPLETE KIT
00-8801-001-00 00880100100 ZIMMER AIR DERMATOME
HANDPIECE
00-8821-000-00 00882100000 ZIMMER ELECTRIC DERMATOME
COMPLETE KIT
HANDPIECE
00-8831-001-00 00883100100 ZIMMER TISSUE BANK DERMATOME
SKIN GRAFT PRODUCTS
DERMATOMES
Skin Grafting Skin Grafting
N/A
N/A
N/A
SKIN GRAFT PRODUCTS
DERMATOMES
N/A
N/A
N/A
SKIN GRAFT PRODUCTS
DERMATOMES
N/A
N/A
N/A
SKIN GRAFT PRODUCTS
DERMATOMES
N/A
N/A
N/A
SKIN GRAFT PRODUCTS
DERMATOMES
N/A
N/A
N/A
00-2195-000-00 00219500000 MESHGRAFT II TISSUE EXPANSION
SYSTEM
00-2195-001-00 00219500100 MESHGRAFT II TISSUE EXPANSION
UNIT
SKIN GRAFT PRODUCTS
MESHERS
N/A
N/A
N/A
SKIN GRAFT PRODUCTS
MESHERS
N/A
N/A
N/A
separately payable.
00-7701-000-00 00770100000 ZIMMER SKIN GRAFT MESHER
SKIN GRAFT PRODUCTS
MESHERS
N/A
N/A
N/A
PAGE 126
Product #
EDI Item #
Item Description
COMPLETE
00-7701-002-00 00770100200 ZIMMER SKIN GRAFT MESHER W/
CUTTERS
00-8800-000-10 00880000010 ZIMMER DERMATOME BLADES
STERILE
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
SKIN GRAFT PRODUCTS
MESHERS
N/A
N/A
N/A
SKIN GRAFT PRODUCTS
MESHERS
N/A
N/A
N/A
SKIN GRAFT PRODUCTS
DISPOSABLE DERMATOME BLADES
N/A
N/A
N/A
separately payable.
00-8831-000-10 00883100010 ZIMMER TISSUE BANK DERMATOME SKIN GRAFT PRODUCTS
BLADES STERILE
DISPOSABLE DERMATOME BLADES
N/A
N/A
N/A
separately payable.
00-8801-002-00 00880100200 AIR DERMATOME HOSE
SKIN GRAFT PRODUCTS
DERMATOME ACCESSORIES
N/A
N/A
N/A
00-8801-003-00 00880100300 DERMATOME AUTOCLAVE CASE
SKIN GRAFT PRODUCTS
N/A
N/A
N/A
00-8802-001-00 00880200100 WIDTH PLATE, 1 IN
SKIN GRAFT PRODUCTS
N/A
N/A
N/A
00-8802-002-00 00880200200 WIDTH PLATE, 2 IN
SKIN GRAFT PRODUCTS
N/A
N/A
N/A
separately payable.
00-8802-003-00 00880200300 WIDTH PLATE, 3 IN
SKIN GRAFT PRODUCTS
N/A
N/A
N/A
separately payable.
00-8802-004-00 00880200400 WIDTH PLATE, 4 IN
SKIN GRAFT PRODUCTS
N/A
N/A
N/A
separately payable.
00-8802-015-00 00880201500 WIDTH PLATE, 1.5 IN
SKIN GRAFT PRODUCTS
N/A
N/A
N/A
separately payable.
00-8803-000-00 00880300000 DERMATOME SCREWDRIVER
SKIN GRAFT PRODUCTS
N/A
N/A
N/A
00-8803-001-10 00880300110
SKIN GRAFT PRODUCTS
N/A
N/A
N/A
separately payable.
POWER SUPPLY
AUTOCLAVE CASE
3 IN WIDTH PLATE
4 IN WIDTH PLATE
POWER SUPPLY
06-0018-104-06 06001810406 AIR DERMATOME MANUAL
SKIN GRAFT PRODUCTS
N/A
N/A
N/A
SKIN GRAFT PRODUCTS
N/A
N/A
N/A
SKIN GRAFT PRODUCTS
N/A
N/A
N/A
SKIN GRAFT PRODUCTS
N/A
N/A
N/A
SKIN GRAFT PRODUCTS
N/A
N/A
N/A
SKIN GRAFT PRODUCTS
N/A
N/A
N/A
06-0018-105-79 06001810579 ELECTRIC DERMATOME MANUAL
SKIN GRAFT PRODUCTS
N/A
N/A
N/A
00-2195-012-00 00219501200 DERMACARRIER II, 1.5:1, STERILE
SKIN GRAFT PRODUCTS
DERMACARRIERS
N/A
N/A
N/A
separately payable.
00-2195-013-00 00219501300 DERMACARRIER II, 3:1, STERILE
SKIN GRAFT PRODUCTS
DERMACARRIERS
N/A
N/A
N/A
separately payable.
WIDTH PLATE SCREWS
PAGE 127
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
SKIN GRAFT PRODUCTS
DERMACARRIERS
N/A
N/A
N/A
separately payable.
SKIN GRAFT PRODUCTS
DERMACARRIERS
N/A
N/A
N/A
separately payable.
00-7708-000-10 00770800010 ZIMMER SKIN GRAFT CARRIER, 8 IN, SKIN GRAFT PRODUCTS
STERILE
DERMACARRIERS
N/A
N/A
N/A
separately payable.
00-7716-000-10 00771600010 ZIMMER SKIN GRAFT CARRIER, 16
IN, STERILE
SKIN GRAFT PRODUCTS
DERMACARRIERS
N/A
N/A
N/A
separately payable.
00-2195-006-00 00219500600 MESHGRAFT II AUTOCLAVE CASE
SKIN GRAFT PRODUCTS
MESHER ACCESSORIES
N/A
N/A
N/A
separately payable.
00-2195-022-00 00219502200 MESHGRAFT II RATCHET HANDLE
SKIN GRAFT PRODUCTS
MESHER ACCESSORIES
N/A
N/A
N/A
separately payable.
AUTOCLAVE CASE
RATCHET HANDLE
COMB
00-7703-015-00 00770301500 CUTTER 1.5:1 EXPANSION RATIO
SKIN GRAFT PRODUCTS
MESHER ACCESSORIES
N/A
N/A
N/A
SKIN GRAFT PRODUCTS
MESHER ACCESSORIES
N/A
N/A
N/A
separately payable.
SKIN GRAFT PRODUCTS
MESHER ACCESSORIES
N/A
N/A
N/A
SKIN GRAFT PRODUCTS
MESHER ACCESSORIES
N/A
N/A
N/A
00-7703-020-00 00770302000 CUTTER 2:1 EXPANSION RATIO
SKIN GRAFT PRODUCTS
MESHER ACCESSORIES
N/A
N/A
N/A
SKIN GRAFT PRODUCTS
MESHER ACCESSORIES
N/A
N/A
N/A
SKIN GRAFT PRODUCTS
MESHER ACCESSORIES
N/A
N/A
N/A
MANUAL
06-0018-105-93 06001810593 MESHGRAFT II MANUAL
SKIN GRAFT PRODUCTS
MESHER ACCESSORIES
N/A
N/A
N/A
SKIN GRAFT PRODUCTS
MESHER ACCESSORIES
N/A
N/A
N/A
02-8801-000-00 02880100000 ZIMMER AIR DERMATOME REPAIR
CHARGE
02-8801-002-00 02880100200 AIR DERMATOME HOSE (8801-02)
REPAIR CHARGE
REPAIR CHARGE
02-8821-006-00 02882100600 ELECTRIC DERMATOME POWER
SUPPLY REPAIR CHARGE
02-8831-000-00 02883100000 TISSUE BANK DERMATOME REPAIR
CHARGE
02-2195-000-00 02219500000 MESHGRAFT II REPAIR CHARGE
SKIN GRAFT PRODUCTS
DERMATOME REPAIRS
N/A
N/A
N/A
SKIN GRAFT PRODUCTS
DERMATOME REPAIRS
N/A
N/A
N/A
SKIN GRAFT PRODUCTS
DERMATOME REPAIRS
N/A
N/A
N/A
SKIN GRAFT PRODUCTS
DERMATOME REPAIRS
N/A
N/A
N/A
SKIN GRAFT PRODUCTS
DERMATOME REPAIRS
N/A
N/A
N/A
SKIN GRAFT PRODUCTS
MESHER REPAIRS
N/A
N/A
N/A
02-2195-022-00 02219502200 MESHGRAFT II RATCHET HANDLE
SKIN GRAFT PRODUCTS
REPAIR CHARGE
SKIN GRAFT PRODUCTS
REPAIR CHARGE
02-7701-022-00 02770102200 MESHER RATCHET HANDLE REPAIR SKIN GRAFT PRODUCTS
MESHER REPAIRS
N/A
N/A
N/A
MESHER REPAIRS
N/A
N/A
N/A
MESHER REPAIRS
N/A
N/A
N/A
SHEETING
N/A
N/A
N/A
00-8600-056-00 00860005600 TUCK SHEET, 58 IN X 108 IN,
STERILE
SKIN GRAFT PRODUCTS
PAGE 128
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
00-8600-057-00 00860005700 FLAT SHEET, 40 IN X 72 IN, STERILE SKIN GRAFT PRODUCTS
SHEETING
N/A
N/A
N/A
separately payable.
00-8600-058-00 00860005800 HALF SHEET, 58 IN X 54 IN, STERILE SKIN GRAFT PRODUCTS
SHEETING
N/A
N/A
N/A
separately payable.
00-8600-059-00 00860005900 MINI-SHEET, 20 IN X 30 IN, STERILE
SKIN GRAFT PRODUCTS
SHEETING
N/A
N/A
N/A
separately payable.
00-8600-070-00 00860007000 DISPENSER ROLL, 40 IN X 25 YD,
NON-STERILE
SKIN GRAFT PRODUCTS
SHEETING
N/A
N/A
N/A
separately payable.
00-1112-140-01 00111214001
PALACOS R 1X40 SINGLE
BONE CEMENT& ACCESSORIES
PALACOS BONE CEMENT
Bone
Palacos Bone Cement
Cement &
Accessories
N/A
N/A
N/A
0278-Medical/Surgical Supplies and Devices Other Implant
00-1113-140-01 00111314001
PALACOS R+G 1X40 SINGLE (WITH
GENTAMICIN)
PALACOS BONE CEMENT
Bone
Palacos Bone Cement
Cement &
Accessories
N/A
N/A
N/A
00-1118-140-01 00111814001
PALACOS LV 1X40 SINGLE
PALACOS BONE CEMENT
Bone
Palacos Bone Cement
Cement &
Accessories
N/A
N/A
N/A
00-1119-140-01 00111914001
PALACOS LVG 1X40 SINGLE
PALACOS BONE CEMENT
Bone
Palacos Bone Cement
Cement &
Accessories
N/A
N/A
N/A
00-1101-002-00 00110100200
OSTEOBOND COPOLYMER BONE
CEMENT SINGLE KIT 40GM
OSTEOBOND COPOLYMER BONE CEMENT
Bone
Bone Cement
Cement &
Accessories
N/A
N/A
N/A
00-1101-012-00 00110101200
OSTEOBOND COPOLYMER BONE
CEMENT TEN PK 40GM
OSTEOBOND COPOLYMER BONE CEMENT
Bone
Bone Cement
Cement &
Accessories
N/A
N/A
N/A
FEMORAL PREP KITS
Bone
Bone Cement
Cement & Accessories
Accessories
N/A
N/A
N/A
separately payable.
00-5049-055-00 00504905500 FEMORAL BONE CEMENT PREP KIT BONE CEMENT& ACCESSORIES
FEMORAL PREP KITS
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
00-5049-055-10 00504905510 FEMORAL BONE CEMENT PREP KIT BONE CEMENT& ACCESSORIES
10 PACK
FEMORAL PREP KITS
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
00-5059-013-00 00505901300 FEMORAL BONE BRUSHES
FEMORAL PREP KITS
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
00-5059-080-00 00505908000 ORTHO DRI FEMORAL CANAL
SPONGE
FEMORAL PREP KITS
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
00-5049-053-00 00504905300 QUIK-USE CURETTE 10 PACK
PAGE 129
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
00-5069-012-00 00506901200 HARRIS FEMORAL PRESSURIZER
INTACT GREATER TROC
PRESSURIZERS
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
00-5069-019-00 00506901900 FEMORAL NOZZLE SEAL INTACT
GREATER TROCHANTER
PRESSURIZERS
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
00-5069-020-00 00506902000 FEMORAL NOZZLE SEAL
TROCHANTER OFF
PRESSURIZERS
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
00-5069-051-00 00506905100 MILLER FEMORAL CANAL
PRESSURIZERS MEDIUM
PRESSURIZERS
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
00-5069-059-00 00506905900 MILLER BONE CEMENT INJECTOR
CANCELLOUS PRESS SMALL
PRESSURIZERS
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
CANCELLOUS PRESS LARGE
PRESSURIZERS
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
PRESURIZERS SMALL
PRESSURIZERS
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
PRESSURIZERS LARGE
PRESSURIZERS
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
00-4032-050-00 00403205000 CHARNLEY TYPE ACETABULAR CUP BONE CEMENT& ACCESSORIES
CEMENT RESTRICTORS
RESTRICTORS
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
00-4043-020-00 00404302000 CEMENT RESTRICTORS
RESTRICTORS
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
00-4045-009-00 00404500900 CEMENT RESTRICTORS FLAT DISK
RESTRICTORS
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
00-1102-012-00 00110201200
ZIMMER DOUGH-TYPE BONE
CEMENT 40GM/20ML SINGLE
ZIMMER BONE CEMENT
Bone
Bone Cement
Cement &
Accessories
N/A
N/A
N/A
00-1102-022-00 00110202200
ZIMMER DOUGH-TYPE BONE
CEMENT 40GM/20ML 10 PACK
ZIMMER BONE CEMENT
Bone
Bone Cement
Cement &
Accessories
N/A
N/A
N/A
00-1109-001-00 00110900100
ZIMMER POLY-PLUG INSERTER
BONE PLUGS/INSERTERS
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
PAGE 130
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
00-1109-009-00 00110900900
ZIMMER POLY-PLUG MEDULLARY
PLUG, 9MM
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
00-1109-011-00 00110901100
PLUG, 11MM
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
00-1109-013-00 00110901300
PLUG, 13MM
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
00-1109-015-00 00110901500
PLUG, 15MM
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
00-1109-017-00 00110901700
PLUG, 17MM
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
00-1109-019-00 00110901900
PLUG, 19MM
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
00-8011-010-01 00801101001
12MM/16MM PLUGS WITH INSERTER BONE CEMENT& ACCESSORIES
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
00-8011-020-01 00801102001
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
00-8011-020-12 00801102012
ALLEN PLUG HDPE/BAS04 7C/12FL
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
00-8011-020-16 00801102016
ALLEN PLUG HDPE/BASO4 8C/16FL
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
00-8011-020-20 00801102020
ALLEN PLUG HDPE/BASO4 10C/20FL BONE CEMENT& ACCESSORIES
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
00-8011-020-24 00801102024
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
00-8011-020-28 00801102028
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
PAGE 131
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
00-8011-020-32 00801102032
ALLEN PLUG HDPE/BASO4,16C/32FL BONE CEMENT& ACCESSORIES
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
00-8011-030-01 00801103001
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
00-8011-210-00 00801121000
ALLEN PLUG INSERTER METAL
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
0961
0961
STUHMER/WEBER INTRAMED PLUG, BONE CEMENT& ACCESSORIES
PLUG SIZE 1
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
3202
3202
PLUG SIZE 2
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
3208
3208
PLUG SIZE 2.5
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
3203
3203
PLUG SIZE 3
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
3209
3209
PLUG SIZE 3.5
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
3204
3204
PLUG SIZE 4
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
3205
3205
PLUG SIZE 5
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
3206
3206
PLUG SIZE 6
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
3207
3207
SIZE 7
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
0981
0981
S/W INTRAMED PLUG W/ DRAIN SIZE BONE CEMENT& ACCESSORIES
1, 8.1MM DIAMETER
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
PAGE 132
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
3222
3222
2, 10.6MM DIAMETER
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
3228
3228
2.5,11.8MM DIAMETE
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
3223
3223
3, 13.5MM DIAMETER
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
3229
3229
3.5, 14.7MM DIAMET
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
3224
3224
4, 16.0MM DIAMETER
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
3225
3225
5, 18.5MM DIAMETER
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
3226
3226
6, 21.0MM DIAMETER
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
3227
3227
7, 24.0MM DIAMETER
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
00-5069-006-00 00506900600 MILLER RATCHET INJECTOR
INJECTORS/NOZZLES
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
00-5069-008-00 00506900800 POWER-FLO CEMENT INJECTOR
(CGUN)
INJECTORS/NOZZLES
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
00-5069-041-00 00506904100 MILLER 90-DEGREE INJECTOR
NOZZLE
INJECTORS/NOZZLES
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
00-5069-045-00 00506904500 90 DEGREE BREAKAWAY NOZZLE
INJECTORS/NOZZLES
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
FLEX NOZZLE 12X0.25IN
INJECTORS/NOZZLES
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
PAGE 133
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
FLEX NOZZLE 16X0.38IN
INJECTORS/NOZZLES
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
BEZEL
INJECTORS/NOZZLES
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
00-5069-070-00 00506907000 MILLER TAPERED CEMENT NOZZLE BONE CEMENT& ACCESSORIES
INJECTORS/NOZZLES
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
00-5069-091-00 00506909100 MILLER 90-DEGREE SHORT TIP
INJECTOR NOZZLE
INJECTORS/NOZZLES
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
00-5049-001-00 00504900100 QUICK-VAC MIXING BOWL SINGLE
VACUUM MIXING SYSTEMS
Bone
Bone Cement
Accessories
N/A
N/A
N/A
00-5049-001-10 00504900110
Bone
Bone Cement
Accessories
N/A
N/A
N/A
00-5049-021-01 00504902101 QUICK-VAC MIXING SYSTEM SINGLE BONE CEMENT& ACCESSORIES
Bone
Bone Cement
Accessories
N/A
N/A
N/A
00-5049-025-01 00504902501 ZIMMER POWER-MIX VACUUM
CEMENT MIXING SYSTEM
Bone
Bone Cement
Accessories
N/A
N/A
N/A
00-5049-035-01 00504903501 ZIMMER COMPACT MIXING SYS
Bone
Bone Cement
Accessories
N/A
N/A
N/A
00-5049-045-01 00504904501 3 DOSE COMPACT VACUUM MIXING BONE CEMENT& ACCESSORIES
SYSTEM
Bone
Bone Cement
Accessories
N/A
N/A
N/A
00-5049-009-00 00504900900 MONOMER BOWL DEFLECTOR RING BONE CEMENT& ACCESSORIES
MONOMER FUME EVACUATION BOWLS
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
00-5049-010-00 00504901000 MONOMER BOWL WITH DEFLECTOR BONE CEMENT& ACCESSORIES
RING
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
00-5049-030-00 00504903000 SUPER BOWL MIXING/EVACUATING BONE CEMENT& ACCESSORIES
SYSTEM
Bone
Bone Cement
Accessories
N/A
N/A
N/A
00-5049-040-00 00504904000 SUPER BOWL SECOND USE KIT
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
00-5049-011-00 00504901100
DISPOSABLE MIXING BOWLS
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
QUICK-VAC MIXING BOWL 10 PACK
DISPOSABLE MIXING BOWLS WITH
SPATULA
PAGE 134
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
00-5049-013-00 00504901300 BONE CEMENT MIXING SPATULAS
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
93.00.56
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
00-4044-019-00 00404401900 MEDULLARY VENT TUBING*
ACCESSORIES
Bone
Bone Cement
Accessories
N/A
N/A
N/A
00-5049-038-00 00504903800 STRYKER/QUICK-VAC ADAPTER
ACCESSORIES
Bone
Bone Cement
Accessories
N/A
N/A
N/A
00-5049-085-00 00504908500 ZIMMER VACUUM FOOT PUMP II
NITROGEN
ACCESSORIES
Bone
Bone Cement
Accessories
N/A
N/A
N/A
00-5049-086-00 00504908600 ZIMMER VACUUM FOOT PUMP II AIR BONE CEMENT& ACCESSORIES
ACCESSORIES
Bone
Bone Cement
Accessories
N/A
N/A
N/A
00-5051-005-00 00505100500 MONOMER FUME FILTER WITH 3/8
ADAPTORS
ACCESSORIES
Bone
Bone Cement
Accessories
N/A
N/A
N/A
00-5069-052-00 00506905200 MILLER CARTRIDGE KITS
ACCESSORIES
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
70-2000-070-00 70200007000 GLOVE LINER, SMALL
SURGICAL GLOVE LINERS
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
70-2000-075-00 70200007500 GLOVE LINER, MEDIUM
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
70-2000-080-00 70200008000 GLOVE LINER, LARGE
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
70-2000-085-00 70200008500 GLOVE LINER, X-LARGE
Bone
Bone Cement
Accessories
N/A
N/A
N/A
separately payable.
01040158
01040158
BOPS CHARGER CORD
POWER TOOLS & ACCESSORIES
BRASSELER ORTHOPAEDIC POWER SYSTEM Brasseler
BS Large Bone Common N/A
(BOPS)
Power Tools Accessrs
N/A
N/A
PMX00505
PMX00505
BOPS POWER MODULE
(BOPS)
N/A
N/A
PMX00520
PMX00520
BOPS 4-BAY CHARGER
(BOPS)
N/A
N/A
PMX00521
PMX00521
BOPS CHARGER BAY COVER
(BOPS)
N/A
N/A
PMX00530
PMX00530
BOPS CHARGER MODULE
(BOPS)
N/A
N/A
930056
DISPOSABLE MIXING BOWL
W/SPATULA (12 PK, NON-STER)
PAGE 135
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
PMX00550
PMX00550
BOPS STERILE TRANS SLEEVE
(BOPS)
N/A
N/A
PMX00570
PMX00570
BOPS AUTOCLAVE CASE
(BOPS)
N/A
N/A
PMX00580
PMX00580
BOPS CANISTER LID
(BOPS)
N/A
N/A
PMX08500
PMX08500
BOPS MODULAR HANDPIECE
BS Large Bone
(BOPS)
Power Tools Handpieces
N/A
N/A
N/A
PMX12500
PMX12500
BOPS SAGITTAL/OSCIL SAW
BS Large Bone
(BOPS)
N/A
N/A
N/A
PMX14500
PMX14500
BOPS RECIPROCATOR SAW
BS Large Bone
(BOPS)
N/A
N/A
N/A
PMX14901
PMX14901
STERNUM SAW GUARD
(BOPS)
N/A
N/A
PMX08901
PMX08901
BOPS PIN DRIVER
BOPS PIN/WIRE DRIVERS
Brasseler
N/A
N/A
PMX08902
PMX08902
BOPS WIRE DRIVER
BOPS PIN/WIRE DRIVERS
Brasseler
N/A
N/A
0103103
0103103
BOPS 5/32 CHUCK KEY
LARGE BONE DRILL ATTACHMENTS
Brasseler
N/A
N/A
0103104
0103104
BOPS 1/4 CHUCK KEY
Brasseler
N/A
N/A
PMX08905
PMX08905
TRINKLE/AO DRILL
Brasseler
N/A
N/A
PMX08910
PMX08910
1/4 JACOBS DRILL
Brasseler
N/A
N/A
PMX08915
PMX08915
5/32 JACOBS CHUCK
Brasseler
N/A
N/A
PMX08920
PMX08920
HUDSON DRILL
Brasseler
N/A
N/A
PMX08925
PMX08925
ZIMMER DRILL
Brasseler
N/A
N/A
PMX08930
PMX08930
1/4 KEYLESS CHUCK
Brasseler
N/A
N/A
PMX08935
PMX08935
3MM KEYLESS CHUCK
Brasseler
N/A
N/A
PMX08911
PMX08911
HI TORQUE 1/4 CHUCK
LARGE BONE REAMER ATTACHMENTS
Brasseler
N/A
N/A
PMX08950
PMX08950
HUDSON REAMER
Brasseler
N/A
N/A
PMX08955
PMX08955
ZIMMER REAMER
Brasseler
N/A
N/A
PMX08960
PMX08960
AO REAMER
Brasseler
N/A
N/A
B60119035
B60119035
ST 90.0 X 11.0MM
LARGE BONE SAW BLADES
Brasseler
BS BOPS Blades - Large N/A
Power Tools Bone
N/A
N/A
Comment 1
Comment 2
Comment 3
separately payable.
separately payable.
PAGE 136
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
B60119050
B60119050
ST 90.0 X 11.0MM
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
B60189035
B60189035
ST 90.0 X 18.0MM
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
B60189050
B60189050
ST 90.0 X 18.0MM
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
B602510050
B602510050
ST 100.0 X 25.0MM
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
B60257535
B60257535
ST 75.0 X 25.0MM
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
B60259050
B60259050
ST 90.0 X 25.0MM
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
B60259053
B60259053
ST 90.0 X 25.0MM
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200001
K200001
LI 90.0 X 19.0MM .054 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200001T
K200001T
LI 90.0 X 19.0MM .054 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200002
K200002
LI 90.0 X 19.0MM .039 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200003
K200003
LI 90.0 X 31.0MM .054 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200004
K200004
LI 90.0 X 31.0MM .039 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200005
K200005
LI 90.0 X 25.4MM .054 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
PAGE 137
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
K200005I
K200005I
LI 90.0 X 25.4MM .058 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200005J
K200005J
LI 90.0 X 25.4MM .047 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200006
K200006
LI 90.0 X 25.4MM .039 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200006I
K200006I
LI 90.0 X 25.4MM .039 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200007
K200007
LI 90.0 X 12.5MM .054 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200008
K200008
LI 90.0 X 12.5MM .039 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200021
K200021
MD 90.0 X 19.0MM .054 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200021T
K200021T
MD 90.0 X 19.0MM .054 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200022
K200022
MD 90.0 X 19.0MM .039 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200023
K200023
MD 90.0 X 31.0MM .054 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200024
K200024
MD 90.0 X 31.0MM .039 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200025
K200025
MD 90.0 X 25.4MM .054 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200025I
K200025I
MD 90.0 X 25.4MM .058 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
PAGE 138
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
K200025J
K200025J
MD 90.0 X 25.4MM .047 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200026
K200026
MD 90.0 X 25.4MM .039 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200026F
K200026F
MD 90.0 X 25.4MM .035 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200026I
K200026I
MD 90.0 X 25.4MM .039 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200027
K200027
MD 90.0 X 12.5MM .054 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K2000302
K2000302
ST 85.0 X 25.0MM .035 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K2000305
K2000305
ST 70.0 X 25.0MM .015 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K2000328
K2000328
ST 95.0 X 25.0MM .050 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200041
K200041
ST 90.0 X 19.0MM .054 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200042
K200042
ST 90.0 X 19.0MM .039 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200043
K200043
ST 90.0 X 31.0MM
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200045
K200045
ST 90.0 X 25.4MM .054 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200045I
K200045I
ST 90.0 X 25.4MM .058 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
PAGE 139
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
K200045J
K200045J
ST 90.0 X 25.4MM .047 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200046
K200046
ST 90.0 X 25.4MM .039 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200047
K200047
ST 90.0 X 12.5MM .054 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K2000501
K2000501
SY 70.0 X 19.0MMM .039 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K2000503
K2000503
SY 70.0 X 25.4MM .035 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K2000504
K2000504
SY 70.0 X 25.4MM .039 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K2000505
K2000505
SY 70.0 X 25.4MM .047 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K2000507
K2000507
SY 50.0 X 25.4MM .035 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K2000508
K2000508
SY 50.0 X 12.5MM .035 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200051
K200051
SY 90.0 X 19.0MM .054 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200051T
K200051T
SY 90.0 X 19.0MM .054 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200052
K200052
SY 90.0 X 19.0MM .039 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200053
K200053
SY 90.0 X 31.0MM .054 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
PAGE 140
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
K200055
K200055
SY 90.0 X 25.4MM .054 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200055I
K200055I
SY 90.0 X 25.4MM .058 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200055J
K200055J
SY 90.0 X 25.4MM .047 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200056
K200056
SY 90.0 X 25.4MM .039 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200056I
K200056I
SY 90.0 X 25.4MM .039 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200057
K200057
SY 90.0 X 12.5MM .054 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200058
K200058
SY 90.0 X 12.5MM .039 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200061
K200061
ST 90.0 X 19.5MM .054 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200062
K200062
ST 90.0 X 19.5MM .039 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200063
K200063
ST 90.0 X 31.0MM .054 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200064
K200064
ST 90.0 X 31.0MM .039 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200065
K200065
ST 90.0 X 25.4MM .054 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200065I
K200065I
ST 90.0 X 25.4MM .058 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
PAGE 141
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
K200065J
K200065J
ST 90.0 X 25.4MM .047 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200065T
K200065T
ST 90.0 X 25.4MM .054 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200066
K200066
ST 90.0 X 25.4MM .039 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200066I
K200066I
ST 90.0 X 25.4MM .039 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200066IS
K200066IS
LI 25.0 X 90.0MM .039 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200067
K200067
ST 90.0 X 12.5MM .054 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200067J
K200067J
ST 90.0 X 12.5MM .047 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200068
K200068
ST 90.0 X 12.5MM .039 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200069
K200069
ST 100.0 X 19.0MM .047 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200071
K200071
ST 90.0 X 19.0MM .054 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200072
K200072
LI 90.0 X 19.0MM .039 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200073
K200073
LI 90.0 X 31.0MM .054 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200074
K200074
LI 90.0 X 31.0MM .039 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
PAGE 142
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
K200075
K200075
LI 90.0 X 25.4MM .054 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200075I
K200075I
LI 90.0 X 25.4MM .054 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200075J
K200075J
LI 90.0 X 25.4MM .047 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200076
K200076
LI 90.0 X 25.4MM .039 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200076I
K200076I
LI 90.0 X 25.4MM .039 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200077
K200077
LI 90.0 X 12.5MM .054 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K200078
K200078
LI 90.0 X 12.5MM .039 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K6129035
K6129035
ST 90.0 X 12.0MM
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K6129039
K6129039
ST 90.0 X 12.0MM
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K6129050
K6129050
ST 90.0 X 12.0MM
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K61910050
K61910050
ST 100.0 X 19.0MM
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K6197535
K6197535
ST 75.0 X 19.0MM
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K6199035
K6199035
ST 90.0 X 19.0MM
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
PAGE 143
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
K6199050
K6199050
ST 90.0 X 19.0MM
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K6199054
K6199054
ST 90.0 X 19.0MM
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K62510050
K62510050
ST 100.0 X 25.0MM
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K6257535
K6257535
ST 75.0 X 25.0MM
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K6259035
K6259035
ST 90.0 X 25.0MM
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K6259039
K6259039
ST 90.0 X 25.0MM
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K6259047
K6259047
ST 90.0 X 25.0MM
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K6259050
K6259050
ST 90.0 X 25.0MM
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K6259054
K6259054
ST 90.0 X 25.0MM
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K6259058
K6259058
ST 90.0 X 25.0MM
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K7129035
K7129035
LI 90.0 X 12.5MM K2000
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K7129050
K7129050
LI 90.0 X 12.5MM K2000
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K7199035
K7199035
LI 90.0 X 19.0MM K2000
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
PAGE 144
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
K7199050
K7199050
LI 90.0 X 19.0MM K2000
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K7199054
K7199054
LI 90.0 X 19.0MM K2000
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K72510050
K72510050
LI 100.0 X 25.0MM K2000
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K7259035
K7259035
LI 90.0 X 25.0MM K2000
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K7259039
K7259039
LI 90.0 X 25.0MM K2000
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K7259047
K7259047
LI 90.0 X 25.0MM K2000
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K7259050
K7259050
LI 90.0 X 25.0MM K2000
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K7259054
K7259054
LI 90.0 X 25.0MM K2000
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
K7259058
K7259058
LI 90.0 X 25.0MM K2000
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM101L
KM101L
MD 90.0 X 19.0MM .062 OSC
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM102L
KM102L
MD 90.0 X 29.0MM .066 OSC
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM10P
KM10P
MD 53.6 X 9.4MM RECIP
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM1100
KM1100
ST 62.5/11.5MM CUT EDGE
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
PAGE 145
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
KM110010
KM110010
MD 90.0 X 25.4MM .050 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM110020
KM110020
ST 90.0 X 25.4MM .050 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM110030
KM110030
LI 90.0 X 25.4MM .050 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM110210
KM110210
ST 90.0 X 25.4MM .035 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM110220
KM110220
ST 90.0 X 25.4MM .035 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM110230
KM110230
MD 90.0 X 25.4MM .035 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM11065
KM11065
ST 13.0MM CUT EDGE
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM111070
KM111070
ST 60.0 X 12.4MM .035 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM111810
KM111810
MD 90.0 X 25.4MM .054 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM112010
KM112010
ST 90.0 X 25.4MM .056 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM112030
KM112030
MD 90.0 X 25.4MM .056 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM112040
KM112040
LI 90.0 X 25.4MM .056 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM112184
KM112184
ST 60.0 X 12.4MM .050 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
PAGE 146
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
KM112212
KM112212
ST 90.0 X 25.4MM .050 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM112213
KM112213
ST 90.0 X 25.4MM .035 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM112214
KM112214
60.0 X 12.7MM .035 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM112215
KM112215
ST 60.0 X 12.5MM .054 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM112217
KM112217
ST 84.5 X 25.4MM .035 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM112220
KM112220
ST 90.0 X 25.0MM .058 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM112222
KM112222
ST 90.0 X 25.5MM .049 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM112235
KM112235
MD 90.0 X 12.4MM .035 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM112236
KM112236
LI 90.0 X 12.4MM .035 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM112261
KM112261
LI 90.0 X 12.4MM .035 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM112269
KM112269
LI 90.0 X 25.4MM .035 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM112270
KM112270
LI 90.0 X 25.4MM .050 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM112324
KM112324
ST 85.0 X 12.7MM .035 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
PAGE 147
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
KM112325
KM112325
ST 90.0 X 12.7MM .050 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM11P
KM11P
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM120136
KM120136
MD 19.5 X 86MM 1.27MM
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM120144
KM120144
LI 86.0 X 19.5MM .050 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM120176
KM120176
ST 19.5 X 86MM 1.27MM
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM120184
KM120184
SY 19.5 X 86MM 1.27MM
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM12P
KM12P
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM13P
KM13P
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM155236
KM155236
MD 13.5 X 64MM 0.9MM
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM155272
KM155272
ST 60.0 X 13.5 .09MM
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM155284
KM155284
SY 64.0 X 13.5MM .035 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM193L
KM193L
MD 90.0 X 25.0MM .039 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM195L
KM195L
MD 25.0 X 9.5MM .025 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
PAGE 148
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
KM196L
KM196L
MD 85.0 X 25.4MM .054 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM197L
KM197L
MD 90.0 X 19.5MM .054 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM198L
KM198L
MD 90.0 X 30.0MM .054 IN
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM205L
KM205L
MD 85.0 X 31.0MM .039 OS
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM21L
KM21L
MD 60.0 X 15.5MM .062 OSC
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM227937
KM227937
MD 12.5 X 76MM 0.9MM
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM227973
KM227973
ST 71.6 X 12.7MM
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM22L
KM22L
MD 61.5 X 31.5MM .062 OSC
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM23L
KM23L
MD 60.0 X 15.5MM .043 OSC
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM24L
KM24L
MD 61.5 X 31.5MM .044 OSC
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM250R
KM250R
ST 60.0 X 6.35MM RECIP
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM251
KM251
LI 60.0X32.0MM OSC
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM256
KM256
LI 60.0X33.0MM OSC
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
PAGE 149
Product #
EDI Item #
Item Description
Header 1
Header 2
Product Type
Description
Product
2011 HCPCS Code
(If Applicable)
Payment System
2011 Long HCPCS
Descriptior
Comment 1
Comment 2
Comment 3
KM25L
KM25L
MD 30.0 X 7.0MM .040 OSC
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM26L
KM26L
MD 60.0 X 15.2MM .062 OSC
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM272
KM272
LI 70.0X19.0MM OSC
Brasseler
Power Tools Bone
N/A
N/A
separately payable.
KM274
KM274
LI 80.0X19.0MM OSC
Brasseler
BS BOPS Blades - Large

Zimmer Surgical Products to HCPCS Code Crosswalk

Transcription

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