Prior Authorization Code Updates

2012 Prior Auth Code Changes, effective February 1, 2012
Codes Removed for 2012
Code
00190
43752
43760
43761
43765
44139
46930
49653
49655
49657
54161
55706
93351
93352
93455
93797
93798
A7017
A7020
A7042
B9004
B9006
C1713
C1715
C1717
C1721
C1722
C1760
C1762
C1763
C1766
C1768
C1769
C1770
C1771
C1772
C1773
C1776
C1777
C1778
C1779
C1780
C1781
Code Description
anes facial b1s/skl nos
naso/oro-gastric tube plmt req phys&fluor gdn
change gastrostomy tube percutaneous w/o guide
reposition gastric feeding tube thru duodenum
CHANGE OF GASTROSTOMY TUBE COMPLICATED
moblj splenic flxr pfrmd conjunct w/prtl colct
EXCISION CONDYLOMATA ANAL COMPLICATED
LAP RPR HRNA XCPT INCAL/INGUN NCRC8/STRANGULATED
incarcerated or strangulated hernia repair
laps rpr recurrent incal hrna ncrc8/stangulated
circumcision >28 days
Prostate biopsies, stereotactic template
ECHO TTHRC R-T 2D -+M-MODE REST&STRS CONT ECG
echocardographic contrast agent during stress echocardiography
CORONARY ART/GRFT ANGIO S
phys svcs f/o/p car rhab w/o cont ecg mntr
phys svcs f/o/p car rhab w/cont ecg mntr
Nebulizer not used w oxygen
Sterile H2O or NSS w lgv neb
Implanted pleural catheter
Parenteral infus pump portab
Parenteral infus pump statio
Anchor/screw bn/bn,tis/bn
Brachytherapy needle
Brachytx, non-str,HDR Ir-192
AICD, dual chamber
AICD, single chamber
Closure dev, vasc
Conn tiss, human(inc fascia)
Conn tiss, non-human
Intro/sheath,strble,non-peel
Graft, vascular
Guide wire
Imaging coil, MR, insertable
Rep dev, urinary, w/sling
Infusion pump, programmable
Ret dev, insertable
Joint device (implantable)
Lead, AICD, endo single coil
Lead, neurostimulator
Lead, pmkr, transvenous VDD
Lens, intraocular (new tech)
Mesh (implantable)
1111.MM.P.WM 12/11
Managed Health Services
1099 N. Meridian Street, Suite 400 • Indianapolis, IN 46204 • (877) 647-4848 • mhsindiana.com
C1782
C1784
C1785
C1786
C1787
C1788
C1789
C1813
C1815
C1816
C1817
C1874
C1875
C1876
C1877
C1878
C1879
C1880
C1881
C1882
C1883
C1891
C1892
C1893
C1895
C1896
C1897
C1898
C1899
C2615
C2617
C2619
C2620
C2621
C2622
C2625
C2626
C2629
C2631
E0320
E0325
E0326
E0330
E0570
E0571
E0572
E0574
E0575
Morcellator
Ocular dev, intraop, det ret
Pmkr, dual, rate-resp
Pmkr, single, rate-resp
Patient progr, neurostim
Port, indwelling, imp
Prosthesis, breast, imp
Prosthesis, penile, inflatab
Pros, urinary sph, imp
Receiver/transmitter, neuro
Septal defect imp sys
Stent, coated/cov w/del sys
Stent, coated/cov w/o del sy
Stent, non-coa/non-cov w/del
Stent, non-coat/cov w/o del
Matrl for vocal cord
Tissue marker, implantable
Vena cava filter
Dialysis access system
AICD, other than sing/dual
Adapt/ext, pacing/neuro lead
Infusion pump,non-prog, perm
Intro/sheath,fixed,peel-away
Intro/sheath, fixed,non-peel
Lead, AICD, endo dual coil
Lead, AICD, non sing/dual
Lead, neurostim test kit
Lead, pmkr, other than trans
Lead, pmkr/AICD combination
Sealant, pulmonary, liquid
Stent, non-cor, tem w/o del
Pmkr, dual, non rate-resp
Pmkr, single, non rate-resp
Pmkr, other than sing/dual
Prosthesis, penile, non-inf
Stent, non-cor, tem w/del sy
Infusion pump, non-prog,temp
Intro/sheath, laser
Rep dev, urinary, w/o sling
BEDPAN,INCLUDES FRAC AND STAND. PANS
Urinal male jug-type
Urinal female jug-type
URINAL,MALE,DAY/NIGHT
Nebulizer with compression
Aerosol compressor for svneb
Aerosol compressor adjust pr
Ultrasonic generator w svneb
Nebulizer ultrasonic
1111.MM.P.WM 12/11
Managed Health Services
1099 N. Meridian Street, Suite 400 • Indianapolis, IN 46204 • (877) 647-4848 • mhsindiana.com
E0580
E0585
E0600
E0603
E0607
E0610
E0615
E0617
E0618
E0619
E0779
E0780
E0781
E0782
E0783
E0785
E0785
E0786
E0786
E0790
E0791
E1066
E1069
E1353
E1355
E1356
E1360
E1370
E1371
E1372
E1373
E1374
E1405
E1406
E2206
E2210
E2211
E2212
E2213
E2214
E2215
E2216
E2217
E2218
E2219
E2220
E2221
E2222
Nebulizer for use w/ regulat
Nebulizer w/ compressor & he
Suction pump portab hom modl
Personal Electronic Breast Pump
Blood glucose monitor home
Pacemaker monitr audible/vis
Pacemaker monitr digital/vis
Automatic ext defibrillator
Apnea monitor
Apnea monitor w recorder
Amb infusion pump mechanical
Mech amb infusion pump <8hrs
External ambulatory infus pu
Non-programble infusion pump
Programmable infusion pump
Replacement impl pump cathet
Replacement impl pump cathet
Implantable pump replacement
Implantable pump replacement
PARENT INFUSION PUMP
XREF E0791
Parenteral infusion pump sta
Wheelchair battery charger
Wheelchair deep cycle batter
Oxygen supplies regulator
Oxygen supplies stand/rack
BREATHING CIRCUITS XREF A4618
REPLACE,SUPPLY,ACC.FOR EFF USE DME,OWNED/PAT
COMPRESSED AIR CYLINDER PER CUBIC FOOT
FACE TENT XREF A4619
Oxy suppl heater for nebuliz
TRACH MASK OR COLLAR XREF A4621
VARIABLE CONCENTRATION MASK XREF A4620
O2/water vapor enrich w/heat
O2/water vapor enrich w/o he
Complete wheel lock assembly
Wheelchair bearings
Pneumatic propulsion tire
Pneumatic prop tire tube
Pneumatic prop tire insert
Pneumatic caster tire each
Pneumatic caster tire tube
Foam filled propulsion tire
Foam filled caster tire each
Foam propulsion tire each
Foam caster tire any size ea
Solid propulsion tire each
Solid caster tire each
Solid caster integrated whl
1111.MM.P.WM 12/11
Managed Health Services
1099 N. Meridian Street, Suite 400 • Indianapolis, IN 46204 • (877) 647-4848 • mhsindiana.com
E2223
E2224
E2225
E2226
E2227
E2228
E2364
E2365
E2366
E2371
E2372
G0108
G0109
K0043
K0044
K0045
K0059
K0060
K0061
K0062
K0063
K0064
K0066
K0067
K0068
K0074
K0075
K0076
K0078
K0079
K0080
K0081
K0082
K0083
K0084
K0085
K0086
K0087
K0088
K0089
K0090
K0091
K0092
K0093
K0094
K0095
K0096
K0097
Valve replacement only each
Propulsion whl excludes tire
Caster wheel excludes tire
Caster fork replacement only
Gear reduction drive wheel
Mwc acc, wheelchair brake
U1nonsealed leadacid battery
U1 sealed leadacid battery
Battery charger, single mode
Gr27 sealed leadacid battery
Gr27 non-sealed leadacid
Diab manage trn per indiv
Diab manage trn ind/group
Ftrst lower extension tube
Ftrst upper hanger bracket
Footrest complete assembly
Plastic coated handrim each
Steel handrim each
Aluminum handrim each
Handrim 8-10 vert/obliq proj
Hndrm 12-16 vert/obliq proj
Zero pressure tube flat free
Solid tire any size each
Pneumatic tire any size each
Pneumatic tire tube each
Pneumatic caster tire each
Semi-pneumatic caster tire
Solid caster tire each
Pneumatic caster tire tube
Wheel lock extension pair
Anti-rollback device pair
Wheel lock assembly complete
22 nf nonsealed leadacid
22nf sealed leadacid battery
Gr24 nonsealed leadacid
Gr24 sealed leadacid battery
U1nonsealed leadacid battery
U1 sealed leadacid battery
Battery charger, single mode
Battery charger, dual mode
Rear tire power wheelchair
Rear tire tube power whlchr
Rear assem cmplt powr whlchr
Rear zero pressure tire tube
Wheel tire for power base
Wheel tire tube each base
Wheel assem powr base complt
Wheel zero presure tire tube
1111.MM.P.WM 12/11
Managed Health Services
1099 N. Meridian Street, Suite 400 • Indianapolis, IN 46204 • (877) 647-4848 • mhsindiana.com
K0098
K0099
K0104
K0106
K0107
K0733
L3915
L8615
L8619
Q0478
Q0479
Q3001
V5070
V5080
V5150
V5190
V5230
Drive belt power wheelchair
Pwr wheelchair front caster
Cylinder tank carrier
Arm trough each
Wheelchair tray
12-24hr sealed lead acid
WHO w nontor jnt(s) prefab
Coch implant headset replace
Replace cochlear processor
POWER ADAPTER, COMBO VAD
POWER MODULE COMBO VAD, R
Brachytherapy Radioelements
Glasses air conduction
Glasses bone conduction
Glasses binaural hearing aid
Glasses cros hearing aid
Glasses bicros hearing aid
1111.MM.P.WM 12/11
Managed Health Services
1099 N. Meridian Street, Suite 400 • Indianapolis, IN 46204 • (877) 647-4848 • mhsindiana.com
2012 Code Additions to Complete Code Sets
Code
11970
11971
11975
11976
11977
14301
14302
14350
19307
19370
19371
19396
19499
21206
21210
21215
21230
21235
21240
21242
21243
21244
21245
21246
21247
21248
21249
21255
21256
21260
21261
21263
21267
21268
21299
37501
37761
38204
42842
42844
42845
42860
42870
42890
42892
Description of code
REPLACEMENT OF TUSSUE EXP
REMOVAL OF TISSUE EXPANDE
INSERTION OR REINSERTION TISSUE EXPANSION
REMOVAL WITHOUT REINSERTI
REMOVAL WITH REINSERTION
SKIN TISSUE REARRANGEMENT
SKIN TISSUE REARRANGE ADD
FILLETED FINGER OR TOE FL
mast modf rad w/ax lymph nod w/wo pect/alis min
opn priprostc capsul brst
priprostc capslctomy brst
prepj moulage custom brst implt
unlis px brst
osteot maxl sgmtl
grf b1 nsl max/malar areas
grf b1 mndbl
grf rib crtlg autog f/c/n/e
grf ear crtlg autog nose/ear
arthrp tmprmand jt +-agrft
arthrp tmprmand jt w/algrft
arthrp tmprmand jt w/prostc jt rplcmt
rcnstj mndbl xtroral w/transosteal b1 plate
rcnstj mndbl/maxl subpriosteal implt prtl
rcnstj mndbl/maxl subpriosteal implt compl
rcnstj mndblr condyle w/b1 cartlg agrfts
rcnstj mndbl/maxl endosteal implt prtl
rcnstj mndbl/maxl endosteal implt compl
rcnstj zygmtc arch/glenoid fossa w/b1 cartlg
rcnstj orbit w/osteot&w/b1 grfs
pri/bital osteot hyptlsm w/b1 grfs xtrc
pri/bital osteot hyptlsm w/b1 grfs intra-&xtrc
pri/bital osteot hyptlsm w/b1 grfs w/fhd
orb rpsg osteot uni w/b1 grfs xtrc
orb rpsg osteot uni w/b1 grfs intra-&xtrc
unlis cranfcl&maxlfcl px
unlis vasc ndsc px
LIGATE LEG VEINS OPEN
mgmt rcp hematop progenitor cell don search&cell
rad rescj tonsil w/o clsr
rad rescj tonsil clsr w/local flap
rad rescj tonsil clsr w/oth flap
exc tonsil tags
exc/dstrj lngl tonsil any meth spx
lmtd pharyngectomy
rescj lat phrngl wall/pyriform sinus dir clsr
1111.MM.P.WM 12/11
Managed Health Services
1099 N. Meridian Street, Suite 400 • Indianapolis, IN 46204 • (877) 647-4848 • mhsindiana.com
42894
42900
42950
42953
42972
42999
43260
43261
43262
43263
43264
43265
43267
43268
43269
43653
43659
43860
43865
43999
44799
47560
47561
47579
47630
47740
47741
48999
49650
49651
49659
49900
49904
49905
49906
49999
54164
58346
58548
58550
58552
58553
58554
58570
58571
58572
58573
58578
rescj pharyngeal wall req clsr w/myoq flap
sutr pharynx wnd/inj
pharyngoplasty plstc/rcnstv opration pharynx
pharyngoesophgl rpr
ctrl nasphryngl hemrrg 1/2 w/sec surg ivntj
unlis px pharynx adenoids/tonsils
ercp dx collj spec br/wa spx
ercp w/bx 1/mlt
ercp w/sphnctrotomy/papillotomy
ercp w/press meas sphnctr oddi
ercp w/rmvl st1/calculi biliary&/pncrtc duxs
ercp w/dstrj lithotrp st1/calculi any meth
ercp w/insj nasobiliary/nasopncrtc drg tube
ercp w/insj tube/stent bile/pncrtc dux
ercp w/rtrgr rmvl fb&/chng tube/stent
laps surg gastrostomy w/o constj gstr tube spx
unlis laps px stomach
REVISION OF GASTROJEJUNAL
REVISION OF GASTROJEJUNAL
unlis px stomach
UNLISTED PROCEDURE, INTES
laps surg w/gid transhepatc cholangrph w/o bx
laps surg w/gid transhepatc cholangrph w/bx
unlis laps px biliary trc
BILIARY DUCT STONE EXTRAC
CHOLECYSTOENTEROSTOMY; RO
RX-Y/GASTROENTEROSTOMY
unlis px pncrs
LAP ING HERNIA REPAIR INI
LAP ING HERNIA REPAIR REC
LAPARO PROC HERNIA REPAIR
SUTURE, SECONDARY, OF ABD
OMENTAL FLAP EXTRA-ABDOM
OMENTAL FLAP INTRA-ABDOM
FREE OMENTAL FLAP MICROVA
UNLISTED PROCEDURE, ABDOM
frenulotomy pns
insj heyman capsls clinical brachytx
LAP RADICAL HYST
laps w/vag hyst 250 gm/<
LAPARO-VAG HYST INCL T/O
LAPARO-VAG HYST COMPLEX
LAPARO-VAG HYST W/T/O COM
laparoscopy w total hysterectomy uterus 250 g/<
laps total hysterectomy 250 g/< w tube/ovary
laparoscopy total hysterectomy uterus > 250 g
laparoscopy tot hysterectomy > 250 g w tube/ovary
unlis laps uter
1111.MM.P.WM 12/11
Managed Health Services
1099 N. Meridian Street, Suite 400 • Indianapolis, IN 46204 • (877) 647-4848 • mhsindiana.com
58660
58662
58999
59897
59898
64400
64402
64405
64410
64412
64413
64415
64416
64417
64418
64420
64421
64425
64430
64435
64445
64446
64447
64448
64449
64450
64479
64480
64483
64484
64490
64491
64492
64493
64494
64495
64505
64508
64510
64517
64520
64530
64553
64555
64560
64561
64565
64566
laps lss ads spx
laps fulg/exc ovary viscera/prtl surf
UNLISTED PROCEDURE, FEMAL
FETAL INVAS PX W/US
unlis laps maternity care&dlvr
njx anes trigeminal nrv any div/branch
njx anes facial nrv
njx anes grter occipital nrv
njx anes phrenic nrv
njx anes spi accessory nrv
njx anes crv plexus
single nerve block injection, arm nerve
njx anes brach plexus cont nfs cath daily mgmt
njx anes ax nrv
njx anes suprascapular nrv
njx anes intercostal nrv 1
multiple nerve block injections, rib nerves
njx anes ilioingun iliohypogstr nrv
njx anes pudendal nrv
njx anes paracrv nrv
njx anes sciatic nrv 1
njx anes sciatic nrv cont nfs daily mgmt
njx anes fem nrv 1
njx anes fem nrv cont nfs daily mgmt
njx anes lmbr plexus post cont nfs daily mgmt
N BLOCK OTHER PERIPHERAL
njx anes&/strd tfrml edrl crv/thrc 1 lvl
njx anes&/strd tfrml edrl crv/thrc ea lvl
njx anes&/strd tfrml edrl lmbr/sac 1 lvl
njx anes&/strd tfrml edrl lmbr/sac ea lvl
INJ PARAVERT F JNT C/T 1 LEV
INJ PARAVERT F JNT C/T 2 LEV
INJ PARAVERT F JNT C/T 3 LEV
INJ PARAVERT F JNT L/S 1 LEV
INJ PARAVERT F JNT L/S 2 LEV
INJ PARAVERT F JNT L/S 3 LEV
njx anes sphenopalatine ganglion
njx anes crtd sinus spx
njx anes stellate ganglion crv sympathetic
njx anes suprior hypogstr plexus
njx anes lmbr/thrc pvrt sympathetic
njx anes celiac plexus +-rad mntr
prq impltj nstim eltrds crnl nrv
prq impltj nstim eltrds prph nrv
prq impltj nstim eltrds autonomic nrv
prq impltj nstim eltrds sac nrv
prq impltj nstim eltrds neuromuscular
NEUROELTRD STIM POST TIBI
1111.MM.P.WM 12/11
Managed Health Services
1099 N. Meridian Street, Suite 400 • Indianapolis, IN 46204 • (877) 647-4848 • mhsindiana.com
64575
64577
64580
64581
64585
64600
64605
64610
64611
64612
64613
64614
64620
64622
64623
64626
64627
64630
64632
64640
64650
64653
64680
64681
64702
64704
64708
64712
64713
64714
64716
64718
64719
64721
64722
64726
64727
64732
64734
64736
64738
64740
64742
64744
64746
64761
64763
64766
inc impltj nstim eltrds prph nrv
inc impltj nstim eltrds autonomic nrv
inc impltj nstim eltrds neuromuscular
inc impltj nstim eltrds sac nrv
revj/rmvl prph nstim eltrds
dstrj trigeminal nrv supraorb infraorb branch
dstrj nulyt trigeminal nrv 2/3 div
dstrj nulyt trigeminal nrv 2/3 div rad mntr
CHEMODENERV SALIV GLANDS
chemodnrvtj musc musc innervated facial nrv
chemodnrvtj musc nck musc
chemodnrvtj musc xtr&/trnk musc
dstrj nulyt intercostal nrv
dstrj nulyt pvrt facet jt nrv lmbr/sac 1 lvl
dstrj nulyt pvrt facet jt nrv lmbr/sac ea lvl
dstrj nulyt pvrt facet jt nrv crv/thrc 1 lvl
dstrj nulyt pvrt facet jt nrv crv/thrc ea lvl
dstrj nulyt pudendal nrv
N BLOCK INJ COMMON DIGIT
dstrj nulyt oth prph nrv/branch
chemodnrvtj eccrine glnds bth ax
chemodnrvtj eccrine glnds oth area pr d
dstrj nulyt +-rad mntr celiac plexus
dstrj nulyt +-rad mntr suprior hypogstr plexus
neurp dgtal 1/bth sm dgt
neurp nrv hand/foot
neurp major prph nrv arm/leg oth/thn specified
neurp major prph nrv arm/leg sciatic nrv
neurp major prph nrv arm/leg brach plexus
neurp major prph nrv arm/leg lmbr plexus
neurp&/trpos crnl nrv
neurp&/trpos ur nrv elbw
neurp&/trpos ur nrv wrst
neurp&/trpos median nrv carpl tunnel
dcmprn unspecified nrv
dcmprn plntar dgtal nrv
int neurolss req mcrscp
trnsxj/avlsn supraorb nrv
trnsxj/avlsn infraorb nrv
trnsxj/avlsn mental nrv
trnsxj/avlsn inf alveolar nrv osteom
trnsxj/avlsn lngl nrv
trnsxj/avlsn facial nrv diffial/compl
trnsxj/avlsn grter occipital nrv
trnsxj/avlsn phrenic nrv
trnsxj/avlsn pudendal nrv
trnsxj/avlsn obturator nrv xtrpel
trnsxj/avlsn obturator nrv intrapel
1111.MM.P.WM 12/11
Managed Health Services
1099 N. Meridian Street, Suite 400 • Indianapolis, IN 46204 • (877) 647-4848 • mhsindiana.com
64771
64772
64774
64776
64778
64782
64783
64784
64786
64787
64788
64790
64792
64795
65750
65755
65757
67911
67912
67961
67966
67971
67973
67974
67975
67999
69310
69320
69399
69949
71550
71551
71552
71555
74775
75600
75605
75625
75630
75635
76498
76499
78414
78428
78445
78456
78457
78458
trnsxj/avlsn oth crnl nrv xdrl
trnsxj/avlsn oth spi nrv xdrl
exc neuroma cutan nrv surgly identifiable
exc neuroma dgtal nrv 1/bth sm dgt
exc neuroma dgtal nrv ea dgt
exc neuroma hand/foot xcp dgtal nrv
exc neuroma hand/foot ea nrv xcp sm dgt
exc neuroma major prph nrv xcp sciatic
exc neuroma sciatic nrv
impltj nrv end in b1/musc
exc neurofibroma/neurolemmoma cutan nrv
exc neurofibroma/neurolemmoma major prph nrv
exc neurofibroma/neurolemmoma x10sv
bx nrv
keratoplasty pentrg aphk
keratoplasty pentrg pseudophakia
PREP CORNEAL ENDO ALLOGRA
corrj lid retrcj
corrj lagophthalmos impltj upr eyelid lid load
exc&rpr eyelid < one-4th lid mrgn
exc&rpr eyelid > one-4th lid mrgn
rcnstj eyelid full thkns < 2-3rd 1 stg
rcnstj eyelid full thkns tot lwr 1 stg
rcnstj eyelid full thkns tot upr 1 stg
rcnstj eyelid full thkns 2nd stg
unlis eyelids
RECONSTRUCTION OF EXTERNA
RECONSTRUCTION EXTERNAL A
UNLISTED PROCEDURE, EXTER
unlis inner ear
MAGNETIC IMAGE, CHEST (MR
MRI CHEST W/DYE
MRI CHEST W/O & W DYE
MAGNETIC IMAGE, CHEST (MR
PERINEOGRAM (EG, VAGINOGR
AORTOGRAPHY, THORACIC, WI
AORTOGRAPHY, THORACIC, BY
AORTOGRAPHY, ABDOMINAL, T
X-RAY AORTA LEG ARTERIES
CT ANGIO ABDOMINAL ARTERI
MRI PROCEDURE
UNLISTED DIAGNOSTIC RADIO
deter ctr c-v hemodyn non-img +-rx 1/mlt
car shunt detcj
non-car vasc flo img
aqt ven thrombosis img peptide
ven thrombosis img venogram uni
ven thrombosis img venogram bi
1111.MM.P.WM 12/11
Managed Health Services
1099 N. Meridian Street, Suite 400 • Indianapolis, IN 46204 • (877) 647-4848 • mhsindiana.com
78660
78699
78730
78740
78761
78799
78999
90935
90937
90940
90945
90947
90956
90959
90962
90963
90965
90970
90982
90983
90984
90985
99341
99342
99343
99344
99345
99347
99348
99349
99350
99499
99501
99502
99504
99510
B4100
E0182
E0184
E0185
E0186
E0191
E0193
E0194
E0196
E0197
E0198
E0200
DACRYOCYSTOGRAPHY (LACRIM
UNLISTED NERVOUS SYSTEM P
URINARY BLADDER RESIDUAL
URETERAL REFLUX STUDY
TESTICULAR IMAGING/FLOW
UNLISTED GENITOURINARY PR
UNLISTED MISCELLANEOUS PR
HEMODIALYSIS ONE EVALUATI
HEMODIALYSIS REPEATED EVA
HEMODIALYSIS ACCESS STUDY
DIALYSIS ONE EVALUATION
DIALYSIS REPEATED EVAL
HEMODIALYSIS MAINT 21 40KG
ESRD SERV 1 VST P MO 12-1
ESRD SERV 1 VISIT P MO 20
ESRD HOME PT SERV P MO <2
ESRD HOME PT SERV P MO 12
ESRD HOME PT SERV P DAY 2
PERITONEAL DIALYSIS CHRONIC MAIN OVER 40
PERITONEAL DIALYSIS CHRONIC MAIN 21-40KG
PERITONEAL DIALYSIS CHRONIC MAIN 11-20KG
PERITONEAL DIALYSIS CHRONIC MAIN UNDERIO
HOME VISIT NEW PATIENT
HOME VISIT NEW PATIENT
HOME VISIT NEW PATIENT
HOME VISIT NEW PATIENT
HOME VISIT NEW PATIENT
HOME VISIT EST PATIENT
HOME VISIT EST PATIENT
HOME VISIT EST PATIENT
HOME VISIT EST PATIENT
UNLISTED E&M SERVICE
home vst postnatal assmt&f-up care
home vst nb care&assmt
home vst mchnl vntj care
home vst indiv fam/marriage cnsl
FOOD THICKENER ORAL
Replace pump, alt press pad
Dry pressure mattress
Gel pressure mattress pad
Air pressure mattress
Protector heel or elbow
Powered air flotation bed
Air fluidized bed
Gel pressure mattress
Air pressure pad for mattres
Water pressure pad for mattr
HEAT LAMP, WITHOUT STAND
1111.MM.P.WM 12/11
Managed Health Services
1099 N. Meridian Street, Suite 400 • Indianapolis, IN 46204 • (877) 647-4848 • mhsindiana.com
E0202
E0225
E0238
E0239
E0433
E0487
E0656
E0657
E0676
E0840
E0849
E0850
E0855
E0856
E0860
E0870
E0880
E0890
E0900
E0910
E0911
E0912
E0920
E0930
E0935
E0936
E0940
E0941
E0942
E0944
E0945
E0946
E0947
E0948
E2230
G0154
G0155
G0156
K0739
K0762
L0113
L0120
L0130
L0140
L0150
L0160
L0450
L0468
PHOTOHERAPY (BILIRUBIN) L
Hydrocollator unit
NON-ELECTRIC HEAT PAD, MO
HYDROCOLLATOR UNIT, PORTA
PORTABLE LIQUID OXYGEN SY
ELECTRONIC SPIROMETER
SEGMENTAL PNEUMATIC TRUNK
SEGMENTAL PNEUMATIC CHEST
Inter limb compress dev NOS
TRACTION FRAME, ATTACHED
CERVICAL PNEUM TRAC EQUIP
TRACTION STAND, FREE STAN
CERVICAL TRACTION EQUIPME
CERVIC COLLAR W AIR BLADD
TRACTION EQUIPMENT, OVERD
TRACTION FRAME, ATTACHED
TRACTION STAND, FREE STAN
TRACTION FRAME, ATTACHED
TRACTION STAND, FREE STAN
TRAPEZE BARS, A/K/A PATIE
HD TRAPEZE BAR ATTACH TO
HD TRAPEZE BAR FREE STAND
FRACTURE FRAME, ATTACHED
FRACTURE FRAME, FREE STAN
PASSIVE MOTION EXERCISE D
CPM DEVICE, OTHER THAN KN
TRAPEZE BAR, FREE STANDIN
GRAVITY ASSISTED TRACTION
CERVICAL HEAD HARNESS/HAL
PELVIC BELT/HARNESS/BOOT
EXTREMITY BELT/HARNESS
FRACTURE, FRAME, DUAL WIT
FRACTURE FRAME, ATTACHMEN
FRACTURE FRAME, ATTACHMEN
MANUAL STANDING SYSTEM
HHCP-svs of rn,ea 15 min
HHCP-svs of csw,ea 15 min
HHCP-svs of aide,ea 15 min
REPAIR/SVC DME NON-OXYGEN
ADDITION TO LOWER EXTREMI
CRANIAL CERVICAL TORTICOL
Cerv flexible non-adjustable
Flex thermoplastic collar mo
Cervical semi-rigid adjustab
Cerv semi-rig adj molded chn
Cerv semi-rig wire occ/mand
TLSO flex prefab thoracic
TLSO rigid frame prefab pelv
1111.MM.P.WM 12/11
Managed Health Services
1099 N. Meridian Street, Suite 400 • Indianapolis, IN 46204 • (877) 647-4848 • mhsindiana.com
L0474
L0621
L0622
L0623
L0624
L0625
L0626
L0628
L0629
L0630
L0632
L0633
L0634
L0700
L0861
L0970
L0972
L0974
L0976
L0978
L0980
L0982
L0984
L0999
L1010
L1020
L1025
L1030
L1040
L1050
L1060
L1070
L1080
L1085
L1090
L1100
L1110
L1120
L1210
L1220
L1240
L1250
L1260
L1270
L1280
L1290
L1499
L1510
TLSO, TRIPLANAR CTRL, RIG
SIO flex pelvisacral prefab
SIO flex pelvisacral custom
SIO panel prefab
SIO panel custom
LO flexibl L1-below L5 pre
LO sag stays/panels pre-fab
LO flex w/o rigid stays pre
LSO flex w/rigid stays cust
LSO post rigid panel pre
LSO sag rigid frame cust
LSO flexion control prefab
LSO flexion control custom
Ctlso a-p-l control molded
Halo repl liner/interface
Tlso corset front
Lso corset front
Tlso full corset
Lso full corset
Axillary crutch extension
Peroneal straps pair
Stocking supp grips set of f
Protective body sock each
Add to spinal orthosis NOS
Ctlso axilla sling
Kyphosis pad
Kyphosis pad floating
Lumbar bolster pad
Lumbar or lumbar rib pad
Sternal pad
Thoracic pad
Trapezius sling
Outrigger
Outrigger bil w/ vert extens
Lumbar sling
Ring flange plastic/leather
Ring flange plas/leather mol
Covers for upright each
Lateral thoracic extension
Anterior thoracic extension
Lumbar derotation pad
Anterior asis pad
Anterior thoracic derotation
Abdominal pad
Rib gusset (elastic) each
Lateral trochanteric pad
Spinal orthosis NOS
Thkao standing frame
1111.MM.P.WM 12/11
Managed Health Services
1099 N. Meridian Street, Suite 400 • Indianapolis, IN 46204 • (877) 647-4848 • mhsindiana.com
L1600
L1610
L1620
L1630
L1650
L1660
L1810
L1820
L1830
L1836
L1850
L1900
L1902
L1906
L1910
L1930
L2035
L2040
L2180
L2182
L2184
L2186
L2188
L2190
L2192
L2200
L2210
L2220
L2230
L2232
L2240
L2260
L2265
L2270
L2275
L2300
L2310
L2320
L2335
L2360
L2370
L2375
L2380
L2385
L2387
L2390
L2395
L2397
Abduct hip flex frejka w cvr
Abduct hip flex frejka covr
Abduct hip flex pavlik harne
Abduct control hip semi-flex
HO abduction hip adjustable
HO abduction static plastic
Ko elastic with joints
Ko elas w/ condyle pads & jo
Ko immobilizer canvas longit
RIGID KO WO JOINTS
Ko swedish type
Afo sprng wir drsflx calf bd
Afo ankle gauntlet
Afo multiligamentus ankle su
Afo sing bar clasp attach sh
Afo plastic
KAFO plastic pediatric size
Hkafo torsion bil rot straps
Plas shoe insert w ank joint
Drop lock knee
Limited motion knee joint
Adj motion knee jnt lerman t
Quadrilateral brim
Waist belt
Pelvic band & belt thigh fla
Limited ankle motion ea jnt
Dorsiflexion assist each joi
Dorsi & plantar flex ass/res
Split flat caliper stirr & p
Rocker bottom, contact AFO
Round caliper and plate atta
Reinforced solid stirrup
Long tongue stirrup
Varus/valgus strap padded/li
Plastic mod low ext pad/line
ADDITION TO LOWER EXTREMI
ADDITION TO LOWER EXTREMI
NON-MOLDED LACER
Anterior swing band
Extended steel shank
Patten bottom
Torsion ank & half solid sti
Torsion straight knee joint
Straight knee joint heavy du
Add LE poly knee custom KAFO
Offset knee joint each
Offset knee joint heavy duty
Suspension sleeve lower ext
1111.MM.P.WM 12/11
Managed Health Services
1099 N. Meridian Street, Suite 400 • Indianapolis, IN 46204 • (877) 647-4848 • mhsindiana.com
L2405
L2415
L2425
L2430
L2492
L2500
L2530
L2600
L2610
L2620
L2622
L2630
L2640
L2650
L2660
L2670
L2680
L2750
L2755
L2760
L2768
L2770
L2780
L2785
L2795
L2800
L2810
L2820
L2830
L2840
L2850
L2999
L3000
L3001
L3002
L3003
L3010
L3020
L3030
L3031
L3040
L3050
L3060
L3070
L3080
L3090
L3100
L3140
Knee joint drop lock ea jnt
Knee joint cam lock each joi
Knee disc/dial lock/adj flex
Knee jnt ratchet lock ea jnt
Knee lift loop drop lock rin
Thi/glut/ischia wgt bearing
Thigh/wght bear lacer non-mo
Hip clevis/thrust bearing fr
Hip clevis/thrust bearing lo
Pelvic control hip heavy dut
Hip joint adjustable flexion
Pelvic control band & belt u
Pelvic control band & belt b
Pelv & thor control gluteal
Thoracic control thoracic ba
Thorac cont paraspinal uprig
Thorac cont lat support upri
Plating chrome/nickel pr bar
Carbon graphite lamination
Extension per extension per
Ortho sidebar disconnect
Low ext orthosis per bar/jnt
Non-corrosive finish
Drop lock retainer each
Knee control full kneecap
Knee cap medial or lateral p
Knee control condylar pad
Soft interface below knee se
Soft interface above knee se
Tibial length sock fx or equ
Femoral lgth sock fx or equa
Lower extremity orthosis NOS
Ft insert ucb berkeley shell
Foot insert remov molded spe
Foot insert plastazote or eq
Foot insert silicone gel eac
Foot longitudinal arch suppo
Foot longitud/metatarsal sup
Foot arch support remov prem
Foot lamin/prepreg composite
Ft arch suprt premold longit
Foot arch supp premold metat
Foot arch supp longitud/meta
Arch suprt att to sho longit
Arch supp att to shoe metata
Arch supp att to shoe long/m
Hallus-valgus nght dynamic s
Abduction rotation bar shoe
1111.MM.P.WM 12/11
Managed Health Services
1099 N. Meridian Street, Suite 400 • Indianapolis, IN 46204 • (877) 647-4848 • mhsindiana.com
L3150
L3160
L3170
L3201
L3202
L3203
L3204
L3206
L3207
L3208
L3209
L3211
L3212
L3213
L3214
L3251
L3252
L3253
L3260
L3265
L3300
L3310
L3320
L3330
L3332
L3334
L3340
L3350
L3360
L3370
L3380
L3390
L3400
L3410
L3420
L3430
L3440
L3450
L3455
L3460
L3465
L3470
L3480
L3485
L3500
L3510
L3520
L3530
Abduct rotation bar w/o shoe
Shoe styled positioning dev
Foot plastic heel stabilizer
Oxford w supinat/pronat inf
Oxford w/ supinat/pronator c
Oxford w/ supinator/pronator
Hightop w/ supp/pronator inf
Hightop w/ supp/pronator chi
Hightop w/ supp/pronator jun
Surgical boot each infant
Surgical boot each child
Surgical boot each junior
Benesch boot pair infant
Benesch boot pair child
Benesch boot pair junior
FOOT-SHOE MOLDED TO PATIE
FOOT-SHOE MOLDED TO PATIE
FOOT, MOLDED SHOE PLASTAZ
Ambulatory surgical boot eac
Plastazote sandal each
Sho lift taper to metatarsal
Shoe lift elev heel/sole neo
Shoe lift elev heel/sole cor
Lifts elevation metal extens
Shoe lifts tapered to one-ha
Shoe lifts elevation heel /i
Shoe wedge sach
Shoe heel wedge
Shoe sole wedge outside sole
Shoe sole wedge between sole
Shoe clubfoot wedge
Shoe outflare wedge
Shoe metatarsal bar wedge ro
Shoe metatarsal bar between
Full sole/heel wedge btween
Sho heel count plast reinfor
Heel leather reinforced
Shoe heel sach cushion type
Shoe heel new leather standa
Shoe heel new rubber standar
Shoe heel thomas with wedge
Shoe heel thomas extend to b
Shoe heel pad & depress for
Shoe heel pad removable for
Ortho shoe add leather insol
Orthopedic shoe add rub insl
O shoe add felt w leath insl
Ortho shoe add half sole
1111.MM.P.WM 12/11
Managed Health Services
1099 N. Meridian Street, Suite 400 • Indianapolis, IN 46204 • (877) 647-4848 • mhsindiana.com
L3540
L3550
L3560
L3570
L3580
L3590
L3595
L3600
L3610
L3620
L3630
L3640
L3649
L3650
L3660
L3670
L3674
L3675
L3677
L3702
L3710
L3762
L3766
L3807
L3808
L3890
L3912
L3913
L3919
L3921
L3923
L3925
L3927
L3929
L3931
L3933
L3935
L3956
L3970
L3972
L3974
L3982
L3984
L3995
L3999
L4002
L4045
L4205
Ortho shoe add full sole
O shoe add standard toe tap
O shoe add horseshoe toe tap
O shoe add instep extension
O shoe add instep velcro clo
O shoe convert to sof counte
Ortho shoe add march bar
Trans shoe calip plate exist
Trans shoe caliper plate new
Trans shoe solid stirrup exi
Trans shoe solid stirrup new
Shoe dennis browne splint bo
Orthopedic shoe modifica NOS
Shlder fig 8 abduct restrain
Abduct restrainer canvas&web
Acromio/clavicular canvas&we
SO AIRPLANE W/WO JOINT CF
Canvas vest SO
SO hard plastic stabilizer
EO w/o joints CF
Elbow elastic with metal joi
Rigid EO wo joints
EWHFO w/joint(s) CF
WHFO,no joint, prefabricated
WHFO, rigid w/o joints
Torsion mechanism wrist/elbo
Flex glove w/elastic finger
HFO w/o joints CF
HO w/o joints CF
HFO w/joint(s) CF
HFO w/o joints PF
FO pip/dip with joint/spring
FO pip/dip w/o joint/spring
HFO nontorsion joint, prefab
WHFO nontorsion joint prefab
FO w/o joints CF
FO nontorsion joint CF
Add joint upper ext orthosis
Elevat proximal arm support
Offset/lat rocker arm w/ ela
Mobile arm support supinator
Upper ext fx orthosis rad/ul
Upper ext fx orthosis wrist
Sock fracture or equal each
Upper limb orthosis NOS
Replace strap, any orthosis
Replace non-molded thigh lac
Ortho dvc repair per 15 min
1111.MM.P.WM 12/11
Managed Health Services
1099 N. Meridian Street, Suite 400 • Indianapolis, IN 46204 • (877) 647-4848 • mhsindiana.com
L4210
L4350
L4360
L4370
L4380
L4386
L4392
L4394
L4396
L4398
L5160
L5200
L5210
L5220
L5230
L5250
L5270
L5280
L5301
L5311
L5321
L5331
L5341
L5400
L5410
L5420
L5430
L5450
L5460
L5500
L5505
L5510
L5520
L5530
L5535
L5540
L5550
L5560
L5570
L5580
L5585
L5590
L5595
L5600
L5618
L5620
L5626
L5629
Orth dev repair/repl minor p
Ankle control orthosi prefab
Pneumati walking boot prefab
Pneumatic full leg splint
Pneumatic knee splint
Non-pneum walk boot prefab
Replace AFO soft interface
Replace foot drop spint
Static AFO
Foot drop splint recumbent
Mold socket bent knee shin s
Kne sing axis fric shin sach
No knee/ankle joints w/ ft b
No knee joint with artic ali
Fem focal defic constant fri
Hip canad sing axi cons fric
Tilt table locking hip sing
Hemipelvect canad sing axis
BK mold socket SACH ft endo
Knee disart, SACH ft, endo
AK open end SACH
Hip disart canadian SACH ft
Hemipelvectomy canadian SACH
Postop dress & 1 cast chg bk
Postop dsg bk ea add cast ch
Postop dsg & 1 cast chg ak/d
Postop dsg ak ea add cast ch
Postop app non-wgt bear dsg
Postop app non-wgt bear dsg
Init bk ptb plaster direct
Init ak ischal plstr direct
Prep BK ptb plaster molded
Perp BK ptb thermopls direct
Prep BK ptb thermopls molded
Prep BK ptb open end socket
Prep BK ptb laminated socket
PREP A/KN-DIS ISCH P.SUS USMC PLAS SOC D
Prep AK ischial plast molded
Prep AK ischial direct form
Prep AK ischial thermo mold
Prep AK ischial open end
Prep AK ischial laminated
Hip disartic sach thermopls
Hip disart sach laminat mold
Test socket symes
Test socket below knee
Test socket hip disarticulat
Below knee acrylic socket
1111.MM.P.WM 12/11
Managed Health Services
1099 N. Meridian Street, Suite 400 • Indianapolis, IN 46204 • (877) 647-4848 • mhsindiana.com
L5632
L5634
L5636
L5639
L5640
L5642
L5643
L5644
L5645
L5646
L5647
L5648
L5649
L5650
L5651
L5652
L5653
L5654
L5655
L5656
L5658
L5661
L5665
L5666
L5668
L5670
L5671
L5672
L5673
L5676
L5677
L5678
L5679
L5680
L5682
L5683
L5684
L5685
L5686
L5688
L5690
L5692
L5694
L5695
L5696
L5697
L5698
L5699
Symes type ptb brim design s
Symes type poster opening so
Symes type medial opening so
Below knee wood socket
Knee disarticulat leather so
Above knee leather socket
Hip flex inner socket ext fr
Above knee wood socket
Bk flex inner socket ext fra
Below knee cushion socket
Below knee suction socket
Above knee cushion socket
Isch containmt/narrow m-l so
Tot contact ak/knee disart s
Ak flex inner socket ext fra
Suction susp ak/knee disart
Knee disart expand wall sock
Socket insert symes
Socket insert below knee
Socket insert knee articulat
Socket insert above knee
Multi-durometer symes
Multi-durometer below knee
Below knee cuff suspension
Socket insert w/o lock lower
Bk molded supracondylar susp
BK/AK locking mechanism
Bk removable medial brim sus
Socket insert w lock mech
Bk knee joints single axis p
Bk knee joints polycentric p
Bk joint covers pair
Socket insert w/o lock mech
Bk thigh lacer non-molded
Bk thigh lacer glut/ischia m
Initial custom socket insert
Bk fork strap
Below knee sus/seal sleeve
Bk back check
Bk waist belt webbing
Bk waist belt padded and lin
Ak pelvic control belt light
Ak pelvic control belt pad/l
Ak sleeve susp neoprene/equa
Ak/knee disartic pelvic join
Ak/knee disartic pelvic band
Ak/knee disartic silesian ba
Shoulder harness
1111.MM.P.WM 12/11
Managed Health Services
1099 N. Meridian Street, Suite 400 • Indianapolis, IN 46204 • (877) 647-4848 • mhsindiana.com
L5701
L5702
L5703
L5704
L5705
L5706
L5707
L5710
L5711
L5712
L5714
L5716
L5718
L5722
L5724
L5726
L5728
L5780
L5781
L5782
L5785
L5790
L5795
L5810
L5811
L5812
L5814
L5816
L5818
L5822
L5824
L5826
L5828
L5830
L5840
L5845
L5848
L5850
L5855
L5856
L5857
L5858
L5910
L5920
L5925
L5930
L5940
L5950
Replace socket above knee
Replace socket hip
Symes ankle w/o (SACH) foot
Custom shape cover BK
Custom shape cover AK
Custom shape cvr knee disart
Custom shape cvr hip disart
Kne-shin exo sng axi mnl loc
Knee-shin exo mnl lock ultra
Knee-shin exo frict swg & st
Knee-shin exo variable frict
Knee-shin exo mech stance ph
Knee-shin exo frct swg & sta
Knee-shin pneum swg frct exo
Knee-shin exo fluid swing ph
Knee-shin ext jnts fld swg e
Knee-shin fluid swg & stance
Knee-shin pneum/hydra pneum
Lower limb pros vacuum pump
HD low limb pros vacuum pump
Exoskeletal bk ultralt mater
Exoskeletal ak ultra-light m
Exoskel hip ultra-light mate
Endoskel knee-shin mnl lock
Endo knee-shin mnl lck ultra
Endo knee-shin frct swg & st
Endo knee-shin hydral swg ph
Endo knee-shin polyc mch sta
Endo knee-shin frct swg & st
Endo knee-shin pneum swg frc
Endo knee-shin fluid swing p
Miniature knee joint
Endo knee-shin fluid swg/sta
Endo knee-shin pneum/swg pha
Multi-axial knee/shin system
Knee-shin sys stance flexion
Knee-shin sys hydraul stance
Endo ak/hip knee extens assi
Mech hip extension assist
Elec knee-shin swing/stance
Elec knee-shin swing only
Stance phase only
Endo below knee alignable sy
Endo ak/hip alignable system
Above knee manual lock
High activity knee frame
Endo bk ultra-light material
Endo ak ultra-light material
1111.MM.P.WM 12/11
Managed Health Services
1099 N. Meridian Street, Suite 400 • Indianapolis, IN 46204 • (877) 647-4848 • mhsindiana.com
L5960
L5962
L5964
L5966
L5968
L5970
L5971
L5972
L5973
L5974
L5975
L5976
L5978
L5979
L5980
L5981
L5982
L5984
L5985
L5986
L5987
L5988
L5990
L5999
L6000
L6010
L6020
L6025
L6050
L6055
L6100
L6110
L6120
L6130
L6200
L6205
L6250
L6300
L6310
L6320
L6350
L6360
L6370
L6380
L6382
L6384
L6386
L6388
Endo hip ultra-light materia
Below knee flex cover system
Above knee flex cover system
Hip flexible cover system
Multiaxial ankle w dorsiflex
Foot external keel sach foot
SACH foot, replacement
Flexible keel foot
ANK-FOOT SYS DORS-PLANT F
Foot single axis ankle/foot
Combo ankle/foot prosthesis
Energy storing foot
Ft prosth multiaxial ankl/ft
Multi-axial ankle/ft prosth
Flex foot system
Flex-walk sys low ext prosth
Exoskeletal axial rotation u
Endoskeletal axial rotation
Lwr ext dynamic prosth pylon
Multi-axial rotation unit
Shank ft w vert load pylon
Vertical shock reducing pylo
User adjustable heel height
Lowr extremity prosthes NOS
Par hand robin-aids thum rem
Hand robin-aids little/ring
Part hand robin-aids no fing
Part hand disart myoelectric
Wrst MLd sck flx hng tri pad
Wrst mold sock w/exp interfa
Elb mold sock flex hinge pad
Elbow mold sock suspension t
Elbow mold doub splt soc ste
Elbow stump activated lock h
Elbow mold outsid lock hinge
Elbow molded w/ expand inter
Elbow inter loc elbow forarm
Shlder disart int lock elbow
Shoulder passive restor comp
Shoulder passive restor cap
Thoracic intern lock elbow
Thoracic passive restor comp
Thoracic passive restor cap
Postop dsg cast chg wrst/elb
Postop dsg cast chg elb dis/
Postop dsg cast chg shlder/t
Postop ea cast chg & realign
Postop applicat rigid dsg on
1111.MM.P.WM 12/11
Managed Health Services
1099 N. Meridian Street, Suite 400 • Indianapolis, IN 46204 • (877) 647-4848 • mhsindiana.com
L6400
L6450
L6500
L6550
L6570
L6580
L6582
L6584
L6586
L6588
L6590
L6600
L6605
L6610
L6611
L6615
L6616
L6620
L6621
L6623
L6624
L6625
L6628
L6629
L6630
L6632
L6635
L6637
L6638
L6640
L6641
L6642
L6645
L6646
L6647
L6648
L6650
L6655
L6660
L6665
L6670
L6672
L6675
L6676
L6677
L6680
L6682
L6691
Below elbow prosth tiss shap
Elb disart prosth tiss shap
Above elbow prosth tiss shap
Shldr disar prosth tiss shap
Scap thorac prosth tiss shap
Wrist/elbow bowden cable mol
Wrist/elbow bowden cbl dir f
Elbow fair lead cable molded
Elbow fair lead cable dir fo
Shdr fair lead cable molded
PREPARATORY, SHOULDER DIS
Polycentric hinge pair
Single pivot hinge pair
Flexible metal hinge pair
Additional switch, ext power
Disconnect locking wrist uni
Disconnect insert locking wr
Flexion/extension wrist unit
Flex/ext wrist w/wo friction
Spring-ass rot wrst w/ latch
Flex/ext/rotation wrist unit
Rotation wrst w/ cable lock
Quick disconn hook adapter o
Lamination collar w/ couplin
Stainless steel any wrist
Latex suspension sleeve each
Lift assist for elbow
Nudge control elbow lock
Elec lock on manual pw elbow
Shoulder abduction joint pai
Excursion amplifier pulley t
Excursion amplifier lever ty
Shoulder flexion-abduction j
Multipo locking shoulder jnt
Shoulder lock actuator
Ext pwrd shlder lock/unlock
Shoulder universal joint
Standard control cable extra
Heavy duty control cable
Teflon or equal cable lining
Hook to hand cable adapter
Harness chest/shlder saddle
Harness figure of 8 sing con
Harness figure of 8 dual con
UE triple control harness
Test sock wrist disart/bel e
Test sock elbw disart/above
Removable insert each
1111.MM.P.WM 12/11
Managed Health Services
1099 N. Meridian Street, Suite 400 • Indianapolis, IN 46204 • (877) 647-4848 • mhsindiana.com
L6694
L6695
L6696
L6697
L6698
L6703
L6704
L6706
L6707
L6708
L6709
L6711
L6712
L6713
L6714
L6721
L6722
L6805
L6810
L6881
L6882
L6883
L6884
L6885
L6890
L6895
L6900
L6905
L6910
L6915
L6920
L6925
L6930
L6935
L6940
L6945
L6950
L6955
L6960
L6965
L6970
L6975
L7007
L7008
L7009
L7040
L7045
L7170
Elbow socket ins use w/lock
Elbow socket ins use w/o lck
Cus elbo skt in for con/atyp
Cus elbo skt in not con/atyp
Below/above elbow lock mech
Term dev, passive hand mitt
Term dev, sport/rec/work att
Term dev mech hook vol open
Term dev mech hook vol close
Term dev mech hand vol open
Term dev mech hand vol close
PED TERM DEV, HOOK, VOL O
PED TERM DEV, HOOK, VOL C
PED TERM DEV, HAND, VOL O
PED TERM DEV, HAND, VOL C
HOOK/HAND, HVY DTY, VOL O
HOOK/HAND, HVY DTY, VOL C
Term dev modifier wrist unit
Term dev precision pinch dev
Term dev auto grasp feature
Microprocessor control uplmb
Replc sockt below e/w disa
Replc sockt above elbow disa
Replc sockt shldr dis/interc
Prefab glove for term device
Custom glove for term device
Hand restorat thumb/1 finger
Hand restoration multiple fi
Hand restoration no fingers
Hand restoration replacmnt g
Wrist disarticul switch ctrl
Wrist disart myoelectronic c
Below elbow switch control
Below elbow myoelectronic ct
Elbow disarticulation switch
Elbow disart myoelectronic c
Above elbow switch control
Above elbow myoelectronic ct
Shldr disartic switch contro
Shldr disartic myoelectronic
Interscapular-thor switch ct
Interscap-thor myoelectronic
Adult electric hand
Pediatric electric hand
Adult electric hook
Prehensile actuator
Pediatric electric hook
Electronic elbow hosmer swit
1111.MM.P.WM 12/11
Managed Health Services
1099 N. Meridian Street, Suite 400 • Indianapolis, IN 46204 • (877) 647-4848 • mhsindiana.com
L7180
L7181
L7185
L7186
L7190
L7191
L7260
L7261
L7266
L7272
L7274
L7360
L7362
L7364
L7366
L7367
L7368
L7400
L7401
L7402
L7403
L7404
L7405
L7499
L7500
L7510
L7520
L7600
L7900
L8000
L8001
L8002
L8010
L8015
L8020
L8030
L8035
L8039
L8040
L8041
L8042
L8043
L8044
L8045
L8046
L8047
L8048
L8049
Electronic elbow sequential
Electronic elbo simultaneous
Electron elbow adolescent sw
Electron elbow child switch
Elbow adolescent myoelectron
Elbow child myoelectronic ct
Electron wrist rotator otto
Electron wrist rotator utah
Servo control steeper or equ
Analogue control unb or equa
Proportional ctl 12 volt uta
Six volt bat otto bock/eq ea
Battery chrgr six volt otto
Twelve volt battery utah/equ
Battery chrgr 12 volt utah/e
Replacemnt lithium ionbatter
Lithium ion battery charger
Add UE prost be/wd, ultlite
Add UE prost a/e ultlite mat
Add UE prost s/d ultlite mat
Add UE prost b/e acrylic
Add UE prost a/e acrylic
Add UE prost s/d acrylic
Upper extremity prosthes NOS
Prosthetic dvc repair hourly
Prosthetic device repair rep
Repair prosthesis per 15 min
Prosthetic donning sleeve
Male vacuum erection system
Mastectomy bra
Breast prosthesis bra & form
Brst prsth bra & bilat form
Mastectomy sleeve
Ext breastprosthesis garment
Mastectomy form
Breast prosthesis silicone/e
Custom breast prosthesis
Breast prosthesis NOS
Nasal prosthesis
Midfacial prosthesis
Orbital prosthesis
Upper facial prosthesis
Hemi-facial prosthesis
Auricular prosthesis
Partial facial prosthesis
Nasal septal prosthesis
Unspec maxillofacial prosth
Repair maxillofacial prosth
1111.MM.P.WM 12/11
Managed Health Services
1099 N. Meridian Street, Suite 400 • Indianapolis, IN 46204 • (877) 647-4848 • mhsindiana.com
L8300
L8310
L8320
L8330
L8400
L8410
L8415
L8417
L8420
L8430
L8435
L8440
L8460
L8465
L8470
L8480
L8485
L8499
L8501
L8505
L8507
L8509
L8510
L8511
L8512
L8513
L8514
L8515
L8627
L8628
L8681
L8682
L8683
L8684
L8689
L8691
L8692
L9900
S0265
S1040
S2053
S2055
S2061
S2070
S2079
S2080
S2225
S3800
Truss single w/ standard pad
Truss double w/ standard pad
Truss addition to std pad wa
Truss add to std pad scrotal
Sheath below knee
Sheath above knee
Sheath upper limb
Pros sheath/sock w gel cushn
Prosthetic sock multi ply BK
Prosthetic sock multi ply AK
Pros sock multi ply upper lm
Shrinker below knee
Shrinker above knee
Shrinker upper limb
Pros sock single ply BK
Pros sock single ply AK
Pros sock single ply upper l
Unlisted misc prosthetic ser
Tracheostomy speaking valve
Artificial larynx, accessory
Trach-esoph voice pros pt in
Trach-esoph voice pros md in
Voice amplifier
Indwelling trach insert
Gel cap for trach voice pros
Trach pros cleaning device
Repl trach puncture dilator
Gel cap app device for trach
CID EXT SPEECH PROCESS RE
CID EXT CONTROLLER REPL
Pt prgrm for implt neurostim
Implt neurostim radiofq rec
Radiofq trsmtr for implt neu
Radiof trsmtr implt scrl neu
External recharg sys intern
OSSEOINTEGRATED SND PROC
NON-OSSEOINTEGRATED SND P
O&P supply/accessory/service
GENETIC COUNSEL 15 MINS
CRANIAL REMOLDING ORTHOSI
Transplantation of small int
Harvesting of donor multivis
Donor lobectomy (lung)
CYSTO LASER TX URETERAL C
LAP ESOPHAGOMYOTOMY
Laup
MYRINGOTOMY LASER-ASSIST
Genetic testing ALS
1111.MM.P.WM 12/11
Managed Health Services
1099 N. Meridian Street, Suite 400 • Indianapolis, IN 46204 • (877) 647-4848 • mhsindiana.com
S3818
S3819
S3820
S3822
S3823
S3828
S3829
S3833
S3834
S3840
S3843
S3844
S3852
S3854
S3860
S3861
S3865
S3866
S3870
S8120
S8121
S9122
S9124
S9125
S9126
S9127
S9128
S9129
S9131
S9325
S9326
S9327
S9328
S9329
S9330
S9331
S9335
S9338
S9339
S9340
S9341
S9342
S9343
S9345
S9346
S9347
S9348
S9355
BRCA1 gene anal
BRCA2 gene anal
Comp BRCA1/BRCA2
Sing mutation brst/ovar
3 mutation brst/ovar
Comp MLH1 gene
Comp MLH2 gene
Comp APC sequence
Sing mutation APC
DNA analysis RET-oncogene
DNA analysis factor v
DNA analysis deafness
DNA analysis APOE alzheimer
Gene profile panel breast
GENET TEST CARDIAC ION-CO
GENETIC TEST BRUGADA
COMP GENET TEST HYP CARDI
SPEC GENE TEST HYP CARDIO
CGH TEST DEVELOPMENTAL DE
O2 CONTENTS GAS CUBIC FT
O2 CONTENTS LIQUID LB
Home health aide or certifie
Nursing care, in the home; b
Respite care, in the home, p
Hospice care, in the home, p
Social work visit, in the ho
Speech therapy, in the home,
Occupational therapy, in the
PT in the home per diem
HIT pain mgmt per diem
HIT cont pain per diem
HIT int pain per diem
HIT pain imp pump diem
HIT chemo per diem
HIT cont chem diem
HIT intermit chemo diem
HT hemodialysis diem
HIT immunotherapy diem
HIT periton dialysis diem
HIT enteral per diem
HIT enteral grav diem
HIT enteral pump diem
HIT enteral bolus nurs
HIT anti-hemophil diem
HIT alpha-1-proteinas diem
HIT longterm infusion diem
HIT sympathomim diem
HIT chelation diem
1111.MM.P.WM 12/11
Managed Health Services
1099 N. Meridian Street, Suite 400 • Indianapolis, IN 46204 • (877) 647-4848 • mhsindiana.com
S9357
S9359
S9361
S9363
S9364
S9365
S9366
S9367
S9368
S9370
S9372
S9373
S9381
S9472
S9474
S9475
S9476
S9562
S9590
V2626
V2628
V2629
V2797
V5010
V5014
V5020
V5267
V5298
HIT enzyme replace diem
HIT anti-tnf per diem
HIT diuretic infus diem
HIT anti-spasmotic diem
HIT tpn total diem
HIT tpn 1 liter diem
HIT tpn 2 liter diem
HIT tpn 3 liter diem
HIT tpn over 3l diem
HT inj antiemetic diem
HT inj anticoag diem
HIT hydra total diem
HIT high risk/escort
Cardiac rehabilitation progr
Enterostomal therapy by a re
Ambulatory setting substance
Vestibular rehab per diem
HT inj palivizumab diem
HT irrigation diem
REDUCTION OF OCULAR PROST
FABRICATION AND FITTING O
NOT OTHERWISE CLASSIFIED,
Vis item/svc in other code
ASSESSMENT FOR HEARING AI
REPAIR/MODIFICATION OF A
CONFORMITY EVALUATION
Hearing aid supply/accessory
Hearing aid noc
1111.MM.P.WM 12/11
Managed Health Services
1099 N. Meridian Street, Suite 400 • Indianapolis, IN 46204 • (877) 647-4848 • mhsindiana.com