Current Social Services Blanket Code HCPCS Code Billing Table Updated: 01/27/2016
Social Service Blanket Code Group Description HCPCS Code Procedure Code Short Description
SA875 Bathroom aids, toileting, and supplies SA875 E0160 Sitz type bath or equipment
SA875 Bathroom aids, toileting, and supplies SA875 E0161 Sitz bath/equipment w/faucet
SA875 Bathroom aids, toileting, and supplies SA875 E0162 Sitz bath chair
SA875 Bathroom aids, toileting, and supplies SA875 E0163 Commode chair with fixed arm
SA875 Bathroom aids, toileting, and supplies SA875 E0165 Commode chair with detacharm
SA875 Bathroom aids, toileting, and supplies SA875 E0167 Commode chair pail or pan
SA875 Bathroom aids, toileting, and supplies SA875 E0168 Heavyduty/wide commode chair
SA875 Bathroom aids, toileting, and supplies SA875 E0170 Commode chair electric
SA875 Bathroom aids, toileting, and supplies SA875 E0171 Commode chair non-electric
SA875 Bathroom aids, toileting, and supplies SA875 E0172 Seat lift mechanism toilet
SA875 Bathroom aids, toileting, and supplies SA875 E0175 Commode chair foot rest
SA875 Bathroom aids, toileting, and supplies SA875 E0240 Bath/shower chair
SA875 Bathroom aids, toileting, and supplies SA875 E0241 Bath tub wall rail
SA875 Bathroom aids, toileting, and supplies SA875 E0243 Toilet rail
SA875 Bathroom aids, toileting, and supplies SA875 E0244 Toilet seat raised
SA875 Bathroom aids, toileting, and supplies SA875 E0245 Tub stool or bench
SA875 Bathroom aids, toileting, and supplies SA875 E0246 Transfer tub rail attachment
SA875 Bathroom aids, toileting, and supplies SA875 E0247 Trans bench w/wo comm open
SA875 Bathroom aids, toileting, and supplies SA875 E0248 HDtrans bench w/wo comm open
SA875 Bathroom aids, toileting, and supplies SA875 E0275 Bed pan standard
SA875 Bathroom aids, toileting, and supplies SA875 E0276 Bed pan fracture
SA875 Bathroom aids, toileting, and supplies SA875 E0325 Urinal male jug-type
SA875 Bathroom aids, toileting, and supplies SA875 E0326 Urinal female jug-type
SA875 Bathroom aids, toileting, and supplies SA875 E1310 Whirlpool non-portable
SA876 Communication devices and supplies SA876 E2500 SGD digitized pre-rec <=8min
SA876 Communication devices and supplies SA876 E2502 SGD prerec msg >8min <=20min
SA876 Communication devices and supplies SA876 E2504 SGD prerec msg>20min <=40min
SA876 Communication devices and supplies SA876 E2506 SGD prerec msg > 40 min
SA876 Communication devices and supplies SA876 E2508 SGD spelling phys contact
SA876 Communication devices and supplies SA876 E2510 SGD w multi methods msg/accs
SA876 Communication devices and supplies SA876 E2511 SGD sftwre prgrm for PC/PDA
SA876 Communication devices and supplies SA876 E2512 SGD accessory, mounting sys
SA876 Communication devices and supplies SA876 E2599 SGD accessory noc
SA877 Diabetic equipment and supplies SA877 A4230 Infus insulin pump non needl
SA877 Diabetic equipment and supplies SA877 A4231 Infusion insulin pump needle
SA877 Diabetic equipment and supplies SA877 A4232 Syringe w/needle insulin 3cc
SA877 Diabetic equipment and supplies SA877 A4233 Alkalin batt for glucose mon
SA877 Diabetic equipment and supplies SA877 A4234 J-cell batt for glucose mon
SA877 Diabetic equipment and supplies SA877 A4235 Lithium batt for glucose mon
SA877 Diabetic equipment and supplies SA877 A4236 Silvr oxide batt glucose mon
SA877 Diabetic equipment and supplies SA877 A4245 Alcohol wipes per box
SA877 Diabetic equipment and supplies SA877 A4252 Blood ketone test or strip
SA877 Diabetic equipment and supplies SA877 A4253 Blood glucose/reagent strips
SA877 Diabetic equipment and supplies SA877 A4255 Glucose monitor platforms
SA877 Diabetic equipment and supplies SA877 A5500 Diab shoe for density insert
SA877 Diabetic equipment and supplies SA877 A5501 Diabetic custom molded shoe
SA877 Diabetic equipment and supplies SA877 A5503 Diabetic shoe w/roller/rockr
SA877 Diabetic equipment and supplies SA877 A5504 Diabetic shoe with wedge
SA877 Diabetic equipment and supplies SA877 A5505 Diab shoe w/metatarsal bar
SA877 Diabetic equipment and supplies SA877 A5506 Diabetic shoe w/off set heel
SA877 Diabetic equipment and supplies SA877 A5507 Modification diabetic shoe
SA877 Diabetic equipment and supplies SA877 A5508 Diabetic deluxe shoe
SA877 Diabetic equipment and supplies SA877 A5510 Compression form shoe insert
SA877 Diabetic equipment and supplies SA877 A5512 Multi den insert direct form
SA877 Diabetic equipment and supplies SA877 A5513 Multi den insert custom mold
SA877 Diabetic equipment and supplies SA877 A6531 Compression stocking BK30-40
SA877 Diabetic equipment and supplies SA877 E0607 Blood glucose monitor home
SA877 Diabetic equipment and supplies SA877 E2100 Bld glucose monitor w voice
SA877 Diabetic equipment and supplies SA877 E2101 Bld glucose monitor w lance
SA878 Hospital beds and supplies SA878 E0250 Hosp bed fixed ht w/ mattres
SA878 Hospital beds and supplies SA878 E0251 Hosp bed fixd ht w/o mattres
SA878 Hospital beds and supplies SA878 E0255 Hospital bed var ht w/ mattr
SA878 Hospital beds and supplies SA878 E0256 Hospital bed var ht w/o matt
SA878 Hospital beds and supplies SA878 E0260 Hosp bed semi-electr w/ matt
25
Current Social Services Blanket Code HCPCS Code Billing Table Updated: 01/27/2016
Social Service Blanket Code Group Description HCPCS Code Procedure Code Short Description
SA878 Hospital beds and supplies SA878 E0261 Hosp bed semi-electr w/o mat
SA878 Hospital beds and supplies SA878 E0265 Hosp bed total electr w/ mat
SA878 Hospital beds and supplies SA878 E0266 Hosp bed total elec w/o matt
SA878 Hospital beds and supplies SA878 E0270 Hospital bed institutional t
SA878 Hospital beds and supplies SA878 E0271 Mattress innerspring
SA878 Hospital beds and supplies SA878 E0272 Mattress foam rubber
SA878 Hospital beds and supplies SA878 E0277 Powered pres-redu air mattrs
SA878 Hospital beds and supplies SA878 E0280 Bed cradle
SA878 Hospital beds and supplies SA878 E0290 Hosp bed fx ht w/o rails w/m
SA878 Hospital beds and supplies SA878 E0291 Hosp bed fx ht w/o rail w/o
SA878 Hospital beds and supplies SA878 E0292 Hosp bed var ht w/o rail w/o
SA878 Hospital beds and supplies SA878 E0293 Hosp bed var ht w/o rail w/
SA878 Hospital beds and supplies SA878 E0294 Hosp bed semi-elect w/ mattr
SA878 Hospital beds and supplies SA878 E0295 Hosp bed semi-elect w/o matt
SA878 Hospital beds and supplies SA878 E0296 Hosp bed total elect w/ matt
SA878 Hospital beds and supplies SA878 E0297 Hosp bed total elect w/o mat
SA878 Hospital beds and supplies SA878 E0300 Enclosed ped crib hosp grade
SA878 Hospital beds and supplies SA878 E0301 HD hosp bed, 350-600 lbs
SA878 Hospital beds and supplies SA878 E0302 Ex hd hosp bed > 600 lbs
SA878 Hospital beds and supplies SA878 E0303 Hosp bed hvy dty xtra wide
SA878 Hospital beds and supplies SA878 E0304 Hosp bed xtra hvy dty x wide
SA878 Hospital beds and supplies SA878 E0305 Rails bed side half length
SA878 Hospital beds and supplies SA878 E0310 Rails bed side full length
SA878 Hospital beds and supplies SA878 E0316 Bed safety enclosure
SA878 Hospital beds and supplies SA878 E0328 Ped hospital bed, manual
SA878 Hospital beds and supplies SA878 E0329 Ped hospital bed semi/elect
SA878 Hospital beds and supplies SA878 E0350 Control unit bowel system
SA878 Hospital beds and supplies SA878 E0352 Disposable pack w/bowel syst
SA878 Hospital beds and supplies SA878 E0371 Nonpower mattress overlay
SA878 Hospital beds and supplies SA878 E0372 Powered air mattress overlay
SA878 Hospital beds and supplies SA878 E0373 Nonpowered pressure mattress
SA879 Miscellaneous SA879 94005 Home vent mgmt supervision
SA879 Miscellaneous SA879 94760 Measure blood oxygen level
SA879 Miscellaneous SA879 94772 Breath recording, infant
SA879 Miscellaneous SA879 A4206 1 CC sterile syringe&needle
SA879 Miscellaneous SA879 A4207 2 CC sterile syringe&needle
SA879 Miscellaneous SA879 A4208 3 CC sterile syringe&needle
SA879 Miscellaneous SA879 A4209 5+ CC sterile syringe&needle
SA879 Miscellaneous SA879 A4210 Nonneedle injection device
SA879 Miscellaneous SA879 A4211 Supp for self-adm injections
SA879 Miscellaneous SA879 A4213 20+ CC syringe only
SA879 Miscellaneous SA879 A4215 Sterile needle
SA879 Miscellaneous SA879 A4216 Sterile water/saline, 10 ml
SA879 Miscellaneous SA879 A4217 Sterile water/saline, 500 ml
SA879 Miscellaneous SA879 A4220 Infusion pump refill kit
SA879 Miscellaneous SA879 A4221 Maint drug infus cath per wk
SA879 Miscellaneous SA879 A4222 Infusion supplies with pump
SA879 Miscellaneous SA879 A4223 Infusion supplies w/o pump
SA879 Miscellaneous SA879 A4244 Alcohol or peroxide per pint
SA879 Miscellaneous SA879 A4246 Betadine/phisohex solution
SA879 Miscellaneous SA879 A4247 Betadine/iodine swabs/wipes
SA879 Miscellaneous SA879 A4248 Chlorhexidine antisept
SA879 Miscellaneous SA879 A4250 Urine reagent strips/tablets
SA879 Miscellaneous SA879 A4256 Calibrator solution/chips
SA879 Miscellaneous SA879 A4258 Lancet device each
SA879 Miscellaneous SA879 A4259 Lancets per box
SA879 Miscellaneous SA879 A4265 Paraffin
SA879 Miscellaneous SA879 A4281 Replacement breastpump tube
SA879 Miscellaneous SA879 A4282 Replacement breastpump adpt
SA879 Miscellaneous SA879 A4283 Replacement breastpump cap
SA879 Miscellaneous SA879 A4284 Replcmnt breast pump shield
SA879 Miscellaneous SA879 A4285 Replcmnt breast pump bottle
SA879 Miscellaneous SA879 A4286 Replcmnt breastpump lok ring
SA879 Miscellaneous SA879 A4290 Sacral nerve stim test lead
25
Current Social Services Blanket Code HCPCS Code Billing Table Updated: 01/27/2016
Social Service Blanket Code Group Description HCPCS Code Procedure Code Short Description
SA879 Miscellaneous SA879 A4435 1PC OST PCH DRAIN HGH OUTPUT
SA879 Miscellaneous SA879 A4458 Reusable enema bag
SA879 Miscellaneous SA879 A4461 Surgicl dress hold non-reuse
SA879 Miscellaneous SA879 A4463 Surgical dress holder reuse
SA879 Miscellaneous SA879 A4465 Non-elastic extremity binder
SA879 Miscellaneous SA879 A4466 Elastic garment/covering
SA879 Miscellaneous SA879 A4490 Above knee surgical stocking
SA879 Miscellaneous SA879 A4495 Thigh length surg stocking
SA879 Miscellaneous SA879 A4500 Below knee surgical stocking
SA879 Miscellaneous SA879 A4510 Full length surg stocking
SA879 Miscellaneous SA879 A4520 Incontinence garment anytype
SA879 Miscellaneous SA879 A4554 Disposable underpads
SA879 Miscellaneous SA879 A4556 Electrodes, pair
SA879 Miscellaneous SA879 A4557 Lead wires, pair
SA879 Miscellaneous SA879 A4558 Conductive gel or paste
SA879 Miscellaneous SA879 A4561 Pessary rubber, any type
SA879 Miscellaneous SA879 A4562 Pessary, non rubber,any type
SA879 Miscellaneous SA879 A4565 Slings
SA879 Miscellaneous SA879 A4566 SHOULD SLING/VEST/ABRESTRAIN
SA879 Miscellaneous SA879 A4570 Splint
SA879 Miscellaneous SA879 A4595 TENS suppl 2 lead per month
SA879 Miscellaneous SA879 A4602 REPLACE LITHIUM BATTERY 1.5V
SA879 Miscellaneous SA879 A4605 Trach suction cath close sys
SA879 Miscellaneous SA879 A4606 Oxygen probe used w oximeter
SA879 Miscellaneous SA879 A4630 Repl bat t.e.n.s. own by pt
SA879 Miscellaneous SA879 A4633 Uvl replacement bulb
SA879 Miscellaneous SA879 A4634 Replacement bulb th lightbox
SA879 Miscellaneous SA879 A4639 Infrared ht sys replcmnt pad
SA879 Miscellaneous SA879 A4640 Alternating pressure pad
SA879 Miscellaneous SA879 A4649 Surgical supplies
SA879 Miscellaneous SA879 A4928 Surgical mask
SA879 Miscellaneous SA879 A4930 Sterile, gloves per pair
SA879 Miscellaneous SA879 A4931 Reusable oral thermometer
SA879 Miscellaneous SA879 A4932 Reusable rectal thermometer
SA879 Miscellaneous SA879 A6530 Compression stocking BK18-30
SA879 Miscellaneous SA879 A6532 Compression stocking BK40-50
SA879 Miscellaneous SA879 A6533 Gc stocking thighlngth 18-30
SA879 Miscellaneous SA879 A6534 Gc stocking thighlngth 30-40
SA879 Miscellaneous SA879 A6535 Gc stocking thighlngth 40-50
SA879 Miscellaneous SA879 A6536 Gc stocking full lngth 18-30
SA879 Miscellaneous SA879 A9180 Lice treatment, topical
SA879 Miscellaneous SA879 E0181 Press pad alternating w/ pum
SA879 Miscellaneous SA879 E0182 Replace pump, alt press pad
SA879 Miscellaneous SA879 E0184 Dry pressure mattress
SA879 Miscellaneous SA879 E0185 Gel pressure mattress pad
SA879 Miscellaneous SA879 E0186 Air pressure mattress
SA879 Miscellaneous SA879 E0188 Synthetic sheepskin pad
SA879 Miscellaneous SA879 E0189 Lambswool sheepskin pad
SA879 Miscellaneous SA879 E0190 Positioning cushion
SA879 Miscellaneous SA879 E0191 Protector heel or elbow
SA879 Miscellaneous SA879 E0193 Powered air flotation bed
SA879 Miscellaneous SA879 E0194 Air fluidized bed
SA879 Miscellaneous SA879 E0196 Gel pressure mattress
SA879 Miscellaneous SA879 E0197 Air pressure pad for mattres
SA879 Miscellaneous SA879 E0198 Water pressure pad for mattr
SA879 Miscellaneous SA879 E0199 Dry pressure pad for mattres
SA879 Miscellaneous SA879 E0225 Hydrocollator unit
SA879 Miscellaneous SA879 E0230 Ice cap or collar
SA879 Miscellaneous SA879 E0232 Warming card for NWT
SA879 Miscellaneous SA879 E0235 Paraffin bath unit portable
SA879 Miscellaneous SA879 E0236 Pump for water circulating p
SA879 Miscellaneous SA879 E0239 Hydrocollator unit portable
SA879 Miscellaneous SA879 E0274 Over-bed table
SA879 Miscellaneous SA879 E0600 Suction pump portab hom modl
25
Current Social Services Blanket Code HCPCS Code Billing Table Updated: 01/27/2016
Social Service Blanket Code Group Description HCPCS Code Procedure Code Short Description
SA879 Miscellaneous SA879 E0601 CONT AIRWAY PRESSURE DEVICE
SA879 Miscellaneous SA879 E0619 Apnea monitor w recorder
SA879 Miscellaneous SA879 E0621 Patient lift sling or seat
SA879 Miscellaneous SA879 E0627 Seat lift incorp lift-chair
SA879 Miscellaneous SA879 E0628 Seat lift for pt furn-electr
SA879 Miscellaneous SA879 E0629 Seat lift for pt furn-non-el
SA879 Miscellaneous SA879 E0630 Patient lift hydraulic
SA879 Miscellaneous SA879 E0635 Patient lift electric
SA879 Miscellaneous SA879 E0636 PT support & positioning sys
SA879 Miscellaneous SA879 E0637 COMBINATION SIT TO STAND SYS
SA879 Miscellaneous SA879 E0638 STANDING FRAME SYS
SA879 Miscellaneous SA879 E0639 Moveable patient lift system
SA879 Miscellaneous SA879 E0640 Fixed patient lift system
SA879 Miscellaneous SA879 E0641 MULTI-POSITION STND FRAM SYS
SA879 Miscellaneous SA879 E0642 DYNAMIC STANDING FRAME
SA879 Miscellaneous SA879 E0650 Pneuma compresor non-segment
SA879 Miscellaneous SA879 E0651 Pneum compressor segmental
SA879 Miscellaneous SA879 E0652 Pneum compres w/cal pressure
SA879 Miscellaneous SA879 E0655 Pneumatic appliance half arm
SA879 Miscellaneous SA879 E0656 Segmental pneumatic trunk
SA879 Miscellaneous SA879 E0657 Segmental pneumatic chest
SA879 Miscellaneous SA879 E0660 Pneumatic appliance full leg
SA879 Miscellaneous SA879 E0665 Pneumatic appliance full arm
SA879 Miscellaneous SA879 E0666 Pneumatic appliance half leg
SA879 Miscellaneous SA879 E0667 Seg pneumatic appl full leg
SA879 Miscellaneous SA879 E0668 Seg pneumatic appl full arm
SA879 Miscellaneous SA879 E0669 Seg pneumatic appli half leg
SA879 Miscellaneous SA879 E0671 Pressure pneum appl full leg
SA879 Miscellaneous SA879 E0672 Pressure pneum appl full arm
SA879 Miscellaneous SA879 E0673 Pressure pneum appl half leg
SA879 Miscellaneous SA879 E0675 Pneumatic compression device
SA879 Miscellaneous SA879 E0691 UVL PNL 2 SQ FT OR LESS
SA879 Miscellaneous SA879 E0692 Uvl sys panel 4 ft
SA879 Miscellaneous SA879 E0693 Uvl sys panel 6 ft
SA879 Miscellaneous SA879 E0694 Uvl md cabinet sys 6 ft
SA879 Miscellaneous SA879 E0700 Safety equipment
SA879 Miscellaneous SA879 E0705 Transfer device
SA879 Miscellaneous SA879 E0720 Tens two lead
SA879 Miscellaneous SA879 E0731 Conductive garment for tens/
SA879 Miscellaneous SA879 E0740 Incontinence treatment systm
SA879 Miscellaneous SA879 E0744 Neuromuscular stim for scoli
SA879 Miscellaneous SA879 E0747 Elec osteogen stim not spine
SA879 Miscellaneous SA879 E0748 Elec osteogen stim spinal
SA879 Miscellaneous SA879 E0749 Elec osteogen stim implanted
SA879 Miscellaneous SA879 E0760 Osteogen ultrasound stimltor
SA879 Miscellaneous SA879 E0762 Trans elec jt stim dev sys
SA879 Miscellaneous SA879 E0765 Nerve stimulator for tx n&v
SA879 Miscellaneous SA879 E0776 Iv pole
SA879 Miscellaneous SA879 E0779 Amb infusion pump mechanical
SA879 Miscellaneous SA879 E0780 Mech amb infusion pump <8hrs
SA879 Miscellaneous SA879 E0781 External ambulatory infus pu
SA879 Miscellaneous SA879 E0784 Ext amb infusn pump insulin
SA879 Miscellaneous SA879 E0791 Parenteral infusion pump sta
SA879 Miscellaneous SA879 E0830 Ambulatory traction device
SA879 Miscellaneous SA879 E0840 Tract frame attach headboard
SA879 Miscellaneous SA879 E0849 Cervical pneum trac equip
SA879 Miscellaneous SA879 E0850 Traction stand free standing
SA879 Miscellaneous SA879 E0855 Cervical traction equipment
SA879 Miscellaneous SA879 E0856 CERVIC COLLAR W AIR BLADDERS
SA879 Miscellaneous SA879 E0860 Tract equip cervical tract
SA879 Miscellaneous SA879 E0870 Tract frame attach footboard
SA879 Miscellaneous SA879 E0880 Trac stand free stand extrem
SA879 Miscellaneous SA879 E0890 Traction frame attach pelvic
SA879 Miscellaneous SA879 E0900 Trac stand free stand pelvic
25
Current Social Services Blanket Code HCPCS Code Billing Table Updated: 01/27/2016
Social Service Blanket Code Group Description HCPCS Code Procedure Code Short Description
SA879 Miscellaneous SA879 E0910 Trapeze bar attached to bed
SA879 Miscellaneous SA879 E0911 HD trapeze bar attach to bed
SA879 Miscellaneous SA879 E0912 HD trapeze bar free standing
SA879 Miscellaneous SA879 E0920 Fracture frame attached to b
SA879 Miscellaneous SA879 E0930 Fracture frame free standing
SA879 Miscellaneous SA879 E0935 Cont pas motion exercise dev
SA879 Miscellaneous SA879 E0936 CPM device, other than knee
SA879 Miscellaneous SA879 E0940 Trapeze bar free standing
SA879 Miscellaneous SA879 E0941 Gravity assisted traction de
SA879 Miscellaneous SA879 E0942 Cervical head harness/halter
SA879 Miscellaneous SA879 E0944 Pelvic belt/harness/boot
SA879 Miscellaneous SA879 E0945 Belt/harness extremity
SA879 Miscellaneous SA879 E0946 Fracture frame dual w cross
SA879 Miscellaneous SA879 E0947 Fracture frame attachmnts pe
SA879 Miscellaneous SA879 E0948 Fracture frame attachmnts ce
SA879 Miscellaneous SA879 E1031 Rollabout chair with casters
SA879 Miscellaneous SA879 E1037 Transport chair, ped size
SA879 Miscellaneous SA879 E1038 Transport chair pt wt<=300lb
SA879 Miscellaneous SA879 E1039 Transport chair pt wt >300lb
SA879 Miscellaneous SA879 E1399 Durable medical equipment mi
SA879 Miscellaneous SA879 E2000 Gastric suction pump hme mdl
SA879 Miscellaneous SA879 E2402 Neg press wound therapy pump
SA879 Miscellaneous SA879 S1040 Cranial remolding orthosis
SA879 Miscellaneous SA879 S8431 Compression bandage
SA879 Miscellaneous SA879 T5001 Position seat spec orth need
SA879 Miscellaneous SA879 T5999 Supply, nos
SA880 Mobility Aids and supplies SA880 A4635 Underarm crutch pad
SA880 Mobility Aids and supplies SA880 A4636 Handgrip for cane etc
SA880 Mobility Aids and supplies SA880 A4637 Repl tip cane/crutch/walker
SA880 Mobility Aids and supplies SA880 E0100 Cane adjust/fixed with tip
SA880 Mobility Aids and supplies SA880 E0105 Cane adjust/fixed quad/3 pro
SA880 Mobility Aids and supplies SA880 E0110 Crutch forearm pair
SA880 Mobility Aids and supplies SA880 E0111 Crutch forearm each
SA880 Mobility Aids and supplies SA880 E0112 Crutch underarm pair wood
SA880 Mobility Aids and supplies SA880 E0113 Crutch underarm each wood
SA880 Mobility Aids and supplies SA880 E0114 Crutch underarm pair no wood
SA880 Mobility Aids and supplies SA880 E0116 Crutch underarm each no wood
SA880 Mobility Aids and supplies SA880 E0117 Underarm springassist crutch
SA880 Mobility Aids and supplies SA880 E0118 Crutch substitute
SA880 Mobility Aids and supplies SA880 E0130 Walker rigid adjust/fixed ht
SA880 Mobility Aids and supplies SA880 E0135 Walker folding adjust/fixed
SA880 Mobility Aids and supplies SA880 E0140 Walker w trunk support
SA880 Mobility Aids and supplies SA880 E0141 Rigid wheeled walker adj/fix
SA880 Mobility Aids and supplies SA880 E0143 Walker folding wheeled w/o s
SA880 Mobility Aids and supplies SA880 E0144 Enclosed walker w rear seat
SA880 Mobility Aids and supplies SA880 E0147 Walker variable wheel resist
SA880 Mobility Aids and supplies SA880 E0148 Heavyduty walker no wheels
SA880 Mobility Aids and supplies SA880 E0149 Heavy duty wheeled walker
SA880 Mobility Aids and supplies SA880 E0153 Forearm crutch platform atta
SA880 Mobility Aids and supplies SA880 E0154 Walker platform attachment
SA880 Mobility Aids and supplies SA880 E0155 Walker wheel attachment,pair
SA880 Mobility Aids and supplies SA880 E0156 Walker seat attachment
SA880 Mobility Aids and supplies SA880 E0157 Walker crutch attachment
SA880 Mobility Aids and supplies SA880 E0158 Walker leg extenders set of4
SA880 Mobility Aids and supplies SA880 E0159 Brake for wheeled walker
SA880 Mobility Aids and supplies SA880 E1800 Adjust elbow ext/flex device
SA880 Mobility Aids and supplies SA880 E1801 SPS elbow device
SA880 Mobility Aids and supplies SA880 E1802 Adjst forearm pro/sup device
SA880 Mobility Aids and supplies SA880 E1805 Adjust wrist ext/flex device
SA880 Mobility Aids and supplies SA880 E1806 SPS wrist device
SA880 Mobility Aids and supplies SA880 E1810 Adjust knee ext/flex device
SA880 Mobility Aids and supplies SA880 E1811 SPS knee device
SA880 Mobility Aids and supplies SA880 E1815 Adjust ankle ext/flex device
SA880 Mobility Aids and supplies SA880 E1816 SPS ankle device
25
Current Social Services Blanket Code HCPCS Code Billing Table Updated: 01/27/2016
Social Service Blanket Code Group Description HCPCS Code Procedure Code Short Description
SA880 Mobility Aids and supplies SA880 E1818 SPS forearm device
SA880 Mobility Aids and supplies SA880 E1820 Soft interface material
SA880 Mobility Aids and supplies SA880 E1821 Replacement interface SPSD
SA880 Mobility Aids and supplies SA880 E1825 Adjust finger ext/flex devc
SA880 Mobility Aids and supplies SA880 E1830 Adjust toe ext/flex device
SA880 Mobility Aids and supplies SA880 E1840 Adj shoulder ext/flex device
SA880 Mobility Aids and supplies SA880 E1902 AAC non-electronic board
SA880 Mobility Aids and supplies SA880 E8000 Posterior gait trainer
SA880 Mobility Aids and supplies SA880 E8001 Upright gait trainer
SA880 Mobility Aids and supplies SA880 E8002 Anterior gait trainer
SA881 Nutrition equipment and supplies SA881 97804 Medical nutrition, group
SA881 Nutrition equipment and supplies SA881 B4164 Parenteral 50% dextrose solu
SA881 Nutrition equipment and supplies SA881 B4168 Parenteral sol amino acid 3.
SA881 Nutrition equipment and supplies SA881 B4172 Parenteral sol amino acid 5.
SA881 Nutrition equipment and supplies SA881 B4176 Parenteral sol amino acid 7-
SA881 Nutrition equipment and supplies SA881 B4178 Parenteral sol amino acid >
SA881 Nutrition equipment and supplies SA881 B4180 Parenteral sol carb > 50%
SA881 Nutrition equipment and supplies SA881 B4185 Parenteral sol 10 gm lipids
SA881 Nutrition equipment and supplies SA881 B4189 Parenteral sol amino acid &
SA881 Nutrition equipment and supplies SA881 B4193 Parenteral sol 52-73 gm prot
SA881 Nutrition equipment and supplies SA881 B4197 Parenteral sol 74-100 gm pro
SA881 Nutrition equipment and supplies SA881 B4199 Parenteral sol > 100gm prote
SA881 Nutrition equipment and supplies SA881 B4216 Parenteral nutrition additiv
SA881 Nutrition equipment and supplies SA881 B4220 Parenteral supply kit premix
SA881 Nutrition equipment and supplies SA881 B4222 Parenteral supply kit homemi
SA881 Nutrition equipment and supplies SA881 B4224 Parenteral administration ki
SA881 Nutrition equipment and supplies SA881 B5000 Parenteral sol renal-amirosy
SA881 Nutrition equipment and supplies SA881 B5100 PARENTERAL SOLUTION HEPATIC
SA881 Nutrition equipment and supplies SA881 B5200 PARENTERAL SOL HEPATIC FREAM
SA881 Nutrition equipment and supplies SA881 B9004 Parenteral infus pump portab
SA881 Nutrition equipment and supplies SA881 B9006 Parenteral infus pump statio
SA881 Nutrition equipment and supplies SA881 B9999 Parenteral supp not othrws c
SA882 Orthotic equipment and supplies SA882 A4280 Brst prsths adhsv attchmnt
SA882 Orthotic equipment and supplies SA882 L0112 Cranial cervical orthosis
SA882 Orthotic equipment and supplies SA882 L0113 Cranial cervical torticollis
SA882 Orthotic equipment and supplies SA882 L0120 CERV FLEX N/ADJ FOAM PRE OTS
SA882 Orthotic equipment and supplies SA882 L0130 Flex thermoplastic collar mo
SA882 Orthotic equipment and supplies SA882 L0140 Cervical semi-rigid adjustab
SA882 Orthotic equipment and supplies SA882 L0150 Cerv semi-rig adj molded chn
SA882 Orthotic equipment and supplies SA882 L0160 CERV SR WIRE OCC/MAN PRE OTS
SA882 Orthotic equipment and supplies SA882 L0170 Cervical collar molded to pt
SA882 Orthotic equipment and supplies SA882 L0172 CERV COL SR FOAM 2PC PRE OTS
SA882 Orthotic equipment and supplies SA882 L0174 CERV SR 2PC THOR EXT PRE OTS
SA882 Orthotic equipment and supplies SA882 L0180 Cer post col occ/man sup adj
SA882 Orthotic equipment and supplies SA882 L0190 Cerv collar supp adj cerv ba
SA882 Orthotic equipment and supplies SA882 L0200 Cerv col supp adj bar & thor
SA882 Orthotic equipment and supplies SA882 L0220 Thor rib belt custom fabrica
SA882 Orthotic equipment and supplies SA882 L0430 DEWALL POSTURE PROTECTOR
SA882 Orthotic equipment and supplies SA882 L0450 TLSO FLEX TRUNK/THOR PRE OTS
SA882 Orthotic equipment and supplies SA882 L0452 tlso flex custom fab thoraci
SA882 Orthotic equipment and supplies SA882 L0454 TLSO TRNK SJ-T9 PRE CST
SA882 Orthotic equipment and supplies SA882 L0456 TLSO FLEX TRNK SJ-SS PRE CST
SA882 Orthotic equipment and supplies SA882 L0458 TLSO 2Mod symphis-xipho pre
SA882 Orthotic equipment and supplies SA882 L0460 TLSO 2 SHL SYMPHYS-STERN CST
SA882 Orthotic equipment and supplies SA882 L0462 TLSO 3Mod sacro-scap pre
SA882 Orthotic equipment and supplies SA882 L0464 TLSO 4Mod sacro-scap pre
SA882 Orthotic equipment and supplies SA882 L0466 TLSO R FRAM SOFT ANT PRE CST
SA882 Orthotic equipment and supplies SA882 L0468 TLSO RIG FRAM PELVIC PRE CST
SA882 Orthotic equipment and supplies SA882 L0470 TLSO rigid frame pre subclav
SA882 Orthotic equipment and supplies SA882 L0472 TLSO rigid frame hyperex pre
SA882 Orthotic equipment and supplies SA882 L0474
TLSO, TRIPLANAR CONTROL, RIGID POSTERIOR
FRAME W/FLEX SOFT APRON ANT W/MULT STRAPS CODE
DISC PER CMS/USE L0470
SA882 Orthotic equipment and supplies SA882 L0480 TLSO rigid plastic custom fa
25
Current Social Services Blanket Code HCPCS Code Billing Table Updated: 01/27/2016
Social Service Blanket Code Group Description HCPCS Code Procedure Code Short Description
SA882 Orthotic equipment and supplies SA882 L0482 TLSO rigid lined custom fab
SA882 Orthotic equipment and supplies SA882 L0484 TLSO rigid plastic cust fab
SA882 Orthotic equipment and supplies SA882 L0486 TLSO rigidlined cust fab two
SA882 Orthotic equipment and supplies SA882 L0488 TLSO rigid lined pre one pie
SA882 Orthotic equipment and supplies SA882 L0490 TLSO rigid plastic pre one
SA882 Orthotic equipment and supplies SA882 L0491 TLSO 2 piece rigid shell
SA882 Orthotic equipment and supplies SA882 L0492 TLSO 3 piece rigid shell
SA882 Orthotic equipment and supplies SA882 L0621 SIO FLEX PELVIC/SACR PRE OTS
SA882 Orthotic equipment and supplies SA882 L0622 SIO flex pelvisacral custom
SA882 Orthotic equipment and supplies SA882 L0623 SIO RIG PNL PELV/SAC PRE OTS
SA882 Orthotic equipment and supplies SA882 L0624 SIO panel custom
SA882 Orthotic equipment and supplies SA882 L0625 LO FLEX L1-BELOW L5 PRE OTS
SA882 Orthotic equipment and supplies SA882 L0626 LO SAG RIG PNL STAYS PRE CST
SA882 Orthotic equipment and supplies SA882 L0627 LO SAG RI AN/POS PNL PRE CST
SA882 Orthotic equipment and supplies SA882 L0628 LSO FLEX NO RI STAYS PRE OTS
SA882 Orthotic equipment and supplies SA882 L0629 LSO flex w/rigid stays cust
SA882 Orthotic equipment and supplies SA882 L0630 LSO R POST PNL SJ-T9 PRE CST
SA882 Orthotic equipment and supplies SA882 L0631 LSO SAG R AN/POS PNL PRE CST
SA882 Orthotic equipment and supplies SA882 L0632 LSO sag rigid frame cust
SA882 Orthotic equipment and supplies SA882 L0633 LSO SC R POS/LAT PNL PRE CST
SA882 Orthotic equipment and supplies SA882 L0634 LSO flexion control custom
SA882 Orthotic equipment and supplies SA882 L0635 LSO sagit rigid panel prefab
SA882 Orthotic equipment and supplies SA882 L0636 LSO sagittal rigid panel cus
SA882 Orthotic equipment and supplies SA882 L0637 LSO SC R ANT/POS PNL PRE CST
SA882 Orthotic equipment and supplies SA882 L0638 LSO sag-coronal panel custom
SA882 Orthotic equipment and supplies SA882 L0639 LSO S/C SHELL/PANEL PREFAB
SA882 Orthotic equipment and supplies SA882 L0640 LSO s/c shell/panel custom
SA882 Orthotic equipment and supplies SA882 L0700 Ctlso a-p-l control molded
SA882 Orthotic equipment and supplies SA882 L0710 Ctlso a-p-l control w/ inter
SA882 Orthotic equipment and supplies SA882 L0810 Halo cervical into jckt vest
SA882 Orthotic equipment and supplies SA882 L0820 Halo cervical into body jack
SA882 Orthotic equipment and supplies SA882 L0830 Halo cerv into milwaukee typ
SA882 Orthotic equipment and supplies SA882 L0859 MRI compatible system
SA882 Orthotic equipment and supplies SA882 L0861 Halo repl liner/interface
SA882 Orthotic equipment and supplies SA882 L0970 Tlso corset front
SA882 Orthotic equipment and supplies SA882 L0972 Lso corset front
SA882 Orthotic equipment and supplies SA882 L0974 Tlso full corset
SA882 Orthotic equipment and supplies SA882 L0976 Lso full corset
SA882 Orthotic equipment and supplies SA882 L0978 Axillary crutch extension
SA882 Orthotic equipment and supplies SA882 L0980 PERONEAL STRAPS PAIR PRE OTS
SA882 Orthotic equipment and supplies SA882 L0982 STOCKING SUP GRIPS 4 PRE OTS
SA882 Orthotic equipment and supplies SA882 L0984 PROTECT BODY SOCK EA PRE OTS
SA882 Orthotic equipment and supplies SA882 L0999 Add to spinal orthosis NOS
SA882 Orthotic equipment and supplies SA882 L1000 Ctlso milwauke initial model
SA882 Orthotic equipment and supplies SA882 L1001 CTLSO infant immobilizer
SA882 Orthotic equipment and supplies SA882 L1005 Tension based scoliosis orth
SA882 Orthotic equipment and supplies SA882 L1010 Ctlso axilla sling
SA882 Orthotic equipment and supplies SA882 L1020 Kyphosis pad
SA882 Orthotic equipment and supplies SA882 L1025 Kyphosis pad floating
SA882 Orthotic equipment and supplies SA882 L1030 Lumbar bolster pad
SA882 Orthotic equipment and supplies SA882 L1040 Lumbar or lumbar rib pad
SA882 Orthotic equipment and supplies SA882 L1050 Sternal pad
SA882 Orthotic equipment and supplies SA882 L1060 Thoracic pad
SA882 Orthotic equipment and supplies SA882 L1070 Trapezius sling
SA882 Orthotic equipment and supplies SA882 L1080 Outrigger
SA882 Orthotic equipment and supplies SA882 L1085 Outrigger bil w/ vert extens
SA882 Orthotic equipment and supplies SA882 L1090 Lumbar sling
SA882 Orthotic equipment and supplies SA882 L1100 Ring flange plastic/leather
SA882 Orthotic equipment and supplies SA882 L1110 Ring flange plas/leather mol
SA882 Orthotic equipment and supplies SA882 L1120 Covers for upright each
SA882 Orthotic equipment and supplies SA882 L1200 Furnsh initial orthosis only
SA882 Orthotic equipment and supplies SA882 L1210 Lateral thoracic extension
SA882 Orthotic equipment and supplies SA882 L1220 Anterior thoracic extension
SA882 Orthotic equipment and supplies SA882 L1230 Milwaukee type superstructur
25
Current Social Services Blanket Code HCPCS Code Billing Table Updated: 01/27/2016
Social Service Blanket Code Group Description HCPCS Code Procedure Code Short Description
SA882 Orthotic equipment and supplies SA882 L1240 Lumbar derotation pad
SA882 Orthotic equipment and supplies SA882 L1250 Anterior asis pad
SA882 Orthotic equipment and supplies SA882 L1260 Anterior thoracic derotation
SA882 Orthotic equipment and supplies SA882 L1270 Abdominal pad
SA882 Orthotic equipment and supplies SA882 L1280 Rib gusset (elastic) each
SA882 Orthotic equipment and supplies SA882 L1290 Lateral trochanteric pad
SA882 Orthotic equipment and supplies SA882 L1300 Body jacket mold to patient
SA882 Orthotic equipment and supplies SA882 L1310 Post-operative body jacket
SA882 Orthotic equipment and supplies SA882 L1499 Spinal orthosis NOS
SA882 Orthotic equipment and supplies SA882 L1500 THKAO MOBILITY FRAME
SA882 Orthotic equipment and supplies SA882 L1510 THKAO STANDING FRAME
SA882 Orthotic equipment and supplies SA882 L1520 THKAO SWIVEL WALKER
SA882 Orthotic equipment and supplies SA882 L1600 HO FLEX FREJKA W/COV PRE CST
SA882 Orthotic equipment and supplies SA882 L1610 HO FREJKA COV ONLY PRE CST
SA882 Orthotic equipment and supplies SA882 L1620 HO FLEX PAVLIK HARNS PRE CST
SA882 Orthotic equipment and supplies SA882 L1630 Abduct control hip semi-flex
SA882 Orthotic equipment and supplies SA882 L1640 Pelv band/spread bar thigh c
SA882 Orthotic equipment and supplies SA882 L1650 HO abduction hip adjustable
SA882 Orthotic equipment and supplies SA882 L1652 HO bi thighcuffs w sprdr bar
SA882 Orthotic equipment and supplies SA882 L1660 HO abduction static plastic
SA882 Orthotic equipment and supplies SA882 L1680 Pelvic & hip control thigh c
SA882 Orthotic equipment and supplies SA882 L1685 Post-op hip abduct custom fa
SA882 Orthotic equipment and supplies SA882 L1686 HO post-op hip abduction
SA882 Orthotic equipment and supplies SA882 L1690 Combination bilateral HO
SA882 Orthotic equipment and supplies SA882 L1700 Leg perthes orth toronto typ
SA882 Orthotic equipment and supplies SA882 L1710 Legg perthes orth newington
SA882 Orthotic equipment and supplies SA882 L1720 Legg perthes orthosis trilat
SA882 Orthotic equipment and supplies SA882 L1730 Legg perthes orth scottish r
SA882 Orthotic equipment and supplies SA882 L1755 Legg perthes patten bottom t
SA882 Orthotic equipment and supplies SA882 L1810 KO ELASTIC WITH JOINTS
SA882 Orthotic equipment and supplies SA882 L1820 Ko elas w/ condyle pads & jo
SA882 Orthotic equipment and supplies SA882 L1830 KO IMMOB CANVAS LONG PRE OTS
SA882 Orthotic equipment and supplies SA882 L1831 Knee orth pos locking joint
SA882 Orthotic equipment and supplies SA882 L1832 KO ADJ JNT POS R SUP PRE CST
SA882 Orthotic equipment and supplies SA882 L1834 Ko w/0 joint rigid molded to
SA882 Orthotic equipment and supplies SA882 L1836 KO RIGID W/O JOINTS PRE OTS
SA882 Orthotic equipment and supplies SA882 L1840 Ko derot ant cruciate custom
SA882 Orthotic equipment and supplies SA882 L1843 KO SINGLE UPRIGHT PRE CST
SA882 Orthotic equipment and supplies SA882 L1844 Ko w/adj jt rot cntrl molded
SA882 Orthotic equipment and supplies SA882 L1845 KO DOUBLE UPRIGHT PRE CST
SA882 Orthotic equipment and supplies SA882 L1846 Ko w adj flex/ext rotat mold
SA882 Orthotic equipment and supplies SA882 L1847 KO DBL UPRIGHT W/AIR PRE CST
SA882 Orthotic equipment and supplies SA882 L1850 KO SWEDISH TYPE PRE OTS
SA882 Orthotic equipment and supplies SA882 L1860 Ko supracondylar socket mold
SA882 Orthotic equipment and supplies SA882 L1900 Afo sprng wir drsflx calf bd
SA882 Orthotic equipment and supplies SA882 L1902 Afo ankle gauntlet pre ots
SA882 Orthotic equipment and supplies SA882 L1904 AFO MOLDED ANKLE GAUNTLET
SA882 Orthotic equipment and supplies SA882 L1906 AFO MULTILIG ANK SUP PRE OTS
SA882 Orthotic equipment and supplies SA882 L1907 AFO SUPRAMALLEOLAR CUSTOM
SA882 Orthotic equipment and supplies SA882 L1910 Afo sing bar clasp attach sh
SA882 Orthotic equipment and supplies SA882 L1920 Afo sing upright w/ adjust s
SA882 Orthotic equipment and supplies SA882 L1930 Afo plastic
SA882 Orthotic equipment and supplies SA882 L1932 Afo rig ant tib prefab TCF/=
SA882 Orthotic equipment and supplies SA882 L1940 Afo molded to patient plasti
SA882 Orthotic equipment and supplies SA882 L1945 Afo molded plas rig ant tib
SA882 Orthotic equipment and supplies SA882 L1950 Afo spiral molded to pt plas
SA882 Orthotic equipment and supplies SA882 L1951 AFO spiral prefabricated
SA882 Orthotic equipment and supplies SA882 L1960 Afo pos solid ank plastic mo
SA882 Orthotic equipment and supplies SA882 L1970 Afo plastic molded w/ankle j
SA882 Orthotic equipment and supplies SA882 L1971 AFO w/ankle joint, prefab
SA882 Orthotic equipment and supplies SA882 L1980 Afo sing solid stirrup calf
SA882 Orthotic equipment and supplies SA882 L1990 Afo doub solid stirrup calf
SA882 Orthotic equipment and supplies SA882 L2000 Kafo sing fre stirr thi/calf
SA882 Orthotic equipment and supplies SA882 L2005 KAFO SNG/DBL MECHANICAL ACT
25
Current Social Services Blanket Code HCPCS Code Billing Table Updated: 01/27/2016
Social Service Blanket Code Group Description HCPCS Code Procedure Code Short Description
SA882 Orthotic equipment and supplies SA882 L2010 Kafo sng solid stirrup w/o j
SA882 Orthotic equipment and supplies SA882 L2020 Kafo dbl solid stirrup band/
SA882 Orthotic equipment and supplies SA882 L2030 Kafo dbl solid stirrup w/o j
SA882 Orthotic equipment and supplies SA882 L2034 KAFO pla sin up w/wo k/a cus
SA882 Orthotic equipment and supplies SA882 L2035 KAFO plastic pediatric size
SA882 Orthotic equipment and supplies SA882 L2036 Kafo plas doub free knee mol
SA882 Orthotic equipment and supplies SA882 L2037 Kafo plas sing free knee mol
SA882 Orthotic equipment and supplies SA882 L2038 Kafo w/o joint multi-axis an
SA882 Orthotic equipment and supplies SA882 L2040 Hkafo torsion bil rot straps
SA882 Orthotic equipment and supplies SA882 L2050 Hkafo torsion cable hip pelv
SA882 Orthotic equipment and supplies SA882 L2060 Hkafo torsion ball bearing j
SA882 Orthotic equipment and supplies SA882 L2070 Hkafo torsion unilat rot str
SA882 Orthotic equipment and supplies SA882 L2080 Hkafo unilat torsion cable
SA882 Orthotic equipment and supplies SA882 L2090 Hkafo unilat torsion ball br
SA882 Orthotic equipment and supplies SA882 L2106 Afo tib fx cast plaster mold
SA882 Orthotic equipment and supplies SA882 L2108 Afo tib fx cast molded to pt
SA882 Orthotic equipment and supplies SA882 L2112 Afo tibial fracture soft
SA882 Orthotic equipment and supplies SA882 L2114 Afo tib fx semi-rigid
SA882 Orthotic equipment and supplies SA882 L2116 Afo tibial fracture rigid
SA882 Orthotic equipment and supplies SA882 L2126 Kafo fem fx cast thermoplas
SA882 Orthotic equipment and supplies SA882 L2128 Kafo fem fx cast molded to p
SA882 Orthotic equipment and supplies SA882 L2132 Kafo femoral fx cast soft
SA882 Orthotic equipment and supplies SA882 L2134 Kafo fem fx cast semi-rigid
SA882 Orthotic equipment and supplies SA882 L2136 Kafo femoral fx cast rigid
SA882 Orthotic equipment and supplies SA882 L2180 Plas shoe insert w ank joint
SA882 Orthotic equipment and supplies SA882 L2182 Drop lock knee
SA882 Orthotic equipment and supplies SA882 L2184 Limited motion knee joint
SA882 Orthotic equipment and supplies SA882 L2186 Adj motion knee jnt lerman t
SA882 Orthotic equipment and supplies SA882 L2188 Quadrilateral brim
SA882 Orthotic equipment and supplies SA882 L2190 Waist belt
SA882 Orthotic equipment and supplies SA882 L2192 Pelvic band & belt thigh fla
SA882 Orthotic equipment and supplies SA882 L2200 Limited ankle motion ea jnt
SA882 Orthotic equipment and supplies SA882 L2210 Dorsiflexion assist each joi
SA882 Orthotic equipment and supplies SA882 L2220 Dorsi & plantar flex ass/res
SA882 Orthotic equipment and supplies SA882 L2230 Split flat caliper stirr & p
SA882 Orthotic equipment and supplies SA882 L2232 Rocker bottom, contact AFO
SA882 Orthotic equipment and supplies SA882 L2240 Round caliper and plate atta
SA882 Orthotic equipment and supplies SA882 L2250 Foot plate molded stirrup at
SA882 Orthotic equipment and supplies SA882 L2260 Reinforced solid stirrup
SA882 Orthotic equipment and supplies SA882 L2265 Long tongue stirrup
SA882 Orthotic equipment and supplies SA882 L2270 Varus/valgus strap padded/li
SA882 Orthotic equipment and supplies SA882 L2275 Plastic mod low ext pad/line
SA882 Orthotic equipment and supplies SA882 L2280 Molded inner boot
SA882 Orthotic equipment and supplies SA882 L2300 Abduction bar jointed adjust
SA882 Orthotic equipment and supplies SA882 L2310 Abduction bar-straight
SA882 Orthotic equipment and supplies SA882 L2320 Non-molded lacer
SA882 Orthotic equipment and supplies SA882 L2330 Lacer molded to patient mode
SA882 Orthotic equipment and supplies SA882 L2335 Anterior swing band
SA882 Orthotic equipment and supplies SA882 L2340 Pre-tibial shell molded to p
SA882 Orthotic equipment and supplies SA882 L2350 Prosthetic type socket molde
SA882 Orthotic equipment and supplies SA882 L2360 Extended steel shank
SA882 Orthotic equipment and supplies SA882 L2370 Patten bottom
SA882 Orthotic equipment and supplies SA882 L2375 Torsion ank & half solid sti
SA882 Orthotic equipment and supplies SA882 L2380 Torsion straight knee joint
SA882 Orthotic equipment and supplies SA882 L2385 Straight knee joint heavy du
SA882 Orthotic equipment and supplies SA882 L2387 Add LE poly knee custom KAFO
SA882 Orthotic equipment and supplies SA882 L2390 Offset knee joint each
SA882 Orthotic equipment and supplies SA882 L2395 Offset knee joint heavy duty
SA882 Orthotic equipment and supplies SA882 L2397 Suspension sleeve lower ext
SA882 Orthotic equipment and supplies SA882 L2405 Knee joint drop lock ea jnt
SA882 Orthotic equipment and supplies SA882 L2415 Knee joint cam lock each joi
SA882 Orthotic equipment and supplies SA882 L2425 Knee disc/dial lock/adj flex
SA882 Orthotic equipment and supplies SA882 L2430 Knee jnt ratchet lock ea jnt
SA882 Orthotic equipment and supplies SA882 L2492 Knee lift loop drop lock rin
25
Current Social Services Blanket Code HCPCS Code Billing Table Updated: 01/27/2016
Social Service Blanket Code Group Description HCPCS Code Procedure Code Short Description
SA882 Orthotic equipment and supplies SA882 L2500 Thi/glut/ischia wgt bearing
SA882 Orthotic equipment and supplies SA882 L2510 Th/wght bear quad-lat brim m
SA882 Orthotic equipment and supplies SA882 L2520 Th/wght bear quad-lat brim c
SA882 Orthotic equipment and supplies SA882 L2525 Th/wght bear nar m-l brim mo
SA882 Orthotic equipment and supplies SA882 L2526 Th/wght bear nar m-l brim cu
SA882 Orthotic equipment and supplies SA882 L2530 Thigh/wght bear lacer non-mo
SA882 Orthotic equipment and supplies SA882 L2540 Thigh/wght bear lacer molded
SA882 Orthotic equipment and supplies SA882 L2550 Thigh/wght bear high roll cu
SA882 Orthotic equipment and supplies SA882 L2570 Hip clevis type 2 posit jnt
SA882 Orthotic equipment and supplies SA882 L2580 Pelvic control pelvic sling
SA882 Orthotic equipment and supplies SA882 L2600 Hip clevis/thrust bearing fr
SA882 Orthotic equipment and supplies SA882 L2610 Hip clevis/thrust bearing lo
SA882 Orthotic equipment and supplies SA882 L2620 Pelvic control hip heavy dut
SA882 Orthotic equipment and supplies SA882 L2622 Hip joint adjustable flexion
SA882 Orthotic equipment and supplies SA882 L2624 Hip adj flex ext abduct cont
SA882 Orthotic equipment and supplies SA882 L2627 Plastic mold recipro hip & c
SA882 Orthotic equipment and supplies SA882 L2628 Metal frame recipro hip & ca
SA882 Orthotic equipment and supplies SA882 L2630 Pelvic control band & belt u
SA882 Orthotic equipment and supplies SA882 L2640 Pelvic control band & belt b
SA882 Orthotic equipment and supplies SA882 L2650 Pelv & thor control gluteal
SA882 Orthotic equipment and supplies SA882 L2660 Thoracic control thoracic ba
SA882 Orthotic equipment and supplies SA882 L2670 Thorac cont paraspinal uprig
SA882 Orthotic equipment and supplies SA882 L2680 Thorac cont lat support upri
SA882 Orthotic equipment and supplies SA882 L2750 Plating chrome/nickel pr bar
SA882 Orthotic equipment and supplies SA882 L2755 Carbon graphite lamination
SA882 Orthotic equipment and supplies SA882 L2760 Extension per extension per
SA882 Orthotic equipment and supplies SA882 L2768 Ortho sidebar disconnect
SA882 Orthotic equipment and supplies SA882 L2780 Non-corrosive finish
SA882 Orthotic equipment and supplies SA882 L2785 Drop lock retainer each
SA882 Orthotic equipment and supplies SA882 L2795 Knee control full kneecap
SA882 Orthotic equipment and supplies SA882 L2800 Knee cap medial or lateral p
SA882 Orthotic equipment and supplies SA882 L2810 Knee control condylar pad
SA882 Orthotic equipment and supplies SA882 L2820 Soft interface below knee se
SA882 Orthotic equipment and supplies SA882 L2830 Soft interface above knee se
SA882 Orthotic equipment and supplies SA882 L2840 Tibial length sock fx or equ
SA882 Orthotic equipment and supplies SA882 L2850 Femoral lgth sock fx or equa
SA882 Orthotic equipment and supplies SA882 L2861 Torsion mechanism knee/ankle
SA882 Orthotic equipment and supplies SA882 L2999 Lower extremity orthosis NOS
SA882 Orthotic equipment and supplies SA882 L3000 Ft insert ucb berkeley shell
SA882 Orthotic equipment and supplies SA882 L3001 Foot insert remov molded spe
SA882 Orthotic equipment and supplies SA882 L3002 Foot insert plastazote or eq
SA882 Orthotic equipment and supplies SA882 L3003 Foot insert silicone gel eac
SA882 Orthotic equipment and supplies SA882 L3010 Foot longitudinal arch suppo
SA882 Orthotic equipment and supplies SA882 L3020 Foot longitud/metatarsal sup
SA882 Orthotic equipment and supplies SA882 L3030 Foot arch support remov prem
SA882 Orthotic equipment and supplies SA882 L3031 Foot lamin/prepreg composite
SA882 Orthotic equipment and supplies SA882 L3040 Ft arch suprt premold longit
SA882 Orthotic equipment and supplies SA882 L3050 Foot arch supp premold metat
SA882 Orthotic equipment and supplies SA882 L3060 Foot arch supp longitud/meta
SA882 Orthotic equipment and supplies SA882 L3070 Arch suprt att to sho longit
SA882 Orthotic equipment and supplies SA882 L3080 Arch supp att to shoe metata
SA882 Orthotic equipment and supplies SA882 L3090 Arch supp att to shoe long/m
SA882 Orthotic equipment and supplies SA882 L3100 HALLUS-VALGUS NT DYN PRE OTS
SA882 Orthotic equipment and supplies SA882 L3140 Abduction rotation bar shoe
SA882 Orthotic equipment and supplies SA882 L3150 Abduct rotation bar w/o shoe
SA882 Orthotic equipment and supplies SA882 L3160 Shoe styled positioning dev
SA882 Orthotic equipment and supplies SA882 L3170 FOOT PLAS HEEL STABI PRE OTS
SA882 Orthotic equipment and supplies SA882 L3201 Oxford w supinat/pronat inf
SA882 Orthotic equipment and supplies SA882 L3202 Oxford w/ supinat/pronator c
SA882 Orthotic equipment and supplies SA882 L3203 Oxford w/ supinator/pronator
SA882 Orthotic equipment and supplies SA882 L3204 Hightop w/ supp/pronator inf
SA882 Orthotic equipment and supplies SA882 L3206 Hightop w/ supp/pronator chi
SA882 Orthotic equipment and supplies SA882 L3207 Hightop w/ supp/pronator jun
SA882 Orthotic equipment and supplies SA882 L3208 Surgical boot each infant
25
Current Social Services Blanket Code HCPCS Code Billing Table Updated: 01/27/2016
Social Service Blanket Code Group Description HCPCS Code Procedure Code Short Description
SA882 Orthotic equipment and supplies SA882 L3209 Surgical boot each child
SA882 Orthotic equipment and supplies SA882 L3211 Surgical boot each junior
SA882 Orthotic equipment and supplies SA882 L3212 Benesch boot pair infant
SA882 Orthotic equipment and supplies SA882 L3213 Benesch boot pair child
SA882 Orthotic equipment and supplies SA882 L3214 Benesch boot pair junior
SA882 Orthotic equipment and supplies SA882 L3215 Orthopedic ftwear ladies oxf
SA882 Orthotic equipment and supplies SA882 L3216 Orthoped ladies shoes dpth i
SA882 Orthotic equipment and supplies SA882 L3217 Ladies shoes hightop depth i
SA882 Orthotic equipment and supplies SA882 L3219 Orthopedic mens shoes oxford
SA882 Orthotic equipment and supplies SA882 L3221 Orthopedic mens shoes dpth i
SA882 Orthotic equipment and supplies SA882 L3222 Mens shoes hightop depth inl
SA882 Orthotic equipment and supplies SA882 L3224 Woman's shoe oxford brace
SA882 Orthotic equipment and supplies SA882 L3225 Man's shoe oxford brace
SA882 Orthotic equipment and supplies SA882 L3230 Custom shoes depth inlay
SA882 Orthotic equipment and supplies SA882 L3250 Custom mold shoe remov prost
SA882 Orthotic equipment and supplies SA882 L3251 Shoe molded to pt silicone s
SA882 Orthotic equipment and supplies SA882 L3252 Shoe molded plastazote cust
SA882 Orthotic equipment and supplies SA882 L3253 Shoe molded plastazote cust
SA882 Orthotic equipment and supplies SA882 L3254 Orth foot non-stndard size/w
SA882 Orthotic equipment and supplies SA882 L3255 Orth foot non-standard size/
SA882 Orthotic equipment and supplies SA882 L3257 Orth foot add charge split s
SA882 Orthotic equipment and supplies SA882 L3260 Ambulatory surgical boot eac
SA882 Orthotic equipment and supplies SA882 L3265 Plastazote sandal each
SA882 Orthotic equipment and supplies SA882 L3300 Sho lift taper to metatarsal
SA882 Orthotic equipment and supplies SA882 L3310 Shoe lift elev heel/sole neo
SA882 Orthotic equipment and supplies SA882 L3320 Shoe lift elev heel/sole cor
SA882 Orthotic equipment and supplies SA882 L3330 Lifts elevation metal extens
SA882 Orthotic equipment and supplies SA882 L3332 Shoe lifts tapered to one-ha
SA882 Orthotic equipment and supplies SA882 L3334 Shoe lifts elevation heel /i
SA882 Orthotic equipment and supplies SA882 L3340 Shoe wedge sach
SA882 Orthotic equipment and supplies SA882 L3350 Shoe heel wedge
SA882 Orthotic equipment and supplies SA882 L3360 Shoe sole wedge outside sole
SA882 Orthotic equipment and supplies SA882 L3370 Shoe sole wedge between sole
SA882 Orthotic equipment and supplies SA882 L3380 Shoe clubfoot wedge
SA882 Orthotic equipment and supplies SA882 L3390 Shoe outflare wedge
SA882 Orthotic equipment and supplies SA882 L3400 Shoe metatarsal bar wedge ro
SA882 Orthotic equipment and supplies SA882 L3410 Shoe metatarsal bar between
SA882 Orthotic equipment and supplies SA882 L3420 Full sole/heel wedge btween
SA882 Orthotic equipment and supplies SA882 L3430 Sho heel count plast reinfor
SA882 Orthotic equipment and supplies SA882 L3440 Heel leather reinforced
SA882 Orthotic equipment and supplies SA882 L3450 Shoe heel sach cushion type
SA882 Orthotic equipment and supplies SA882 L3455 Shoe heel new leather standa
SA882 Orthotic equipment and supplies SA882 L3460 Shoe heel new rubber standar
SA882 Orthotic equipment and supplies SA882 L3465 Shoe heel thomas with wedge
SA882 Orthotic equipment and supplies SA882 L3470 Shoe heel thomas extend to b
SA882 Orthotic equipment and supplies SA882 L3480 Shoe heel pad & depress for
SA882 Orthotic equipment and supplies SA882 L3485 Shoe heel pad removable for
SA882 Orthotic equipment and supplies SA882 L3500 Ortho shoe add leather insol
SA882 Orthotic equipment and supplies SA882 L3510 Orthopedic shoe add rub insl
SA882 Orthotic equipment and supplies SA882 L3520 O shoe add felt w leath insl
SA882 Orthotic equipment and supplies SA882 L3530 Ortho shoe add half sole
SA882 Orthotic equipment and supplies SA882 L3540 Ortho shoe add full sole
SA882 Orthotic equipment and supplies SA882 L3550 O shoe add standard toe tap
SA882 Orthotic equipment and supplies SA882 L3560 O shoe add horseshoe toe tap
SA882 Orthotic equipment and supplies SA882 L3570 O shoe add instep extension
SA882 Orthotic equipment and supplies SA882 L3580 O shoe add instep velcro clo
SA882 Orthotic equipment and supplies SA882 L3590 O shoe convert to sof counte
SA882 Orthotic equipment and supplies SA882 L3595 Ortho shoe add march bar
SA882 Orthotic equipment and supplies SA882 L3600 Trans shoe calip plate exist
SA882 Orthotic equipment and supplies SA882 L3610 Trans shoe caliper plate new
SA882 Orthotic equipment and supplies SA882 L3620 Trans shoe solid stirrup exi
SA882 Orthotic equipment and supplies SA882 L3630 Trans shoe solid stirrup new
SA882 Orthotic equipment and supplies SA882 L3640 Shoe dennis browne splint bo
SA882 Orthotic equipment and supplies SA882 L3649 Orthopedic shoe modifica NOS
25
Current Social Services Blanket Code HCPCS Code Billing Table Updated: 01/27/2016
Social Service Blanket Code Group Description HCPCS Code Procedure Code Short Description
SA882 Orthotic equipment and supplies SA882 L3650 SO 8 ABD RESTRAINT PRE OTS
SA882 Orthotic equipment and supplies SA882 L3660 SO 8 AB RSTR CAN/WEB PRE OTS
SA882 Orthotic equipment and supplies SA882 L3670 SO ACRO/CLAV CAN WEB PRE OTS
SA882 Orthotic equipment and supplies SA882 L3671 SO CAP DESIGN W/O JNTS CF
SA882 Orthotic equipment and supplies SA882 L3672 SO airplane w/o jnts CF
SA882 Orthotic equipment and supplies SA882 L3673 SO airplane w/joint CF
SA882 Orthotic equipment and supplies SA882 L3675 SO VEST CANVAS/WEB PRE OTS
SA882 Orthotic equipment and supplies SA882 L3677 SO HARD PLAS STABILI PRE CST
SA882 Orthotic equipment and supplies SA882 L3702 EO w/o joints CF
SA882 Orthotic equipment and supplies SA882 L3710 EO ELAS W/METAL JNTS PRE OTS
SA882 Orthotic equipment and supplies SA882 L3720 Forearm/arm cuffs free motio
SA882 Orthotic equipment and supplies SA882 L3730 Forearm/arm cuffs ext/flex a
SA882 Orthotic equipment and supplies SA882 L3740 Cuffs adj lock w/ active con
SA882 Orthotic equipment and supplies SA882 L3760 EO withjoint, Prefabricated
SA882 Orthotic equipment and supplies SA882 L3762 EO RIGID W/O JOINTS PRE OTS
SA882 Orthotic equipment and supplies SA882 L3763 EWHO rigid w/o jnts CF
SA882 Orthotic equipment and supplies SA882 L3764 EWHO w/joint(s) CF
SA882 Orthotic equipment and supplies SA882 L3765 EWHFO rigid w/o jnts CF
SA882 Orthotic equipment and supplies SA882 L3766 EWHFO w/joint(s) CF
SA882 Orthotic equipment and supplies SA882 L3806 WHFO w/joint(s) custom fab
SA882 Orthotic equipment and supplies SA882 L3807 WHFO W/O JOINTS PRE CST
SA882 Orthotic equipment and supplies SA882 L3808 WHFO, rigid w/o joints
SA882 Orthotic equipment and supplies SA882 L3891 Torsion mechanism wrist/elbo
SA882 Orthotic equipment and supplies SA882 L3900 Hinge extension/flex wrist/f
SA882 Orthotic equipment and supplies SA882 L3901 Hinge ext/flex wrist finger
SA882 Orthotic equipment and supplies SA882 L3904 Whfo electric custom fitted
SA882 Orthotic equipment and supplies SA882 L3905 WHO w/nontorsion jnt(s) CF
SA882 Orthotic equipment and supplies SA882 L3906 WHO w/o joints CF
SA882 Orthotic equipment and supplies SA882 L3908 WHO COCK-UP NONMOLDE PRE OTS
SA882 Orthotic equipment and supplies SA882 L3912 HFO FLEXION GLOVE PRE OTS
SA882 Orthotic equipment and supplies SA882 L3913 HFO w/o joints CF
SA882 Orthotic equipment and supplies SA882 L3915 WHO NONTORSION JNTS PRE CST
SA882 Orthotic equipment and supplies SA882 L3917 METACARP FX ORTHOSIS PRE CST
SA882 Orthotic equipment and supplies SA882 L3919 HO w/o joints CF
SA882 Orthotic equipment and supplies SA882 L3921 HFO w/joint(s) CF
SA882 Orthotic equipment and supplies SA882 L3923 HFO WITHOUT JOINTS PRE CST
SA882 Orthotic equipment and supplies SA882 L3925 FO PIP DIP JNT/SPRNG PRE OTS
SA882 Orthotic equipment and supplies SA882 L3927 FO PIP DIP NO JT SPR PRE OTS
SA882 Orthotic equipment and supplies SA882 L3929 HFO NONTORSION JNTS PRE CST
SA882 Orthotic equipment and supplies SA882 L3931 WHFO nontorsion joint prefab
SA882 Orthotic equipment and supplies SA882 L3933 FO w/o joints CF
SA882 Orthotic equipment and supplies SA882 L3935 FO nontorsion joint CF
SA882 Orthotic equipment and supplies SA882 L3956 Add joint upper ext orthosis
SA882 Orthotic equipment and supplies SA882 L3960 Sewho airplan desig abdu pos
SA882 Orthotic equipment and supplies SA882 L3961 SEWHO cap design w/o jnts CF
SA882 Orthotic equipment and supplies SA882 L3962 Sewho erbs palsey design abd
SA882 Orthotic equipment and supplies SA882 L3964 SEO MOBILE ARM SUP ATT TO WC
SA882 Orthotic equipment and supplies SA882 L3965 ARM SUPP ATT TO WC RANCHO TY
SA882 Orthotic equipment and supplies SA882 L3966 MOBILE ARM SUPPORTS RECLININ
SA882 Orthotic equipment and supplies SA882 L3967 SEWHO airplane w/o jnts CF
SA882 Orthotic equipment and supplies SA882 L3968 FRICTION DAMPENING ARM SUPP
SA882 Orthotic equipment and supplies SA882 L3969 MONOSUSPENSION ARM/HAND SUPP
SA882 Orthotic equipment and supplies SA882 L3970 ELEVAT PROXIMAL ARM SUPPORT
SA882 Orthotic equipment and supplies SA882 L3971 SEWHO cap design w/jnt(s) CF
SA882 Orthotic equipment and supplies SA882 L3972 OFFSET/LAT ROCKER ARM W/ ELA
SA882 Orthotic equipment and supplies SA882 L3973 SEWHO airplane w/jnt(s) CF
SA882 Orthotic equipment and supplies SA882 L3974 MOBILE ARM SUPPORT SUPINATOR
SA882 Orthotic equipment and supplies SA882 L3975 SEWHFO cap design w/o jnt CF
SA882 Orthotic equipment and supplies SA882 L3976 SEWHFO airplane w/o jnts CF
SA882 Orthotic equipment and supplies SA882 L3977 SEWHFO cap desgn w/jnt(s) CF
SA882 Orthotic equipment and supplies SA882 L3978 SEWHFO airplane w/jnt(s) CF
SA882 Orthotic equipment and supplies SA882 L3980 UP EXT FX ORTHOS HUMERAL NOS
SA882 Orthotic equipment and supplies SA882 L3982 Upper ext fx orthosis rad/ul
SA882 Orthotic equipment and supplies SA882 L3984 Upper ext fx orthosis wrist
25
Current Social Services Blanket Code HCPCS Code Billing Table Updated: 01/27/2016
Social Service Blanket Code Group Description HCPCS Code Procedure Code Short Description
SA882 Orthotic equipment and supplies SA882 L3995 Sock fracture or equal each
SA882 Orthotic equipment and supplies SA882 L3999 Upper limb orthosis NOS
SA882 Orthotic equipment and supplies SA882 L4000 Repl girdle milwaukee orth
SA882 Orthotic equipment and supplies SA882 L4002 Replace strap, any orthosis
SA882 Orthotic equipment and supplies SA882 L4010 Replace trilateral socket br
SA882 Orthotic equipment and supplies SA882 L4020 Replace quadlat socket brim
SA882 Orthotic equipment and supplies SA882 L4030 Replace socket brim cust fit
SA882 Orthotic equipment and supplies SA882 L4040 Replace molded thigh lacer
SA882 Orthotic equipment and supplies SA882 L4045 Replace non-molded thigh lac
SA882 Orthotic equipment and supplies SA882 L4050 Replace molded calf lacer
SA882 Orthotic equipment and supplies SA882 L4055 Replace non-molded calf lace
SA882 Orthotic equipment and supplies SA882 L4060 Replace high roll cuff
SA882 Orthotic equipment and supplies SA882 L4070 Replace prox & dist upright
SA882 Orthotic equipment and supplies SA882 L4080 Repl met band kafo-afo prox
SA882 Orthotic equipment and supplies SA882 L4090 Repl met band kafo-afo calf/
SA882 Orthotic equipment and supplies SA882 L4100 Repl leath cuff kafo prox th
SA882 Orthotic equipment and supplies SA882 L4110 Repl leath cuff kafo-afo cal
SA882 Orthotic equipment and supplies SA882 L4130 Replace pretibial shell
SA882 Orthotic equipment and supplies SA882 L4205 Ortho dvc repair per 15 min
SA882 Orthotic equipment and supplies SA882 L4210 Orth dev repair/repl minor p
SA882 Orthotic equipment and supplies SA882 L4350 ANKLE CONTROL ORTHO PRE OTS
SA882 Orthotic equipment and supplies SA882 L4360 PNEUMAT WALKING BOOT PRE CST
SA882 Orthotic equipment and supplies SA882 L4370 PNEUM FULL LEG SPLNT PRE OTS
SA882 Orthotic equipment and supplies SA882 L4380 PNEUMATIC KNEE SPLINT
SA882 Orthotic equipment and supplies SA882 L4386 NON-PNEUM WALK BOOT PRE CST
SA882 Orthotic equipment and supplies SA882 L4392 Replace AFO soft interface
SA882 Orthotic equipment and supplies SA882 L4394 Replace foot drop spint
SA882 Orthotic equipment and supplies SA882 L4396 STATIC OR DYNAMI AFO PRE CST
SA882 Orthotic equipment and supplies SA882 L4398 FOOT DROP SPLINT PRE OTS
SA883 Ostomy care SA883 A4361 Ostomy face plate
SA883 Ostomy care SA883 A4362 Solid skin barrier
SA883 Ostomy care SA883 A4363 Ostomy clamp, replacement
SA883 Ostomy care SA883 A4366 Ostomy vent
SA883 Ostomy care SA883 A4367 Ostomy belt
SA883 Ostomy care SA883 A4368 Ostomy filter
SA883 Ostomy care SA883 A4369 Skin barrier liquid per oz
SA883 Ostomy care SA883 A4371 Skin barrier powder per oz
SA883 Ostomy care SA883 A4372 Skin barrier solid 4x4 equiv
SA883 Ostomy care SA883 A4373 Skin barrier with flange
SA883 Ostomy care SA883 A4375 Drainable plastic pch w fcpl
SA883 Ostomy care SA883 A4376 Drainable rubber pch w fcplt
SA883 Ostomy care SA883 A4377 Drainable plstic pch w/o fp
SA883 Ostomy care SA883 A4378 Drainable rubber pch w/o fp
SA883 Ostomy care SA883 A4379 Urinary plastic pouch w fcpl
SA883 Ostomy care SA883 A4380 Urinary rubber pouch w fcplt
SA883 Ostomy care SA883 A4381 Urinary plastic pouch w/o fp
SA883 Ostomy care SA883 A4382 Urinary hvy plstc pch w/o fp
SA883 Ostomy care SA883 A4383 Urinary rubber pouch w/o fp
SA883 Ostomy care SA883 A4384 Ostomy faceplt/silicone ring
SA883 Ostomy care SA883 A4385 Ost skn barrier sld ext wear
SA883 Ostomy care SA883 A4387 Ost clsd pouch w att st barr
SA883 Ostomy care SA883 A4388 Drainable pch w ex wear barr
SA883 Ostomy care SA883 A4389 Drainable pch w st wear barr
SA883 Ostomy care SA883 A4390 Drainable pch ex wear convex
SA883 Ostomy care SA883 A4391 Urinary pouch w ex wear barr
SA883 Ostomy care SA883 A4392 Urinary pouch w st wear barr
SA883 Ostomy care SA883 A4393 Urine pch w ex wear bar conv
SA883 Ostomy care SA883 A4394 Ostomy pouch liq deodorant
SA883 Ostomy care SA883 A4395 Ostomy pouch solid deodorant
SA883 Ostomy care SA883 A4396 Peristomal hernia supprt blt
SA883 Ostomy care SA883 A4397 Irrigation supply sleeve
SA883 Ostomy care SA883 A4398 Ostomy irrigation bag
SA883 Ostomy care SA883 A4399 Ostomy irrig cone/cath w brs
SA883 Ostomy care SA883 A4400 Ostomy irrigation set
25
Current Social Services Blanket Code HCPCS Code Billing Table Updated: 01/27/2016
Social Service Blanket Code Group Description HCPCS Code Procedure Code Short Description
SA883 Ostomy care SA883 A4402 Lubricant per ounce
SA883 Ostomy care SA883 A4404 Ostomy ring each
SA883 Ostomy care SA883 A4405 Nonpectin based ostomy paste
SA883 Ostomy care SA883 A4406 Pectin based ostomy paste
SA883 Ostomy care SA883 A4407 Ext wear ost skn barr <=4sq"
SA883 Ostomy care SA883 A4408 Ext wear ost skn barr >4sq"
SA883 Ostomy care SA883 A4409 Ost skn barr convex <=4 sq i
SA883 Ostomy care SA883 A4410 Ost skn barr extnd >4 sq
SA883 Ostomy care SA883 A4411 Ost skn barr extnd =4sq
SA883 Ostomy care SA883 A4412 Ost pouch drain high output
SA883 Ostomy care SA883 A4413 2 pc drainable ost pouch
SA883 Ostomy care SA883 A4414 Ost sknbar w/o conv<=4 sq in
SA883 Ostomy care SA883 A4415 Ost skn barr w/o conv >4 sqi
SA883 Ostomy care SA883 A4416 Ost pch clsd w barrier/filtr
SA883 Ostomy care SA883 A4417 Ost pch w bar/bltinconv/fltr
SA883 Ostomy care SA883 A4418 Ost pch clsd w/o bar w filtr
SA883 Ostomy care SA883 A4419 Ost pch for bar w flange/flt
SA883 Ostomy care SA883 A4420 Ost pch clsd for bar w lk fl
SA883 Ostomy care SA883 A4421 Ostomy supply misc
SA883 Ostomy care SA883 A4422 Ost pouch absorbent material
SA883 Ostomy care SA883 A4423 Ost pch for bar w lk fl/fltr
SA883 Ostomy care SA883 A4424 Ost pch drain w bar & filter
SA883 Ostomy care SA883 A4425 Ost pch drain for barrier fl
SA883 Ostomy care SA883 A4426 Ost pch drain 2 piece system
SA883 Ostomy care SA883 A4427 Ost pch drain/barr lk flng/f
SA883 Ostomy care SA883 A4428 Urine ost pouch w faucet/tap
SA883 Ostomy care SA883 A4429 Urine ost pouch w bltinconv
SA883 Ostomy care SA883 A4430 Ost urine pch w b/bltin conv
SA883 Ostomy care SA883 A4431 Ost pch urine w barrier/tapv
SA883 Ostomy care SA883 A4432 Os pch urine w bar/fange/tap
SA883 Ostomy care SA883 A4433 Urine ost pch bar w lock fln
SA883 Ostomy care SA883 A4434 Ost pch urine w lock flng/ft
SA883 Ostomy care SA883 A5051 Pouch clsd w barr attached
SA883 Ostomy care SA883 A5052 Clsd ostomy pouch w/o barr
SA883 Ostomy care SA883 A5053 Clsd ostomy pouch faceplate
SA883 Ostomy care SA883 A5054 Clsd ostomy pouch w/flange
SA883 Ostomy care SA883 A5055 Stoma cap
SA883 Ostomy care SA883 A5061 Pouch drainable w barrier at
SA883 Ostomy care SA883 A5062 Drnble ostomy pouch w/o barr
SA883 Ostomy care SA883 A5063 Drain ostomy pouch w/flange
SA883 Ostomy care SA883 A5071 Urinary pouch w/barrier
SA883 Ostomy care SA883 A5072 Urinary pouch w/o barrier
SA883 Ostomy care SA883 A5073 Urinary pouch on barr w/flng
SA883 Ostomy care SA883 A5081 STOMA PLUG OR SEAL, ANY TYPE
SA883 Ostomy care SA883 A5082 Continent stoma catheter
SA883 Ostomy care SA883 A5083 Stoma absorptive cover
SA883 Ostomy care SA883 A5093 Ostomy accessory convex inse
SA884 Respiratory equipment and supplies SA884 A4450 Non-waterproof tape
SA884 Respiratory equipment and supplies SA884 A4452 Waterproof tape
SA884 Respiratory equipment and supplies SA884 A4481 Tracheostoma filter
SA884 Respiratory equipment and supplies SA884 A4558 Conductive gel or paste
SA884 Respiratory equipment and supplies SA884 A4604 Tubing with heating element
SA884 Respiratory equipment and supplies SA884 A4606 Oxygen probe used w oximeter
SA884 Respiratory equipment and supplies SA884 A4608 TRANSTRACHEAL OXYGEN CATH
SA884 Respiratory equipment and supplies SA884 A4611 HEAVY DUTY BATTERY
SA884 Respiratory equipment and supplies SA884 A4612 BATTERY CABLES
SA884 Respiratory equipment and supplies SA884 A4613 BATTERY CHARGER
SA884 Respiratory equipment and supplies SA884 A4614 Hand-held PEFR meter
SA884 Respiratory equipment and supplies SA884 A4615 Cannula nasal
SA884 Respiratory equipment and supplies SA884 A4616 Tubing (oxygen) per foot
SA884 Respiratory equipment and supplies SA884 A4617 Mouth piece
SA884 Respiratory equipment and supplies SA884 A4618 Breathing circuits
SA884 Respiratory equipment and supplies SA884 A4619 FACE TENT
SA884 Respiratory equipment and supplies SA884 A4620 Variable concentration mask
25
Current Social Services Blanket Code HCPCS Code Billing Table Updated: 01/27/2016
Social Service Blanket Code Group Description HCPCS Code Procedure Code Short Description
SA884 Respiratory equipment and supplies SA884 A4623 Tracheostomy inner cannula
SA884 Respiratory equipment and supplies SA884 A4624 Tracheal suction tube
SA884 Respiratory equipment and supplies SA884 A4625 Trach care kit for new trach
SA884 Respiratory equipment and supplies SA884 A4626 Tracheostomy cleaning brush
SA884 Respiratory equipment and supplies SA884 A4627 Spacer bag/reservoir
SA884 Respiratory equipment and supplies SA884 A4628 Oropharyngeal suction cath
SA884 Respiratory equipment and supplies SA884 A4629 Tracheostomy care kit
SA884 Respiratory equipment and supplies SA884 A7000 Disposable canister for pump
SA884 Respiratory equipment and supplies SA884 A7001 Nondisposable pump canister
SA884 Respiratory equipment and supplies SA884 A7002 Tubing used w suction pump
SA884 Respiratory equipment and supplies SA884 A7003 Nebulizer administration set
SA884 Respiratory equipment and supplies SA884 A7004 Disposable nebulizer sml vol
SA884 Respiratory equipment and supplies SA884 A7005 Nondisposable nebulizer set
SA884 Respiratory equipment and supplies SA884 A7006 Filtered nebulizer admin set
SA884 Respiratory equipment and supplies SA884 A7007 Lg vol nebulizer disposable
SA884 Respiratory equipment and supplies SA884 A7008 Disposable nebulizer prefill
SA884 Respiratory equipment and supplies SA884 A7009 Nebulizer reservoir bottle
SA884 Respiratory equipment and supplies SA884 A7010 Disposable corrugated tubing
SA884 Respiratory equipment and supplies SA884 A7011 Nondispos corrugated tubing
SA884 Respiratory equipment and supplies SA884 A7012 Nebulizer water collec devic
SA884 Respiratory equipment and supplies SA884 A7013 Disposable compressor filter
SA884 Respiratory equipment and supplies SA884 A7014 Compressor nondispos filter
SA884 Respiratory equipment and supplies SA884 A7015 Aerosol mask used w nebulize
SA884 Respiratory equipment and supplies SA884 A7016 Nebulizer dome & mouthpiece
SA884 Respiratory equipment and supplies SA884 A7017 Nebulizer not used w oxygen
SA884 Respiratory equipment and supplies SA884 A7018 Water distilled w/nebulizer
SA884 Respiratory equipment and supplies SA884 A7020
STERILE WATER OR SALINE 1000 ML LOCAL
CODE AFTER 12/03 (50 PER 30 DYS) XWALKED FROM E1399
#870000928
SA884 Respiratory equipment and supplies SA884 A7027 Combination oral/nasal mask
SA884 Respiratory equipment and supplies SA884 A7028 Repl oral cushion combo mask
SA884 Respiratory equipment and supplies SA884 A7029 Repl nasal pillow comb mask
SA884 Respiratory equipment and supplies SA884 A7030 CPAP full face mask
SA884 Respiratory equipment and supplies SA884 A7031 Replacement facemask interfa
SA884 Respiratory equipment and supplies SA884 A7032 Replacement nasal cushion
SA884 Respiratory equipment and supplies SA884 A7033 Replacement nasal pillows
SA884 Respiratory equipment and supplies SA884 A7034 Nasal application device
SA884 Respiratory equipment and supplies SA884 A7035 Pos airway press headgear
SA884 Respiratory equipment and supplies SA884 A7036 Pos airway press chinstrap
SA884 Respiratory equipment and supplies SA884 A7037 Pos airway pressure tubing
SA884 Respiratory equipment and supplies SA884 A7038 Pos airway pressure filter
SA884 Respiratory equipment and supplies SA884 A7039 Filter, non disposable w pap
SA884 Respiratory equipment and supplies SA884 A7044 PAP oral interface
SA884 Respiratory equipment and supplies SA884 A7045 Repl exhalation port for PAP
SA884 Respiratory equipment and supplies SA884 A7046 Repl water chamber, PAP dev
SA884 Respiratory equipment and supplies SA884 A7501 Tracheostoma valve w diaphra
SA884 Respiratory equipment and supplies SA884 A7502 Replacement diaphragm/fplate
SA884 Respiratory equipment and supplies SA884 A7503 HMES filter holder or cap
SA884 Respiratory equipment and supplies SA884 A7504 Tracheostoma HMES filter
SA884 Respiratory equipment and supplies SA884 A7505 HMES or trach valve housing
SA884 Respiratory equipment and supplies SA884 A7506 HMES/trachvalve adhesivedisk
SA884 Respiratory equipment and supplies SA884 A7507 Integrated filter & holder
SA884 Respiratory equipment and supplies SA884 A7508 Housing & Integrated Adhesiv
SA884 Respiratory equipment and supplies SA884 A7509 Heat & moisture exchange sys
SA884 Respiratory equipment and supplies SA884 A7520 Trach/laryn tube non-cuffed
SA884 Respiratory equipment and supplies SA884 A7521 Trach/laryn tube cuffed
SA884 Respiratory equipment and supplies SA884 A7522 Trach/laryn tube stainless
SA884 Respiratory equipment and supplies SA884 A7523 Tracheostomy shower protect
SA884 Respiratory equipment and supplies SA884 A7524 Tracheostoma stent/stud/bttn
SA884 Respiratory equipment and supplies SA884 A7525 Tracheostomy mask
SA884 Respiratory equipment and supplies SA884 A7526 Tracheostomy tube collar
SA884 Respiratory equipment and supplies SA884 A7527 Trach/laryn tube plug/stop
SA884 Respiratory equipment and supplies SA884 A8000 Soft protect helmet prefab
SA884 Respiratory equipment and supplies SA884 A8001 Hard protect helmet prefab
25
Current Social Services Blanket Code HCPCS Code Billing Table Updated: 01/27/2016
Social Service Blanket Code Group Description HCPCS Code Procedure Code Short Description
SA884 Respiratory equipment and supplies SA884 A8002 Soft protect helmet custom
SA884 Respiratory equipment and supplies SA884 A8003 Hard protect helmet custom
SA884 Respiratory equipment and supplies SA884 A8004 Repl soft interface, helmet
SA884 Respiratory equipment and supplies SA884 E0424 Stationary compressed gas 02
SA884 Respiratory equipment and supplies SA884 E0425 Gas system stationary compre
SA884 Respiratory equipment and supplies SA884 E0431 Portable gaseous 02
SA884 Respiratory equipment and supplies SA884 E0433 PORTABLE LIQUID OXYGEN SYS
SA884 Respiratory equipment and supplies SA884 E0434 Portable liquid 02
SA884 Respiratory equipment and supplies SA884 E0439 Stationary liquid 02
SA884 Respiratory equipment and supplies SA884 E0441 Stationary O2 contents, gas
SA884 Respiratory equipment and supplies SA884 E0442 Stationary O2 contents, liq
SA884 Respiratory equipment and supplies SA884 E0443 Portable 02 contents, gas
SA884 Respiratory equipment and supplies SA884 E0444 Portable 02 contents, liquid
SA884 Respiratory equipment and supplies SA884 E0445 Oximeter non-invasive
SA884 Respiratory equipment and supplies SA884 E0450 Vol control vent invasiv int
SA884 Respiratory equipment and supplies SA884 E0459 CHEST WRAP
SA884 Respiratory equipment and supplies SA884 E0460 Neg press vent portabl/statn
SA884 Respiratory equipment and supplies SA884 E0461 Vol control vent noninv int
SA884 Respiratory equipment and supplies SA884 E0463 Press supp vent invasive int
SA884 Respiratory equipment and supplies SA884 E0464 Press supp vent noninv int
SA884 Respiratory equipment and supplies SA884 E0470 RAD w/o backup non-inv intfc
SA884 Respiratory equipment and supplies SA884 E0471 RAD w/backup non inv intrfc
SA884 Respiratory equipment and supplies SA884 E0472 RAD w backup invasive intrfc
SA884 Respiratory equipment and supplies SA884 E0480 Percussor elect/pneum home m
SA884 Respiratory equipment and supplies SA884 E0482 Cough stimulating device
SA884 Respiratory equipment and supplies SA884 E0483 Chest compression gen system
SA884 Respiratory equipment and supplies SA884 E0484 Non-elec oscillatory pep dvc
SA884 Respiratory equipment and supplies SA884 E0500 Ippb all types
SA884 Respiratory equipment and supplies SA884 E0550 Humidif extens supple w ippb
SA884 Respiratory equipment and supplies SA884 E0555 Humidifier for use w/ regula
SA884 Respiratory equipment and supplies SA884 E0560 Humidifier supplemental w/ i
SA884 Respiratory equipment and supplies SA884 E0561 Humidifier nonheated w PAP
SA884 Respiratory equipment and supplies SA884 E0562 Humidifier heated used w PAP
SA884 Respiratory equipment and supplies SA884 E0565 Compressor air power source
SA884 Respiratory equipment and supplies SA884 E0570 Nebulizer with compression
SA884 Respiratory equipment and supplies SA884 E0571 AEROSOL COMPRESSOR FOR SVNEB
SA884 Respiratory equipment and supplies SA884 E0572 Aerosol compressor adjust pr
SA884 Respiratory equipment and supplies SA884 E0574 Ultrasonic generator w svneb
SA884 Respiratory equipment and supplies SA884 E0575 Nebulizer ultrasonic
SA884 Respiratory equipment and supplies SA884 E0580 Nebulizer for use w/ regulat
SA884 Respiratory equipment and supplies SA884 E0585 Nebulizer w/ compressor & he
SA884 Respiratory equipment and supplies SA884 E0605 Vaporizer room type
SA884 Respiratory equipment and supplies SA884 E0618 Apnea monitor
SA884 Respiratory equipment and supplies SA884 E1354 Wheeled cart, port cyl/conc
SA884 Respiratory equipment and supplies SA884 E1355 Oxygen supplies stand/rack
SA884 Respiratory equipment and supplies SA884 E1356 Batt pack/cart, port conc
SA884 Respiratory equipment and supplies SA884 E1357 Battery charger, port conc
SA884 Respiratory equipment and supplies SA884 E1358 DC power adapter, port conc
SA884 Respiratory equipment and supplies SA884 E1372 Oxy suppl heater for nebuliz
SA884 Respiratory equipment and supplies SA884 E1390 Oxygen concentrator
SA884 Respiratory equipment and supplies SA884 E1391 Oxygen concentrator, dual
SA884 Respiratory equipment and supplies SA884 E1392 Portable oxygen concentrator
SA884 Respiratory equipment and supplies SA884 E1405 O2/water vapor enrich w/heat
SA884 Respiratory equipment and supplies SA884 E1406 O2/water vapor enrich w/o he
SA884 Respiratory equipment and supplies SA884 K0462 Temporary replacement eqpmnt
SA884 Respiratory equipment and supplies SA884 K0740 Repair/svc oxygen equipment
SA884 Respiratory equipment and supplies SA884 L8501 Tracheostomy speaking valve
SA884 Respiratory equipment and supplies SA884 S8185 Flutter device
SA884 Respiratory equipment and supplies SA884 S8186 Swivel adaptor
SA884 Respiratory equipment and supplies SA884 S8189 Trach supply noc
SA884 Respiratory equipment and supplies SA884 S8210 Mucus trap
SA884 Respiratory equipment and supplies SA884 S8265 Haberman feeder
SA885 Urinary/incontinence equipment SA885 A4310 Insert tray w/o bag/cath
SA885 Urinary/incontinence equipment SA885 A4311 Catheter w/o bag 2-way latex
25
Current Social Services Blanket Code HCPCS Code Billing Table Updated: 01/27/2016
Social Service Blanket Code Group Description HCPCS Code Procedure Code Short Description
SA885 Urinary/incontinence equipment SA885 A4312 Cath w/o bag 2-way silicone
SA885 Urinary/incontinence equipment SA885 A4313 Catheter w/bag 3-way
SA885 Urinary/incontinence equipment SA885 A4314 Cath w/drainage 2-way latex
SA885 Urinary/incontinence equipment SA885 A4315 Cath w/drainage 2-way silcne
SA885 Urinary/incontinence equipment SA885 A4316 Cath w/drainage 3-way
SA885 Urinary/incontinence equipment SA885 A4320 Irrigation tray
SA885 Urinary/incontinence equipment SA885 A4321 Cath therapeutic irrig agent
SA885 Urinary/incontinence equipment SA885 A4322 Irrigation syringe
SA885 Urinary/incontinence equipment SA885 A4326 Male external catheter
SA885 Urinary/incontinence equipment SA885 A4327 Fem urinary collect dev cup
SA885 Urinary/incontinence equipment SA885 A4328 Fem urinary collect pouch
SA885 Urinary/incontinence equipment SA885 A4330 Stool collection pouch
SA885 Urinary/incontinence equipment SA885 A4331 Extension drainage tubing
SA885 Urinary/incontinence equipment SA885 A4332 Lube sterile packet
SA885 Urinary/incontinence equipment SA885 A4333 Urinary cath anchor device
SA885 Urinary/incontinence equipment SA885 A4334 Urinary cath leg strap
SA885 Urinary/incontinence equipment SA885 A4335 Incontinence supply
SA885 Urinary/incontinence equipment SA885 A4336 Urethral insert
SA885 Urinary/incontinence equipment SA885 A4338 Indwelling catheter latex
SA885 Urinary/incontinence equipment SA885 A4340 Indwelling catheter special
SA885 Urinary/incontinence equipment SA885 A4344 Cath indw foley 2 way silicn
SA885 Urinary/incontinence equipment SA885 A4346 Cath indw foley 3 way
SA885 Urinary/incontinence equipment SA885 A4349 Disposable male external cat
SA885 Urinary/incontinence equipment SA885 A4351 Straight tip urine catheter
SA885 Urinary/incontinence equipment SA885 A4352 Coude tip urinary catheter
SA885 Urinary/incontinence equipment SA885 A4353 Intermittent urinary cath
SA885 Urinary/incontinence equipment SA885 A4354 Cath insertion tray w/bag
SA885 Urinary/incontinence equipment SA885 A4355 Bladder irrigation tubing
SA885 Urinary/incontinence equipment SA885 A4356 Ext ureth clmp or compr dvc
SA885 Urinary/incontinence equipment SA885 A4357 Bedside drainage bag
SA885 Urinary/incontinence equipment SA885 A4358 Urinary leg or abdomen bag
SA885 Urinary/incontinence equipment SA885 A4360 Disposable ext urethral dev
SA885 Urinary/incontinence equipment SA885 A5102 Bedside drain btl w/wo tube
SA885 Urinary/incontinence equipment SA885 A5105 Urinary suspensory
SA885 Urinary/incontinence equipment SA885 A5112 Urinary leg bag
SA885 Urinary/incontinence equipment SA885 A5113 Latex leg strap
SA885 Urinary/incontinence equipment SA885 A5114 Foam/fabric leg strap
SA885 Urinary/incontinence equipment SA885 A5120 Skin barrier, wipe or swab
SA885 Urinary/incontinence equipment SA885 A5121 Solid skin barrier 6x6
SA885 Urinary/incontinence equipment SA885 A5122 Solid skin barrier 8x8
SA885 Urinary/incontinence equipment SA885 A5126 Disk/foam pad +or- adhesive
SA885 Urinary/incontinence equipment SA885 T4521 Adult size brief/diaper sm
SA885 Urinary/incontinence equipment SA885 T4522 Adult size brief/diaper med
SA885 Urinary/incontinence equipment SA885 T4523 Adult size brief/diaper lg
SA885 Urinary/incontinence equipment SA885 T4524 Adult size brief/diaper xl
SA885 Urinary/incontinence equipment SA885 T4525 Adult size pull-on sm
SA885 Urinary/incontinence equipment SA885 T4526 Adult size pull-on med
SA885 Urinary/incontinence equipment SA885 T4527 Adult size pull-on lg
SA885 Urinary/incontinence equipment SA885 T4528 Adult size pull-on xl
SA885 Urinary/incontinence equipment SA885 T4529 Ped size brief/diaper sm/med
SA885 Urinary/incontinence equipment SA885 T4530 Ped size brief/diaper lg
SA885 Urinary/incontinence equipment SA885 T4531 Ped size pull-on sm/med
SA885 Urinary/incontinence equipment SA885 T4532 Ped size pull-on lg
SA885 Urinary/incontinence equipment SA885 T4533 Youth size brief/diaper
SA885 Urinary/incontinence equipment SA885 T4534 Youth size pull-on
SA885 Urinary/incontinence equipment SA885 T4535 Disposable liner/shield/pad
SA885 Urinary/incontinence equipment SA885 T4536 Reusable pull-on any size
SA885 Urinary/incontinence equipment SA885 T4537 Reusable underpad bed size
SA885 Urinary/incontinence equipment SA885 T4538 Diaper serv reusable diaper
SA885 Urinary/incontinence equipment SA885 T4539 Reuse diaper/brief any size
SA885 Urinary/incontinence equipment SA885 T4541 Large disposable underpad
SA885 Urinary/incontinence equipment SA885 T4542 Small disposable underpad
SA885 Urinary/incontinence equipment SA885 T4543 ADULT DISP BRIEF/DIAP ABV XL
SA885 Urinary/incontinence equipment SA885 T4544 ADLT DISP UND/PULL ON ABV XL
25
Current Social Services Blanket Code HCPCS Code Billing Table Updated: 01/27/2016
Social Service Blanket Code Group Description HCPCS Code Procedure Code Short Description
SA886 Wheelchairs and accessories SA886 E0950 Tray
SA886 Wheelchairs and accessories SA886 E0951 Loop heel
SA886 Wheelchairs and accessories SA886 E0952 Toe loop/holder, each
SA886 Wheelchairs and accessories SA886 E0955 Cushioned headrest
SA886 Wheelchairs and accessories SA886 E0956 W/c lateral trunk/hip suppor
SA886 Wheelchairs and accessories SA886 E0957 W/c medial thigh support
SA886 Wheelchairs and accessories SA886 E0958 Whlchr att- conv 1 arm drive
SA886 Wheelchairs and accessories SA886 E0959 Amputee adapter
SA886 Wheelchairs and accessories SA886 E0960 W/c shoulder harness/straps
SA886 Wheelchairs and accessories SA886 E0961 Wheelchair brake extension
SA886 Wheelchairs and accessories SA886 E0966 Wheelchair head rest extensi
SA886 Wheelchairs and accessories SA886 E0967 Manual wc hand rim w project
SA886 Wheelchairs and accessories SA886 E0968 Wheelchair commode seat
SA886 Wheelchairs and accessories SA886 E0969 Wheelchair narrowing device
SA886 Wheelchairs and accessories SA886 E0970 Wheelchair no. 2 footplates
SA886 Wheelchairs and accessories SA886 E0971 Wheelchair anti-tipping devi
SA886 Wheelchairs and accessories SA886 E0972 TRANSFER BOARD OR DEVICE
SA886 Wheelchairs and accessories SA886 E0973 W/Ch access det adj armrest
SA886 Wheelchairs and accessories SA886 E0974 W/Ch access anti-rollback
SA886 Wheelchairs and accessories SA886 E0978 W/C acc,saf belt pelv strap
SA886 Wheelchairs and accessories SA886 E0980 Wheelchair safety vest
SA886 Wheelchairs and accessories SA886 E0981 Seat upholstery, replacement
SA886 Wheelchairs and accessories SA886 E0982 Back upholstery, replacement
SA886 Wheelchairs and accessories SA886 E0983 Add pwr joystick
SA886 Wheelchairs and accessories SA886 E0984 Add pwr tiller
SA886 Wheelchairs and accessories SA886 E0985 W/c seat lift mechanism
SA886 Wheelchairs and accessories SA886 E0986 MAN W/C PUSH-RIM POWR SYSTEM
SA886 Wheelchairs and accessories SA886 E0990 Wheelchair elevating leg res
SA886 Wheelchairs and accessories SA886 E0992 Wheelchair solid seat insert
SA886 Wheelchairs and accessories SA886 E0994 Wheelchair arm rest
SA886 Wheelchairs and accessories SA886 E0995 Wheelchair calf rest
SA886 Wheelchairs and accessories SA886 E1002 Pwr seat tilt
SA886 Wheelchairs and accessories SA886 E1003 Pwr seat recline
SA886 Wheelchairs and accessories SA886 E1004 Pwr seat recline mech
SA886 Wheelchairs and accessories SA886 E1005 Pwr seat recline pwr
SA886 Wheelchairs and accessories SA886 E1006 Pwr seat combo w/o shear
SA886 Wheelchairs and accessories SA886 E1007 Pwr seat combo w/shear
SA886 Wheelchairs and accessories SA886 E1008 Pwr seat combo pwr shear
SA886 Wheelchairs and accessories SA886 E1009 Add mech leg elevation
SA886 Wheelchairs and accessories SA886 E1010 Add pwr leg elevation
SA886 Wheelchairs and accessories SA886 E1011 Ped wc modify width adjustm
SA886 Wheelchairs and accessories SA886 E1014 Reclining back add ped w/c
SA886 Wheelchairs and accessories SA886 E1015 Shock absorber for man w/c
SA886 Wheelchairs and accessories SA886 E1016 Shock absorber for power w/c
SA886 Wheelchairs and accessories SA886 E1017 HD shck absrbr for hd man wc
SA886 Wheelchairs and accessories SA886 E1018 HD shck absrber for hd powwc
SA886 Wheelchairs and accessories SA886 E1020 Residual limb support system
SA886 Wheelchairs and accessories SA886 E1028 W/c manual swingaway
SA886 Wheelchairs and accessories SA886 E1029 W/c vent tray fixed
SA886 Wheelchairs and accessories SA886 E1030 W/c vent tray gimbaled
SA886 Wheelchairs and accessories SA886 E1037 Transport chair, ped size
SA886 Wheelchairs and accessories SA886 E1038 Transport chair pt wt<=300lb
SA886 Wheelchairs and accessories SA886 E1039 Transport chair pt wt >300lb
SA886 Wheelchairs and accessories SA886 E1050 Whelchr fxd full length arms
SA886 Wheelchairs and accessories SA886 E1060 Wheelchair detachable arms
SA886 Wheelchairs and accessories SA886 E1065
POWER ATTACHMENTS(TO CONVERT ANY
WHEELCHAIR TO MOTORIZED WHEELCHAIR, E.G. SOLO)
XOVER ONLY TIL 4/04
SA886 Wheelchairs and accessories SA886 E1070 Wheelchair detachable foot r
SA886 Wheelchairs and accessories SA886 E1083 Hemi-wheelchair fixed arms
SA886 Wheelchairs and accessories SA886 E1084 Hemi-wheelchair detachable a
SA886 Wheelchairs and accessories SA886 E1085 Hemi-wheelchair fixed arms
SA886 Wheelchairs and accessories SA886 E1086 Hemi-wheelchair detachable a
SA886 Wheelchairs and accessories SA886 E1087 Wheelchair lightwt fixed arm
25
Current Social Services Blanket Code HCPCS Code Billing Table Updated: 01/27/2016
Social Service Blanket Code Group Description HCPCS Code Procedure Code Short Description
SA886 Wheelchairs and accessories SA886 E1088 Wheelchair lightweight det a
SA886 Wheelchairs and accessories SA886 E1089 Wheelchair lightwt fixed arm
SA886 Wheelchairs and accessories SA886 E1090 Wheelchair lightweight det a
SA886 Wheelchairs and accessories SA886 E1092 Wheelchair wide w/ leg rests
SA886 Wheelchairs and accessories SA886 E1093 Wheelchair wide w/ foot rest
SA886 Wheelchairs and accessories SA886 E1100 Whchr s-recl fxd arm leg res
SA886 Wheelchairs and accessories SA886 E1110 Wheelchair semi-recl detach
SA886 Wheelchairs and accessories SA886 E1130 Whlchr stand fxd arm ft rest
SA886 Wheelchairs and accessories SA886 E1140 Wheelchair standard detach a
SA886 Wheelchairs and accessories SA886 E1150 Wheelchair standard w/ leg r
SA886 Wheelchairs and accessories SA886 E1160 Wheelchair fixed arms
SA886 Wheelchairs and accessories SA886 E1161 Manual adult wc w tiltinspac
SA886 Wheelchairs and accessories SA886 E1170 Whlchr ampu fxd arm leg rest
SA886 Wheelchairs and accessories SA886 E1171 Wheelchair amputee w/o leg r
SA886 Wheelchairs and accessories SA886 E1172 Wheelchair amputee detach ar
SA886 Wheelchairs and accessories SA886 E1180 Wheelchair amputee w/ foot r
SA886 Wheelchairs and accessories SA886 E1190 Wheelchair amputee w/ leg re
SA886 Wheelchairs and accessories SA886 E1195 Wheelchair amputee heavy dut
SA886 Wheelchairs and accessories SA886 E1200 Wheelchair amputee fixed arm
SA886 Wheelchairs and accessories SA886 E1220 Whlchr special size/constrc
SA886 Wheelchairs and accessories SA886 E1221 Wheelchair spec size w foot
SA886 Wheelchairs and accessories SA886 E1222 Wheelchair spec size w/ leg
SA886 Wheelchairs and accessories SA886 E1223 Wheelchair spec size w foot
SA886 Wheelchairs and accessories SA886 E1224 Wheelchair spec size w/ leg
SA886 Wheelchairs and accessories SA886 E1225 Manual semi-reclining back
SA886 Wheelchairs and accessories SA886 E1226 Manual fully reclining back
SA886 Wheelchairs and accessories SA886 E1227 Wheelchair spec sz spec ht a
SA886 Wheelchairs and accessories SA886 E1228 Wheelchair spec sz spec ht b
SA886 Wheelchairs and accessories SA886 E1229 Pediatric wheelchair NOS
SA886 Wheelchairs and accessories SA886 E1231 Rigid ped w/c tilt-in-space
SA886 Wheelchairs and accessories SA886 E1232 Folding ped wc tilt-in-space
SA886 Wheelchairs and accessories SA886 E1233 Rig ped wc tltnspc w/o seat
SA886 Wheelchairs and accessories SA886 E1234 Fld ped wc tltnspc w/o seat
SA886 Wheelchairs and accessories SA886 E1235 Rigid ped wc adjustable
SA886 Wheelchairs and accessories SA886 E1236 Folding ped wc adjustable
SA886 Wheelchairs and accessories SA886 E1237 Rgd ped wc adjstabl w/o seat
SA886 Wheelchairs and accessories SA886 E1238 Fld ped wc adjstabl w/o seat
SA886 Wheelchairs and accessories SA886 E1239 Ped power wheelchair NOS
SA886 Wheelchairs and accessories SA886 E1240 Whchr litwt det arm leg rest
SA886 Wheelchairs and accessories SA886 E1250 Wheelchair lightwt fixed arm
SA886 Wheelchairs and accessories SA886 E1260 Wheelchair lightwt foot rest
SA886 Wheelchairs and accessories SA886 E1270 Wheelchair lightweight leg r
SA886 Wheelchairs and accessories SA886 E1280 Whchr h-duty det arm leg res
SA886 Wheelchairs and accessories SA886 E1285 Wheelchair heavy duty fixed
SA886 Wheelchairs and accessories SA886 E1290 Wheelchair hvy duty detach a
SA886 Wheelchairs and accessories SA886 E1295 Wheelchair heavy duty fixed
SA886 Wheelchairs and accessories SA886 E1296 Wheelchair special seat heig
SA886 Wheelchairs and accessories SA886 E1297 Wheelchair special seat dept
SA886 Wheelchairs and accessories SA886 E1298 Wheelchair spec seat depth/w
SA886 Wheelchairs and accessories SA886 E2201 Man w/ch acc seat w>=20o<24o
SA886 Wheelchairs and accessories SA886 E2202 Seat width 24-27 in
SA886 Wheelchairs and accessories SA886 E2203 Frame depth less than 22 in
SA886 Wheelchairs and accessories SA886 E2204 Frame depth 22 to 25 in
SA886 Wheelchairs and accessories SA886 E2205 Manual wc accessory, handrim
SA886 Wheelchairs and accessories SA886 E2206 Complete wheel lock assembly
SA886 Wheelchairs and accessories SA886 E2207 Crutch and cane holder
SA886 Wheelchairs and accessories SA886 E2208 Cylinder tank carrier
SA886 Wheelchairs and accessories SA886 E2209 Arm trough each
SA886 Wheelchairs and accessories SA886 E2210 Wheelchair bearings
SA886 Wheelchairs and accessories SA886 E2211 Pneumatic propulsion tire
SA886 Wheelchairs and accessories SA886 E2212 Pneumatic prop tire tube
SA886 Wheelchairs and accessories SA886 E2213 Pneumatic prop tire insert
SA886 Wheelchairs and accessories SA886 E2214 Pneumatic caster tire each
SA886 Wheelchairs and accessories SA886 E2215 Pneumatic caster tire tube
25
Current Social Services Blanket Code HCPCS Code Billing Table Updated: 01/27/2016
Social Service Blanket Code Group Description HCPCS Code Procedure Code Short Description
SA886 Wheelchairs and accessories SA886 E2216 Foam filled propulsion tire
SA886 Wheelchairs and accessories SA886 E2217 Foam filled caster tire each
SA886 Wheelchairs and accessories SA886 E2218 Foam propulsion tire each
SA886 Wheelchairs and accessories SA886 E2219 Foam caster tire any size ea
SA886 Wheelchairs and accessories SA886 E2220 Solid propulsion tire each
SA886 Wheelchairs and accessories SA886 E2221 Solid caster tire each
SA886 Wheelchairs and accessories SA886 E2222 Solid caster integrated whl
SA886 Wheelchairs and accessories SA886 E2224 Propulsion whl excludes tire
SA886 Wheelchairs and accessories SA886 E2225 Caster wheel excludes tire
SA886 Wheelchairs and accessories SA886 E2226 Caster fork replacement only
SA886 Wheelchairs and accessories SA886 E2227 Gear reduction drive wheel
SA886 Wheelchairs and accessories SA886 E2228 Mwc acc, wheelchair brake
SA886 Wheelchairs and accessories SA886 E2230 Manual standing system
SA886 Wheelchairs and accessories SA886 E2231 Solid seat support base
SA886 Wheelchairs and accessories SA886 E2291 Planar back for ped size wc
SA886 Wheelchairs and accessories SA886 E2292 Planar seat for ped size wc
SA886 Wheelchairs and accessories SA886 E2293 Contour back for ped size wc
SA886 Wheelchairs and accessories SA886 E2294 Contour seat for ped size wc
SA886 Wheelchairs and accessories SA886 E2295 Ped dynamic seating frame
SA886 Wheelchairs and accessories SA886 E2300 PWR SEAT ELEVATION SYS
SA886 Wheelchairs and accessories SA886 E2301 PWR STANDING
SA886 Wheelchairs and accessories SA886 E2310 Electro connect btw control
SA886 Wheelchairs and accessories SA886 E2311 Electro connect btw 2 sys
SA886 Wheelchairs and accessories SA886 E2312 Mini-prop remote joystick
SA886 Wheelchairs and accessories SA886 E2313 PWC harness, expand control
SA886 Wheelchairs and accessories SA886 E2321 Hand interface joystick
SA886 Wheelchairs and accessories SA886 E2322 Mult mech switches
SA886 Wheelchairs and accessories SA886 E2323 Special joystick handle
SA886 Wheelchairs and accessories SA886 E2324 Chin cup interface
SA886 Wheelchairs and accessories SA886 E2325 Sip and puff interface
SA886 Wheelchairs and accessories SA886 E2326 Breath tube kit
SA886 Wheelchairs and accessories SA886 E2327 Head control interface mech
SA886 Wheelchairs and accessories SA886 E2328 Head/extremity control inter
SA886 Wheelchairs and accessories SA886 E2329 Head control nonproportional
SA886 Wheelchairs and accessories SA886 E2330 Head control proximity switc
SA886 Wheelchairs and accessories SA886 E2331 Attendant control
SA886 Wheelchairs and accessories SA886 E2340 W/c wdth 20-23 in seat frame
SA886 Wheelchairs and accessories SA886 E2341 W/c wdth 24-27 in seat frame
SA886 Wheelchairs and accessories SA886 E2342 W/c dpth 20-21 in seat frame
SA886 Wheelchairs and accessories SA886 E2343 W/c dpth 22-25 in seat frame
SA886 Wheelchairs and accessories SA886 E2351 Electronic SGD interface
SA886 Wheelchairs and accessories SA886 E2360 22nf nonsealed leadacid
SA886 Wheelchairs and accessories SA886 E2361 22nf sealed leadacid battery
SA886 Wheelchairs and accessories SA886 E2362 Gr24 nonsealed leadacid
SA886 Wheelchairs and accessories SA886 E2363 Gr24 sealed leadacid battery
SA886 Wheelchairs and accessories SA886 E2364 U1nonsealed leadacid battery
SA886 Wheelchairs and accessories SA886 E2365 U1 sealed leadacid battery
SA886 Wheelchairs and accessories SA886 E2366 Battery charger, single mode
SA886 Wheelchairs and accessories SA886 E2367 Battery charger, dual mode
SA886 Wheelchairs and accessories SA886 E2368 Power wc motor replacement
SA886 Wheelchairs and accessories SA886 E2369 Pwr wc gear box replacement
SA886 Wheelchairs and accessories SA886 E2370 Pwr wc motor/gear box combo
SA886 Wheelchairs and accessories SA886 E2371 Gr27 sealed leadacid battery
SA886 Wheelchairs and accessories SA886 E2372 Gr27 non-sealed leadacid
SA886 Wheelchairs and accessories SA886 E2373 Hand/chin ctrl spec joystick
SA886 Wheelchairs and accessories SA886 E2374 Hand/chin ctrl std joystick
SA886 Wheelchairs and accessories SA886 E2375 Non-expandable controller
SA886 Wheelchairs and accessories SA886 E2376 Expandable controller, repl
SA886 Wheelchairs and accessories SA886 E2377 Expandable controller, initl
SA886 Wheelchairs and accessories SA886 E2378 PW ACTUATOR REPLACEMENT
SA886 Wheelchairs and accessories SA886 E2381 Pneum drive wheel tire
SA886 Wheelchairs and accessories SA886 E2382 Tube, pneum wheel drive tire
SA886 Wheelchairs and accessories SA886 E2383 Insert, pneum wheel drive
SA886 Wheelchairs and accessories SA886 E2384 Pneumatic caster tire
25
Current Social Services Blanket Code HCPCS Code Billing Table Updated: 01/27/2016
Social Service Blanket Code Group Description HCPCS Code Procedure Code Short Description
SA886 Wheelchairs and accessories SA886 E2385 Tube, pneumatic caster tire
SA886 Wheelchairs and accessories SA886 E2386 Foam filled drive wheel tire
SA886 Wheelchairs and accessories SA886 E2387 Foam filled caster tire
SA886 Wheelchairs and accessories SA886 E2388 Foam drive wheel tire
SA886 Wheelchairs and accessories SA886 E2389 Foam caster tire
SA886 Wheelchairs and accessories SA886 E2390 Solid drive wheel tire
SA886 Wheelchairs and accessories SA886 E2391 Solid caster tire
SA886 Wheelchairs and accessories SA886 E2392 Solid caster tire, integrate
SA886 Wheelchairs and accessories SA886 E2394 Drive wheel excludes tire
SA886 Wheelchairs and accessories SA886 E2395 Caster wheel excludes tire
SA886 Wheelchairs and accessories SA886 E2396 Caster fork
SA886 Wheelchairs and accessories SA886 E2397 Pwc acc, lith-based battery
SA886 Wheelchairs and accessories SA886 E2601 Gen w/c cushion wdth < 22 in
SA886 Wheelchairs and accessories SA886 E2602 Gen w/c cushion wdth >=22 in
SA886 Wheelchairs and accessories SA886 E2603 Skin protect wc cus wd <22in
SA886 Wheelchairs and accessories SA886 E2604 Skin protect wc cus wd>=22in
SA886 Wheelchairs and accessories SA886 E2605 Position wc cush wdth <22 in
SA886 Wheelchairs and accessories SA886 E2606 Position wc cush wdth>=22 in
SA886 Wheelchairs and accessories SA886 E2607 Skin pro/pos wc cus wd <22in
SA886 Wheelchairs and accessories SA886 E2608 Skin pro/pos wc cus wd>=22in
SA886 Wheelchairs and accessories SA886 E2609 Custom fabricate w/c cushion
SA886 Wheelchairs and accessories SA886 E2610 Powered w/c cushion
SA886 Wheelchairs and accessories SA886 E2611 Gen use back cush wdth <22in
SA886 Wheelchairs and accessories SA886 E2612 Gen use back cush wdth>=22in
SA886 Wheelchairs and accessories SA886 E2613 Position back cush wd <22in
SA886 Wheelchairs and accessories SA886 E2614 Position back cush wd>=22in
SA886 Wheelchairs and accessories SA886 E2615 Pos back post/lat wdth <22in
SA886 Wheelchairs and accessories SA886 E2616 Pos back post/lat wdth>=22in
SA886 Wheelchairs and accessories SA886 E2617 Custom fab w/c back cushion
SA886 Wheelchairs and accessories SA886 E2619 Replace cover w/c seat cush
SA886 Wheelchairs and accessories SA886 E2620 WC planar back cush wd <22in
SA886 Wheelchairs and accessories SA886 E2621 WC planar back cush wd>=22in
SA886 Wheelchairs and accessories SA886 E2622 ADJ SKIN PRO W/C CUS WD<22IN
SA886 Wheelchairs and accessories SA886 E2623 ADJ SKIN PRO WC CUS WD>=22IN
SA886 Wheelchairs and accessories SA886 E2624 ADJ SKIN PRO/POS CUS<22IN
SA886 Wheelchairs and accessories SA886 E2625 ADJ SKIN PRO/POS WC CUS>=22
SA886 Wheelchairs and accessories SA886 K0001 Standard wheelchair
SA886 Wheelchairs and accessories SA886 K0002 Stnd hemi (low seat) whlchr
SA886 Wheelchairs and accessories SA886 K0003 Lightweight wheelchair
SA886 Wheelchairs and accessories SA886 K0004 High strength ltwt whlchr
SA886 Wheelchairs and accessories SA886 K0005 Ultralightweight wheelchair
SA886 Wheelchairs and accessories SA886 K0006 Heavy duty wheelchair
SA886 Wheelchairs and accessories SA886 K0007 Extra heavy duty wheelchair
SA886 Wheelchairs and accessories SA886 K0009 OTHER MANUAL WHEELCHAIR/BASE
SA886 Wheelchairs and accessories SA886 K0010 Stnd wt frame power whlchr
SA886 Wheelchairs and accessories SA886 K0011 Stnd wt pwr whlchr w control
SA886 Wheelchairs and accessories SA886 K0012 Ltwt portbl power whlchr
SA886 Wheelchairs and accessories SA886 K0015 Detach non-adjus hght armrst
SA886 Wheelchairs and accessories SA886 K0017 Detach adjust armrest base
SA886 Wheelchairs and accessories SA886 K0018 Detach adjust armrst upper
SA886 Wheelchairs and accessories SA886 K0019 Arm pad each
SA886 Wheelchairs and accessories SA886 K0020 Fixed adjust armrest pair
SA886 Wheelchairs and accessories SA886 K0037 High mount flip-up footrest
SA886 Wheelchairs and accessories SA886 K0038 Leg strap each
SA886 Wheelchairs and accessories SA886 K0039 Leg strap h style each
SA886 Wheelchairs and accessories SA886 K0040 Adjustable angle footplate
SA886 Wheelchairs and accessories SA886 K0041 Large size footplate each
SA886 Wheelchairs and accessories SA886 K0042 Standard size footplate each
SA886 Wheelchairs and accessories SA886 K0043 Ftrst lower extension tube
SA886 Wheelchairs and accessories SA886 K0044 Ftrst upper hanger bracket
SA886 Wheelchairs and accessories SA886 K0045 Footrest complete assembly
SA886 Wheelchairs and accessories SA886 K0046 Elevat legrst low extension
SA886 Wheelchairs and accessories SA886 K0047 Elevat legrst up hangr brack
SA886 Wheelchairs and accessories SA886 K0050 Ratchet assembly
25
Current Social Services Blanket Code HCPCS Code Billing Table Updated: 01/27/2016
Social Service Blanket Code Group Description HCPCS Code Procedure Code Short Description
SA886 Wheelchairs and accessories SA886 K0051 Cam relese assem ftrst/lgrst
SA886 Wheelchairs and accessories SA886 K0052 Swingaway detach footrest
SA886 Wheelchairs and accessories SA886 K0053 Elevate footrest articulate
SA886 Wheelchairs and accessories SA886 K0056 Seat ht <17 or >=21 ltwt wc
SA886 Wheelchairs and accessories SA886 K0065 Spoke protectors
SA886 Wheelchairs and accessories SA886 K0069 Rear whl complete solid tire
SA886 Wheelchairs and accessories SA886 K0070 Rear whl compl pneum tire
SA886 Wheelchairs and accessories SA886 K0071 Front castr compl pneum tire
SA886 Wheelchairs and accessories SA886 K0072 Frnt cstr cmpl sem-pneum tir
SA886 Wheelchairs and accessories SA886 K0073 Caster pin lock each
SA886 Wheelchairs and accessories SA886 K0077 Front caster assem complete
SA886 Wheelchairs and accessories SA886 K0098 Drive belt power wheelchair
SA886 Wheelchairs and accessories SA886 K0105 Iv hanger
SA886 Wheelchairs and accessories SA886 K0108 W/c component-accessory NOS
SA886 Wheelchairs and accessories SA886 K0195 Elevating whlchair leg rests
SA886 Wheelchairs and accessories SA886 K0601 Repl batt silver oxide 1.5 v
SA886 Wheelchairs and accessories SA886 K0602 Repl batt silver oxide 3 v
SA886 Wheelchairs and accessories SA886 K0603 Repl batt alkaline 1.5 v
SA886 Wheelchairs and accessories SA886 K0604 Repl batt lithium 3.6 v
SA886 Wheelchairs and accessories SA886 K0605 Repl batt lithium 4.5 v
SA886 Wheelchairs and accessories SA886 K0669 SEAT/BACK CUS NO DMEPDAC VER
SA886 Wheelchairs and accessories SA886 K0672 Removable soft interface LE
SA886 Wheelchairs and accessories SA886 K0733 12-24hr sealed lead acid
SA886 Wheelchairs and accessories SA886 K0734 Adj skin pro w/c cus wd<22in
SA886 Wheelchairs and accessories SA886 K0735 Adj skin pro wc cus wd>=22in
SA886 Wheelchairs and accessories SA886 K0736 Adj skin pro/pos wc cus<22in
SA886 Wheelchairs and accessories SA886 K0737 Adj skin pro/pos wc cus>=22o
SA886 Wheelchairs and accessories SA886 K0738 Portable gas oxygen system
SA886 Wheelchairs and accessories SA886 K0800 POV group 1 std up to 300lbs
SA886 Wheelchairs and accessories SA886 K0801 POV group 1 hd 301-450 lbs
SA886 Wheelchairs and accessories SA886 K0802 POV group 1 vhd 451-600 lbs
SA886 Wheelchairs and accessories SA886 K0806 POV group 2 std up to 300lbs
SA886 Wheelchairs and accessories SA886 K0807 POV group 2 hd 301-450 lbs
SA886 Wheelchairs and accessories SA886 K0808 POV group 2 vhd 451-600 lbs
SA886 Wheelchairs and accessories SA886 K0812 Power operated vehicle NOC
SA886 Wheelchairs and accessories SA886 K0813 PWC gp 1 std port seat/back
SA886 Wheelchairs and accessories SA886 K0814 PWC gp 1 std port cap chair
SA886 Wheelchairs and accessories SA886 K0815 PWC gp 1 std seat/back
SA886 Wheelchairs and accessories SA886 K0816 PWC gp 1 std cap chair
SA886 Wheelchairs and accessories SA886 K0820 PWC gp 2 std port seat/back
SA886 Wheelchairs and accessories SA886 K0821 PWC gp 2 std port cap chair
SA886 Wheelchairs and accessories SA886 K0822 PWC gp 2 std seat/back
SA886 Wheelchairs and accessories SA886 K0823 PWC gp 2 std cap chair
SA886 Wheelchairs and accessories SA886 K0824 PWC gp 2 hd seat/back
SA886 Wheelchairs and accessories SA886 K0825 PWC gp 2 hd cap chair
SA886 Wheelchairs and accessories SA886 K0826 PWC gp 2 vhd seat/back
SA886 Wheelchairs and accessories SA886 K0827 PWC gp vhd cap chair
SA886 Wheelchairs and accessories SA886 K0828 PWC gp 2 xtra hd seat/back
SA886 Wheelchairs and accessories SA886 K0829 PWC gp 2 xtra hd cap chair
SA886 Wheelchairs and accessories SA886 K0830 PWC gp2 std seat elevate s/b
SA886 Wheelchairs and accessories SA886 K0831 PWC gp2 std seat elevate cap
SA886 Wheelchairs and accessories SA886 K0835 PWC gp2 std sing pow opt s/b
SA886 Wheelchairs and accessories SA886 K0836 PWC gp2 std sing pow opt cap
SA886 Wheelchairs and accessories SA886 K0837 PWC gp 2 hd sing pow opt s/b
SA886 Wheelchairs and accessories SA886 K0838 PWC gp 2 hd sing pow opt cap
SA886 Wheelchairs and accessories SA886 K0839 PWC gp2 vhd sing pow opt s/b
SA886 Wheelchairs and accessories SA886 K0840 PWC gp2 xhd sing pow opt s/b
SA886 Wheelchairs and accessories SA886 K0841 PWC gp2 std mult pow opt s/b
SA886 Wheelchairs and accessories SA886 K0842 PWC gp2 std mult pow opt cap
SA886 Wheelchairs and accessories SA886 K0843 PWC gp2 hd mult pow opt s/b
SA886 Wheelchairs and accessories SA886 K0848 PWC gp 3 std seat/back
SA886 Wheelchairs and accessories SA886 K0849 PWC gp 3 std cap chair
SA886 Wheelchairs and accessories SA886 K0850 PWC gp 3 hd seat/back
SA886 Wheelchairs and accessories SA886 K0851 PWC gp 3 hd cap chair
25
Current Social Services Blanket Code HCPCS Code Billing Table Updated: 01/27/2016
Social Service Blanket Code Group Description HCPCS Code Procedure Code Short Description
SA886 Wheelchairs and accessories SA886 K0852 PWC gp 3 vhd seat/back
SA886 Wheelchairs and accessories SA886 K0853 PWC gp 3 vhd cap chair
SA886 Wheelchairs and accessories SA886 K0854 PWC gp 3 xhd seat/back
SA886 Wheelchairs and accessories SA886 K0855 PWC gp 3 xhd cap chair
SA886 Wheelchairs and accessories SA886 K0856 PWC gp3 std sing pow opt s/b
SA886 Wheelchairs and accessories SA886 K0857 PWC gp3 std sing pow opt cap
SA886 Wheelchairs and accessories SA886 K0858 PWC gp3 hd sing pow opt s/b
SA886 Wheelchairs and accessories SA886 K0859 PWC gp3 hd sing pow opt cap
SA886 Wheelchairs and accessories SA886 K0860 PWC gp3 vhd sing pow opt s/b
SA886 Wheelchairs and accessories SA886 K0861 PWC gp3 std mult pow opt s/b
SA886 Wheelchairs and accessories SA886 K0862 PWC gp3 hd mult pow opt s/b
SA886 Wheelchairs and accessories SA886 K0863 PWC gp3 vhd mult pow opt s/b
SA886 Wheelchairs and accessories SA886 K0864 PWC gp3 xhd mult pow opt s/b
SA886 Wheelchairs and accessories SA886 K0868 PWC gp 4 std seat/back
SA886 Wheelchairs and accessories SA886 K0869 PWC gp 4 std cap chair
SA886 Wheelchairs and accessories SA886 K0870 PWC gp 4 hd seat/back
SA886 Wheelchairs and accessories SA886 K0871 PWC gp 4 vhd seat/back
SA886 Wheelchairs and accessories SA886 K0877 PWC gp4 std sing pow opt s/b
SA886 Wheelchairs and accessories SA886 K0878 PWC gp4 std sing pow opt cap
SA886 Wheelchairs and accessories SA886 K0879 PWC gp4 hd sing pow opt s/b
SA886 Wheelchairs and accessories SA886 K0880 PWC gp4 vhd sing pow opt s/b
SA886 Wheelchairs and accessories SA886 K0884 PWC gp4 std mult pow opt s/b
SA886 Wheelchairs and accessories SA886 K0885 PWC gp4 std mult pow opt cap
SA886 Wheelchairs and accessories SA886 K0886 PWC gp4 hd mult pow s/b
SA886 Wheelchairs and accessories SA886 K0890 PWC gp5 ped sing pow opt s/b
SA886 Wheelchairs and accessories SA886 K0891 PWC gp5 ped mult pow opt s/b
SA886 Wheelchairs and accessories SA886 K0898 Power wheelchair NOC
SA886 Wheelchairs and accessories SA886 K0899 Pow mobil dev no dmepdac
SA887 Wound care SA887 A4364 Adhesive, liquid or equal
SA887 Wound care SA887 A4450 Non-waterproof tape
SA887 Wound care SA887 A4452 Waterproof tape
SA887 Wound care SA887 A4455 Adhesive remover per ounce
SA887 Wound care SA887 A5131 Appliance cleaner
SA887 Wound care SA887 A6000 Wound warming wound cover
SA887 Wound care SA887 A6010 Collagen based wound filler
SA887 Wound care SA887 A6011 Collagen gel/paste wound fil
SA887 Wound care SA887 A6021 Collagen dressing <=16 sq in
SA887 Wound care SA887 A6022 Collagen drsg>16<=48 sq in
SA887 Wound care SA887 A6023 Collagen dressing >48 sq in
SA887 Wound care SA887 A6024 Collagen dsg wound filler
SA887 Wound care SA887 A6025 Silicone gel sheet, each
SA887 Wound care SA887 A6154 Wound pouch each
SA887 Wound care SA887 A6196 Alginate dressing <=16 sq in
SA887 Wound care SA887 A6197 Alginate drsg >16 <=48 sq in
SA887 Wound care SA887 A6198 alginate dressing > 48 sq in
SA887 Wound care SA887 A6199 Alginate drsg wound filler
SA887 Wound care SA887 A6203 Composite drsg <= 16 sq in
SA887 Wound care SA887 A6204 Composite drsg >16<=48 sq in
SA887 Wound care SA887 A6205 Composite drsg > 48 sq in
SA887 Wound care SA887 A6206 Contact layer <= 16 sq in
SA887 Wound care SA887 A6207 Contact layer >16<= 48 sq in
SA887 Wound care SA887 A6208 Contact layer > 48 sq in
SA887 Wound care SA887 A6209 Foam drsg <=16 sq in w/o bdr
SA887 Wound care SA887 A6210 Foam drg >16<=48 sq in w/o b
SA887 Wound care SA887 A6211 Foam drg > 48 sq in w/o brdr
SA887 Wound care SA887 A6212 Foam drg <=16 sq in w/border
SA887 Wound care SA887 A6213 Foam drg >16<=48 sq in w/bdr
SA887 Wound care SA887 A6214 Foam drg > 48 sq in w/border
SA887 Wound care SA887 A6215 Foam dressing wound filler
SA887 Wound care SA887 A6216 Non-sterile gauze<=16 sq in
SA887 Wound care SA887 A6217 Non-sterile gauze>16<=48 sq
SA887 Wound care SA887 A6218 Non-sterile gauze > 48 sq in
SA887 Wound care SA887 A6219 Gauze <= 16 sq in w/border
SA887 Wound care SA887 A6220 Gauze >16 <=48 sq in w/bordr
25
Current Social Services Blanket Code HCPCS Code Billing Table Updated: 01/27/2016
Social Service Blanket Code Group Description HCPCS Code Procedure Code Short Description
SA887 Wound care SA887 A6221 Gauze > 48 sq in w/border
SA887 Wound care SA887 A6222 Gauze <=16 in no w/sal w/o b
SA887 Wound care SA887 A6223 Gauze >16<=48 no w/sal w/o b
SA887 Wound care SA887 A6224 Gauze > 48 in no w/sal w/o b
SA887 Wound care SA887 A6228 Gauze <= 16 sq in water/sal
SA887 Wound care SA887 A6229 Gauze >16<=48 sq in watr/sal
SA887 Wound care SA887 A6230 Gauze > 48 sq in water/salne
SA887 Wound care SA887 A6231 Hydrogel dsg<=16 sq in
SA887 Wound care SA887 A6232 Hydrogel dsg>16<=48 sq in
SA887 Wound care SA887 A6233 Hydrogel dressing >48 sq in
SA887 Wound care SA887 A6234 Hydrocolld drg <=16 w/o bdr
SA887 Wound care SA887 A6235 Hydrocolld drg >16<=48 w/o b
SA887 Wound care SA887 A6236 Hydrocolld drg > 48 in w/o b
SA887 Wound care SA887 A6237 Hydrocolld drg <=16 in w/bdr
SA887 Wound care SA887 A6238 Hydrocolld drg >16<=48 w/bdr
SA887 Wound care SA887 A6239 Hydrocolld drg > 48 in w/bdr
SA887 Wound care SA887 A6240 Hydrocolld drg filler paste
SA887 Wound care SA887 A6241 Hydrocolloid drg filler dry
SA887 Wound care SA887 A6242 Hydrogel drg <=16 in w/o bdr
SA887 Wound care SA887 A6243 Hydrogel drg >16<=48 w/o bdr
SA887 Wound care SA887 A6244 Hydrogel drg >48 in w/o bdr
SA887 Wound care SA887 A6245 Hydrogel drg <= 16 in w/bdr
SA887 Wound care SA887 A6246 Hydrogel drg >16<=48 in w/b
SA887 Wound care SA887 A6247 Hydrogel drg > 48 sq in w/b
SA887 Wound care SA887 A6248 Hydrogel drsg gel filler
SA887 Wound care SA887 A6250 Skin seal protect moisturizr
SA887 Wound care SA887 A6251 Absorpt drg <=16 sq in w/o b
SA887 Wound care SA887 A6252 Absorpt drg >16 <=48 w/o bdr
SA887 Wound care SA887 A6253 Absorpt drg > 48 sq in w/o b
SA887 Wound care SA887 A6254 Absorpt drg <=16 sq in w/bdr
SA887 Wound care SA887 A6255 Absorpt drg >16<=48 in w/bdr
SA887 Wound care SA887 A6256 Absorpt drg > 48 sq in w/bdr
SA887 Wound care SA887 A6257 Transparent film <= 16 sq in
SA887 Wound care SA887 A6258 Transparent film >16<=48 in
SA887 Wound care SA887 A6259 Transparent film > 48 sq in
SA887 Wound care SA887 A6260 Wound cleanser any type/size
SA887 Wound care SA887 A6261 Wound filler gel/paste /oz
SA887 Wound care SA887 A6262 Wound filler dry form / gram
SA887 Wound care SA887 A6266 Impreg gauze no h20/sal/yard
SA887 Wound care SA887 A6402 Sterile gauze <= 16 sq in
SA887 Wound care SA887 A6403 Sterile gauze>16 <= 48 sq in
SA887 Wound care SA887 A6404 Sterile gauze > 48 sq in
SA887 Wound care SA887 A6407 Packing strips, non-impreg
SA887 Wound care SA887 A6410 Sterile eye pad
SA887 Wound care SA887 A6411 Non-sterile eye pad
SA887 Wound care SA887 A6412 Occlusive eye patch
SA887 Wound care SA887 A6441 Pad band w>=3" <5"/yd
SA887 Wound care SA887 A6442 Conform band n/s w<3"/yd
SA887 Wound care SA887 A6443 Conform band n/s w>=3"<5"/yd
SA887 Wound care SA887 A6444 Conform band n/s w>=5"/yd
SA887 Wound care SA887 A6445 Conform band s w <3"/yd
SA887 Wound care SA887 A6446 Conform band s w>=3" <5"/yd
SA887 Wound care SA887 A6447 Conform band s w >=5"/yd
SA887 Wound care SA887 A6448 Lt compres band <3"/yd
SA887 Wound care SA887 A6449 Lt compres band >=3" <5"/yd
SA887 Wound care SA887 A6450 Lt compres band >=5"/yd
SA887 Wound care SA887 A6451 Mod compres band w>=3"<5"/yd
SA887 Wound care SA887 A6452 High compres band w>=3"<5"yd
SA887 Wound care SA887 A6453 Self-adher band w <3"/yd
SA887 Wound care SA887 A6454 Self-adher band w>=3" <5"/yd
SA887 Wound care SA887 A6455 Self-adher band >=5"/yd
SA887 Wound care SA887 A6456 Zinc paste band w >=3"<5"/yd
SA887 Wound care SA887 A6457 Tubular dressing
SA887 Wound care SA887 A6501 Compres burngarment bodysuit
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Current Social Services Blanket Code HCPCS Code Billing Table Updated: 01/27/2016
Social Service Blanket Code Group Description HCPCS Code Procedure Code Short Description
SA887 Wound care SA887 A6502 Compres burngarment chinstrp
SA887 Wound care SA887 A6503 Compres burngarment facehood
SA887 Wound care SA887 A6504 Cmprsburngarment glove-wrist
SA887 Wound care SA887 A6505 Cmprsburngarment glove-elbow
SA887 Wound care SA887 A6506 Cmprsburngrmnt glove-axilla
SA887 Wound care SA887 A6507 Cmprs burngarment foot-knee
SA887 Wound care SA887 A6508 Cmprs burngarment foot-thigh
SA887 Wound care SA887 A6509 Compres burn garment jacket
SA887 Wound care SA887 A6510 Compres burn garment leotard
SA887 Wound care SA887 A6511 Compres burn garment panty
SA887 Wound care SA887 A6512 Compres burn garment, noc
SA887 Wound care SA887 A6513 Compress burn mask face/neck
SA887 Wound care SA887 A6549 G compression stocking
SA887 Wound care SA887 A6550 Neg pres wound ther drsg set
SA893 Hearing Hardware L7510 Prosthetic device repair rep
SA893 Hearing Hardware L8615 Coch implant headset replace
SA893 Hearing Hardware L8616 Coch implant microphone repl
SA893 Hearing Hardware L8617 Coch implant trans coil repl
SA893 Hearing Hardware L8618 Coch implant tran cable repl
SA893 Hearing Hardware L8619 Coch imp ext proc/contr rplc
SA893 Hearing Hardware L8621 Repl zinc air battery
SA893 Hearing Hardware L8622 Repl alkaline battery
SA893 Hearing Hardware L8623 Lith ion batt CID,non-earlvl
SA893 Hearing Hardware L8624 Lith ion batt CID, ear level
SA893 Hearing Hardware L8627 CID ext speech process repl
SA893 Hearing Hardware L8628 CID ext controller repl
SA893 Hearing Hardware L8629 CID transmit coil and cable
SA893 Hearing Hardware L8691 Osseointegrated snd proc rpl
SA893 Hearing Hardware L8692 Non-osseointegrated snd proc
SA893 Hearing Hardware L8693 AUD OSSEO DEV, ABUTMENT
SA893 Hearing Hardware L9900 O&P supply/accessory/service
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