Skip To: Main content|Subnavigation|
Minnesota Department of Human Services Provider Manual
Advanced Search|  

Orthotic Procedures

Revised: 02-26-2016

Medical authorization requirements for orthotic devices and limits apply to all providers and services.
Refer to the
Orthotics section of the Provider Manual for detailed information.

Procedure Code

Description

Orthotic Devices – Cervical-Thoracic-Lumbar-Sacral (CTLSO)

L0623

Sacroiliac orthosis, provides pelvic-sacral support, with rigid or semi-rigid panels over the sacrum and abdomen, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, prefabricated, includes fitting and adjustment

Spinal Orthosis

L0999

Addition to spinal orthosis, not otherwise specified

Lower Limb
Hip Orthotic (HO)
Knee Orthotic (KO)
Ankle-foot Orthotic (AFO)

L1610

HO, abduction control of hip joints, flexible, prefabricated, includes fitting and adjustment

L1620

HO, abduction control of hip joints, flexible, prefabricated, includes fitting and adjustment

L1650

HO, abduction control of hip joints, static, adjustable, prefabricated, includes fitting and adjustment

L1652

HO, bilateral thigh cuffs with adjustable abductor spreader bar, adult size, prefabricated, includes fitting and adjustment, any type

L1660

HO, abduction control of hip joints, static, plastic, prefabricated, includes fitting and adjustment

L1686

HO, abduction control of hip joint, postoperative hip abduction type, prefabricated, includes fitting and adjustments

L1690

Combination, bilateral, lumbo-sacral, hip, femur orthosis providing adduction and internal rotation control, prefabricated, includes fitting and adjustment

L1810

KO, elastic with joints, prefabricated, includes fitting and adjustment

L1820

KO, elastic with condylar pads and joints, with or without patellar control, prefabricated, includes fitting and adjustment

L1830

KO, immobilizer, canvas longitudinal, prefabricated, includes fitting and adjustment

L1831

KO, locking knee joint(s), positional orthosis, prefabricated, includes fitting and adjustment

L1832

KO, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, includes fitting and adjustment

L1836

KO, rigid, without joint(s), includes soft interface material, prefabricated, includes fitting and adjustment

L1843

KO, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, includes fitting and adjustment

L1845

KO, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, includes fitting and adjustment

L1847

KO, double upright with adjustable joint, with inflatable air support chamber(s), prefabricated, includes fitting and adjustment

L1850

KO, Swedish type, prefabricated, includes fitting and adjustment

L1902

AFO, ankle gauntlet, prefabricated, includes fitting and adjustment

L1906

AFO, multipligamentus ankle support, prefabricated, includes fitting and adjustment

L1910

AFO, posterior, single bar, clasp attachment to shoe counter, prefabricated, includes fitting and adjustment

L1930

AFO, plastic or other material, prefabricated, includes fitting and adjustment

L1932

AFO, rigid anterior tibial section, total carbon fiber or equal material, prefabricated, includes fitting and adjustment

L1951

AFO, spiral, plastic or other material, prefabricated, includes fitting and adjustment

L1971

AFO, plastic or other material with ankle joint, prefabricated, includes fitting and adjustment

L2005

KAFO, any material, single or double upright, stance control, automatic Lock and swing phase release, mechanical activation, includes ankle joint, any type, custom fabricated

L2035

KAFO, full plastic, static (pediatric size), without free motion ankle, prefabricated, includes fitting and adjustment

L2112

AFO, fracture orthosis, tibial fracture orthosis, soft, prefabricated, includes fitting and adjustment

L2114

AFO, fracture orthosis, tibial fracture orthosis, semi-rigid, prefabricated, includes fitting and adjustment

L2116

AFO, fracture orthosis, tibial fracture orthosis, rigid, prefabricated, includes fitting and adjustment

L2132

KAFO, fracture orthosis, femoral fracture cast orthosis, soft, prefabricated, includes fitting and adjustment

L2134

KAFO, fracture orthosis, femoral fracture cast orthosis, semi-rigid, prefabricated, includes fitting and adjustment

L2136

KAFO, fracture orthosis, femoral fracture cast orthosis, rigid, prefabricated, includes fitting and adjustment

Upper Limb, Shoulder Orthotic (SO)

L3650

SO, figure of 8 design, prefabricated, includes fitting and adjustment

L3660

SO, figure of 8 design abduction restrainer, canvas and webbing prefabricated, includes fitting and adjustment

L3670

SO, acromio/clavicular (canvas and webbing typw), prefabricated, includes fitting and adjustment

L3671

SO, shoulder cap design, without joints, may include soft interface, straps, custom fabricated includes fitting and adjustment

L3674

SO, abduction positioning (airplane design), thoracic component and support bar, with or without nontorsion joint/turnbuckle, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3675

SO, vest type abduction restrainer, canvas webbing type or equal, prefabricated includes fitting and adjustment

L3677

SO, hard plastic, should stabilizer, includes fitting and adjustment

Elbow Orthotic (EO)

L3702

EO, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3710

EO, elastic with metal joints, prefab, includes fitting and adjustment

L3720

EO, double upright with forearm/arm cuffs, extension/flexion assist, custom fabricated

L3730

EO, double upright with forearm/arm cuffs, extension/flexion assist, custom fabricated

L3740

EO, double upright with forearm/arm cuffs, adjustable position lock with active control, custom fabricated

L3760

EO, with adjustable position locking joint(s), prefabricated, includes fitting and adjustments any type

L3762

EO, rigid, without joints includes soft interface material, prefabricated, includes fitting and adjustment

L3763

Elbow-wrist-hand orthotic (EWHO), rigid, without joints may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3764

EWHO. Includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3765

Elbow-wrist-hand-finger orthotic (EWHFO), rigid, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3766

EWHFO, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment

Wrist-Hand Finger Orthotic (WHFO)

L3806

WHRO, includes one of more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, custom fabricated, includes fitting and adjustment

L3807

WHFO, without joint(s), prefabricated, includes fitting and adjustments, any type

L3808

WHFO, rigid without joints, may include soft interface material; straps, custom fabricated includes fitting and adjustment

Dynamic Flexor Hinge, Reciprocal Wrist Extension/Flexion, Finger Flexion/Extension (WHFO)

L3900

WHFO, dynamic flexor hinge, reciprocal wrist extension/flexion, finger flexion;/extension, wrist or finger driven, custom fabricated

L3901

WHFO, dynamic flexor hinge, reciprocal wrist extension/flexion, finger flexion/extension, cable driven, custom fabricated

External Power

L3904

WHFO, external powered, electric, custom fabricated

L3905

Wrist-hand orthotic (WHO), includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment

Other – Custom Fitted

L3906

WHO, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3908

WHO, wrist extension control cock-up, nonmolded, prefabricated, includes fitting and adjustment

L3912

Hand-finger orthotic (HFO), flexion glove with elastic finger control, prefabricated, includes fitting and adjustment

L3913

HFO, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3915

WHO, includes one or more nontorsion joints(s), elastic bands, turnbuckles, may include soft interface, straps prefabricated, includes fitting and adjustment

L3917

Hand orthotic (HO), metacarpal fracture orthotic, prefabricated, includes fitting and adjustment

L3919

HS, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3921

HFO, includes one or more nontorsion joints, elastic bands turnbuckles, may include soft interface, straps, custom fabricated includes fitting and adjustment

L3923

HFO, without joints, may include soft interface, straps, prefabricated, includes fitting and adjustment

L3925

Finger orthotic (FO), proximal interphalangeal (PIP)/distal interphalangeal (DIP), nontorsion joint/spring, extension/flexion, may include soft interface material, prefabricated, includes fitting and adjustment

L3927

FO, proximal interphalangeal (PIP)/distal interphalangeal (DIP), without joint/spring, extension/flexion (e.g., static or ring type), may include soft interface material, prefabricated, includes fitting and adjustment

L3929

HFO, includes one or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, prefabricated, includes fitting and adjustment

L3931

WHFO, includes one or more nontorsion joint(s), turnbuckles, elastic band/springs, may include soft interface material, straps, prefabricated, includes fitting and adjustment

L3933

FO, without joints, may include soft interface, custom fabricated, includes fitting and adjustment

L3935

FO, nontorsion joint, may include soft interface, custom fabricated, includes fitting and adjustment

L3956

Addition of joint to upper extremity orthosis, any material; per joint

Shoulder-Elbow-Wrist-Hand Orthosis (SEWHO)

L3960

SEWHO, abduction positioning, airplane design, prefabricated, includes, fitting and adjustment

L3961

SEWHO, shoulder cap design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3962

SEWHO, abduction positioning, Erb’s palsy design, prefabricated, includes fitting and adjustment

L3967

SEWHO, abduction positioning (airplane design), thoracic componenet and support bar, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

Additions to Mobile Arm Supports

L3971

SEWHO, shoulder cap design, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated includes fitting and adjustment

L3973

SWEHO, abduction positioning (airplane design), thoracic component and support bar, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3974

SEO, addition to mobile arm support, supinator

L3975

SEWHO, shoulder cap design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3976

SEWHO, abduction positioning (airplane design), thoracic component and support bar, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3977

SEWHO, shoulder cap design, include one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3978

SEWHO, abduction positioning (airplane design), thoracic component and support bar, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface straps, custom fabricated, includes fitting and adjustment

Fracture Orthoses

L3980

Upper extremity fracture orthotic, humeral, prefabricated, includes fitting and adjustment

L3981

Upper extremity fracture orthosis, humeral, prefabricated, includes shoulder cap design, with or without joints, forearm section, may include soft interface, straps, includes fitting and adjustments

L3982

Upper extremity fracture orthotic, radius/ulnar, prefabricated, includes fitting and adjustment

L3984

Upper extremity fracture orthotic, wrist, prefabricated, includes fitting and adjustment

L3995

Addition to upper extremity orthotic, sock, fracture or equal, each

L3999

Upper limb orthosis, not otherwise specified

Specific Repair/Repairs

L4002

Replacement strap, any orthotic, includes all components, any length, any type

L4205

Repair of orthotic device, labor component, per 15 minutes

L4210

Repair of orthotic device, repair or replace minor parts

L4350

Ankle control orthosis stirrup style, rigid, includes any type interface (e.g., pneumatic, gel), prefabricated, includes fitting and adjustment

L4360

Walking boot, pneumatic, and/or vacuum, with or without joints, with or without interface material, prefabricated, includes fitting and adjustment

L4370

Pneumatic full leg splint, prefabricated, includes fitting and adjustment

L4380

Pneumatic knee splint, prefabricated includes fitting and adjustment

L4386

Walking boot, nonpneumatic, with or without joints, with or without interface material, prefabricated, includes fitting and adjustment

L4392

Replacement soft interface material, static AFO

L4394

Replace soft interface material, foot drop splint

L4396

Static ankle foot orthosis, including soft interface material, adjustable for fit, for positioning, pressure reduction, may be used for minimal ambulation, prefabricated, includes fitting and adjustment

L4398

Foot drop splint, recumbent positioning device, prefabricated, includes fitting and adjustment

Additions: Upper Limb

L6624

Upper extremity addition, flexion/extension and rotation wrist unit

Rate/Report this pageReport/Rate this page

© 2017 Minnesota Department of Human Services Updated: 2/26/16 9:23 AM | Accessibility | Terms/Policy | Contact DHS | Top of Page | Updated: 2/26/16 9:23 AM