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HCPCS Procedure & Supply Codes

Orthotic Devices & Services

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Orthotic Devices -- Upper Limb

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Shoulder-Elbow-Wrist-Hand Orthosis (SEWHO)

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L3975 Sewhfo cap design w/o jnt cf
L3976 Sewhfo airplane w/o jnts cf
L3977 Sewhfo cap desgn w/jnt(s) cf
L3978 Sewhfo airplane w/jnt(s) cf
L3980 Up ext fx orthos humeral nos
L3981 Ue fx orth shoul cap forearm
L3982 Upper ext fx orthosis rad/ul
L3984 Upper ext fx orthosis wrist
L3995 Sock fracture or equal each
L3999 Upper limb orthosis nos
L4000 Repl girdle milwaukee orth
L4002 Replace strap, any orthosis
L4010 Replace trilateral socket br
L4020 Replace quadlat socket brim
L4030 Replace socket brim cust fit
L4040 Replace molded thigh lacer
L4045 Replace non-molded thigh lac
L4050 Replace molded calf lacer
L4055 Replace non-molded calf lace
L4060 Replace high roll cuff
L4070 Replace prox & dist upright
L4080 Repl met band kafo-afo prox
L4090 Repl met band kafo-afo calf/
L4100 Repl leath cuff kafo prox th
L4110 Repl leath cuff kafo-afo cal
L4130 Replace pretibial shell
L4205 Ortho dvc repair per 15 min
L4210 Orth dev repair/repl minor p
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