MEDICAL EQUIPMENT AND SUPPLIES

GROUND RULES AND FEES
1.

GENERAL: Reimbursement for certain medically necessary equipment, devices, or supplies (except for
Prosthetic and/or Orthotic devices) that are appropriate and medically necessary as a result of a
compensable injury shall be limited to the supplier's cost plus 50%. If the charge for a single item
(equipment, device, or supply) or the charge for a line item total is more than $100.00, verification of the
supplier's costs must be attached to the provider's bill.
Reimbursement for any prosthetic and/or orthotic devices (excluding prosthetic surgical implants),
regardless of the charge, shall be limited to the 2005 Medicare Fee Schedule, plus an additional 25%,
as reflected by the L Code System of the 2005 Healthcare Common Procedure Coding System (HCPCS).
Additionally, any charges for any prosthetic and/or orthotic devices shall be billed using the L Code
System of the Healthcare Common Procedure Coding System (HCPCS), and submitted using the CMS
(formerly HCFA) 1500 form or an equivalent form containing the same information.
Included herein are the Prosthetic and Orthotic Fee Schedule Allowances. The 2005 HCPCS allowances
were obtained from Cigna HealthCare who is under contract with CMS as the Durable Medical Equipment
Regional Carrier (DMERC). DMERC provides claims administration for Durable Medical Equipment,
Prosthetics, Orthotics, and Supplies (DMEPOS). The maximum payments, as listed, include an
additional 25% which has been added to the 2005 HCPCS L Codes.
Note carefully the -KM and -KN modifiers applicable to facial prostheses (codes L8040 through L8047):
-KM
-KN

Replacement of facial prosthesis including new impression/moulage.
Replacement of facial prosthesis using previous master model.

Be advised further that the rates contained within this section for the various L Codes will remain
in effect until the next revision of the Kansas Workers Compensation Schedule of Medical Fees.
Any equipment or supplies, including prosthetic and/or orthotic devices, not specifically recommended or
prescribed by a health care provider shall not be reimbursed. In the event, however, a health care
provider recommends and/or prescribes the use of any medical equipment or supplies (e.g., special size
of gauze) that can be purchased over-the-counter, and the injured employee pays for said medical supply
directly, the injured employee is entitled to be reimbursed for the purchase of such equipment or supplies.
The injured employee must submit copies of any receipts and/or proofs of purchase to the employer (or
insurance carrier) for proper reimbursement. However, a pharmacy may bill the insurer directly for
payment, at the usual and customary price for the pharmacy, for items recommended by a health care
provider.
2.

PRIOR AUTHORIZATION: Prior authorization, by the employer (or insurance carrier), is required on
whether to rent or purchase an item. The decision to rent or purchase shall be made by the employer, an
authorized representative, or the insurance carrier, based on a cost comparison of the monthly rental fee,
the prescribing health care provider's estimate of how long the item will be needed, and the purchase
price.

3.

FORMS: Items which are prescribed for work-related injuries should be billed using the CMS 1500 form.

4.

COST CONTAINMENT: Nothing in this section shall preclude an employer (or insurance carrier) from
entering into a contract with a qualified supplier for the renting or purchasing of items that are medically
necessary. Such contract, if less, will supersede the limitation amounts specified herein. Please refer to
K.S.A. 44-510i(e) for further clarification, if necessary.

CPT only copyright 2004 American Medical Association. All Rights Reserved.

109

MEDICAL EQUIPMENT AND SUPPLIES
HCPCS
CODE
L0100
L0110
L0112
L0120
L0130
L0140
L0150
L0160
L0170
L0172
L0174
L0180
L0190
L0200
L0210
L0220
L0430
L0450
L0452
L0454
L0456
L0458
L0460
L0462
L0464
L0466
L0468
L0470
L0472
L0480
L0482
L0484
L0486
L0488
L0490
L0700
L0710
L0810
L0820
L0830
L0860
L0861
L0960
L0970
L0972
L0974
L0976
L0978
L0980
L0982
L0984

MAXIMUM
FEE
$703.10
$174.09
$1,401.54
$33.29
$153.51
$80.31
$134.85
$163.86
$618.41
$120.79
$273.61
$351.23
$493.76
$592.80
$42.26
$128.41
$1,313.95
$184.11
BR
$347.31
$995.95
$893.06
$1,005.20
$1,250.31
$1,488.45
$367.24
$466.41
$643.25
$405.34
$1,735.26
$1,624.01
$1,691.40
$1,774.10
$1,005.20
$283.26
$2,536.41
$2,104.45
$2,589.55
$2,070.60
$3,048.75
$1,146.29
$215.81
$67.43
$107.54
$98.48
$179.49
$167.63
$240.11
$16.43
$17.59
$65.58

HCPCS
CODE
L0999
L1000
L1005
L1010
L1020
L1025
L1030
L1040
L1050
L1060
L1070
L1080
L1085
L1090
L1100
L1110
L1120
L1200
L1210
L1220
L1230
L1240
L1250
L1260
L1270
L1280
L1290
L1300
L1310
L1499
L1500
L1510
L1520
L1600
L1610
L1620
L1630
L1640
L1650
L1652
L1660
L1680
L1685
L1686
L1690
L1700
L1710
L1720
L1730
L1750
L1755

MAXIMUM
FEE
BR
$1,998.04
$3,205.04
$70.48
$81.33
$117.34
$59.86
$74.20
$78.34
$92.58
$84.66
$52.08
$144.84
$87.13
$164.58
$302.76
$37.38
$1,707.53
$246.21
$215.81
$534.89
$73.06
$67.98
$71.19
$72.90
$81.18
$73.96
$1,692.36
$1,803.88
BR
$2,231.20
$1,297.08
$2,618.39
$121.25
$48.64
$130.10
$174.56
$490.10
$229.45
$356.98
$161.03
$1,396.21
$1,119.24
$858.33
$1,936.39
$1,572.64
$1,682.08
$1,456.38
$1,170.50
$185.13
$1,524.38

CPT only copyright 2004 American Medical Association. All Rights Reserved.

110

HCPCS
CODE
L1800
L1810
L1815
L1820
L1825
L1830
L1831
L1832
L1834
L1836
L1840
L1843
L1844
L1845
L1846
L1847
L1850
L1855
L1858
L1860
L1870
L1880
L1900
L1901
L1902
L1904
L1906
L1907
L1910
L1920
L1930
L1932
L1940
L1945
L1950
L1951
L1960
L1970
L1971
L1980
L1990
L2000
L2005
L2010
L2020
L2030
L2035
L2036
L2037
L2038
L2039

MAXIMUM
FEE
$67.33
$94.19
$111.98
$124.91
$51.74
$85.75
$294.73
$572.06
$788.83
$133.63
$886.40
$898.51
$1,893.38
$769.09
$999.00
$575.95
$280.73
$1,033.99
$1,127.49
$1,282.89
$1,062.58
$720.64
$264.34
$17.71
$79.26
$444.79
$113.16
$563.44
$251.63
$328.95
$260.15
$893.59
$509.60
$871.03
$732.43
$840.99
$521.55
$800.29
$469.36
$383.08
$484.15
$954.39
$3,604.61
$874.69
$1,098.70
$1,015.18
$173.45
$1,745.76
$1,567.24
$1,345.30
$2,225.45

MEDICAL EQUIPMENT AND SUPPLIES
HCPCS
CODE
L2040
L2050
L2060
L2070
L2080
L2090
L2106
L2108
L2112
L2114
L2116
L2126
L2128
L2132
L2134
L2136
L2180
L2182
L2184
L2186
L2188
L2190
L2192
L2200
L2210
L2220
L2230
L2232
L2240
L2250
L2260
L2265
L2270
L2275
L2280
L2300
L2310
L2320
L2330
L2335
L2340
L2350
L2360
L2370
L2375
L2380
L2385
L2390
L2395
L2397
L2405

MAXIMUM
FEE
$167.06
$448.24
$565.63
$131.01
$367.79
$457.03
$639.76
$1,005.36
$439.00
$576.98
$709.11
$1,126.74
$1,613.46
$759.04
$910.06
$1,123.51
$111.03
$103.46
$116.56
$146.95
$281.80
$86.85
$425.03
$44.74
$63.25
$79.00
$74.34
BR
$82.91
$393.91
$188.63
$113.09
$50.54
$150.05
$426.08
$263.06
$115.75
$207.00
$391.58
$285.01
$423.23
$917.26
$52.09
$322.06
$114.68
$140.04
$128.15
$103.00
$154.86
$126.78
$87.29

HCPCS
CODE
L2415
L2425
L2430
L2492
L2500
L2510
L2520
L2525
L2526
L2530
L2540
L2550
L2570
L2580
L2600
L2610
L2620
L2622
L2624
L2627
L2628
L2630
L2640
L2650
L2660
L2670
L2680
L2750
L2755
L2760
L2768
L2770
L2780
L2785
L2795
L2800
L2810
L2820
L2830
L2840
L2850
L2860
L2999
L3031
L3160
L3201
L3202
L3203
L3204
L3206
L3207

MAXIMUM
FEE
$121.64
$143.53
$143.53
$95.95
$297.55
$739.53
$433.48
$1,256.58
$644.50
$243.01
$397.81
$270.24
$515.61
$436.70
$193.25
$228.51
$317.65
$303.38
$367.54
$1,613.05
$1,576.45
$233.00
$316.21
$139.39
$175.38
$163.11
$165.00
$86.86
$130.85
$57.16
$130.50
$58.10
$63.68
$31.83
$79.95
$100.36
$73.49
$81.71
$88.40
$42.54
$77.69
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR

CPT only copyright 2004 American Medical Association. All Rights Reserved.

111

HCPCS
CODE
L3208
L3209
L3211
L3212
L3213
L3214
L3215
L3216
L3217
L3219
L3221
L3222
L3224
L3225
L3230
L3250
L3251
L3252
L3253
L3254
L3255
L3257
L3260
L3265
L3320
L3485
L3649
L3650
L3651
L3652
L3660
L3670
L3675
L3677
L3700
L3701
L3710
L3720
L3730
L3740
L3760
L3762
L3800
L3805
L3807
L3810
L3815
L3820
L3825
L3830
L3835

MAXIMUM
FEE
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
$67.63
$78.66
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
$64.81
$60.01
$180.86
$118.51
$138.83
$159.91
BR
$79.26
$18.59
$113.83
$630.55
$988.40
$1,045.46
$455.75
$98.00
$202.10
$319.98
$227.88
$66.38
$55.74
$122.25
$60.55
$94.53
$106.00

MEDICAL EQUIPMENT AND SUPPLIES
HCPCS
CODE
L3840
L3845
L3850
L3855
L3860
L3890
L3900
L3901
L3904
L3906
L3907
L3908
L3909
L3910
L3911
L3912
L3914
L3916
L3917
L3918
L3920
L3922
L3923
L3924
L3926
L3928
L3930
L3932
L3934
L3936
L3938
L3940
L3942
L3944
L3946
L3948
L3950
L3952
L3954
L3956
L3960
L3962
L3963
L3980
L3982
L3984
L3985
L3986
L3995
L3999
L4000

MAXIMUM
FEE
$68.85
$74.75
$124.55
$142.04
$189.25
BR
$1,490.46
$1,727.11
$2,696.40
$368.05
$467.73
$56.06
$12.90
$430.85
$22.60
$108.03
$104.11
$134.90
$96.25
$81.73
$106.35
$107.44
$35.48
$120.21
$110.63
$68.46
$72.81
$57.70
$58.40
$97.46
$100.73
$121.83
$78.10
$120.58
$108.80
$58.93
$181.34
$180.43
$102.53
BR
$741.69
$771.10
$1,536.13
$338.99
$358.13
$381.44
$538.16
$546.36
$30.11
BR
$1,334.49

HCPCS
CODE
L4002
L4010
L4020
L4030
L4040
L4045
L4050
L4055
L4060
L4070
L4080
L4090
L4100
L4110
L4130
L4205
L4210
L4350
L4360
L4370
L4380
L4386
L4392
L4394
L4396
L4398
L5000
L5010
L5020
L5050
L5060
L5100
L5105
L5150
L5160
L5200
L5210
L5220
L5230
L5250
L5270
L5280
L5301
L5311
L5321
L5331
L5341
L5400
L5410
L5420
L5430

MAXIMUM
FEE
BR
$707.43
$911.13
$490.26
$404.88
$332.34
$438.46
$268.95
$307.96
$301.14
$115.28
$108.96
$103.50
$84.78
$514.66
BR
BR
$84.11
$260.54
$177.64
$101.06
$158.78
$22.74
$16.56
$162.08
$74.61
$529.11
$1,413.19
$1,986.63
$2,319.14
$3,055.60
$2,640.38
$3,730.51
$4,109.24
$4,366.66
$3,535.83
$2,611.18
$3,056.81
$4,069.51
$5,845.73
$6,123.48
$6,010.25
$2,608.01
$3,925.33
$3,294.79
$5,569.59
$5,692.90
$1,356.96
$504.40
$1,828.18
$598.80

CPT only copyright 2004 American Medical Association. All Rights Reserved.

112

HCPCS
CODE
L5450
L5460
L5500
L5505
L5510
L5520
L5530
L5535
L5540
L5560
L5570
L5580
L5585
L5590
L5595
L5600
L5610
L5611
L5613
L5614
L5616
L5617
L5618
L5620
L5622
L5624
L5626
L5628
L5629
L5630
L5631
L5632
L5634
L5636
L5637
L5638
L5639
L5640
L5642
L5643
L5644
L5645
L5646
L5647
L5648
L5649
L5650
L5651
L5652
L5653
L5654

MAXIMUM
FEE
$493.43
$647.20
$1,686.56
$1,974.39
$1,732.25
$1,759.51
$1,844.14
$2,041.00
$2,263.26
$2,176.90
$2,407.86
$2,613.75
$2,787.33
$2,816.11
$4,036.41
$4,498.53
$2,767.31
$1,851.50
$2,991.00
$1,693.09
$1,594.11
$560.79
$298.15
$283.74
$365.58
$364.45
$488.79
$507.31
$318.59
$577.89
$440.46
$252.43
$327.89
$258.58
$289.60
$487.86
$1,123.94
$670.29
$636.41
$1,560.28
$647.23
$799.85
$549.26
$1,063.23
$722.21
$1,908.63
$489.39
$1,203.88
$437.05
$675.36
$355.34

MEDICAL EQUIPMENT AND SUPPLIES
HCPCS
CODE
L5655
L5656
L5658
L5661
L5665
L5666
L5668
L5670
L5671
L5672
L5673
L5676
L5677
L5678
L5679
L5680
L5681
L5682
L5683
L5684
L5685
L5686
L5688
L5690
L5692
L5694
L5695
L5696
L5697
L5698
L5699
L5700
L5701
L5702
L5704
L5705
L5706
L5707
L5710
L5711
L5712
L5714
L5716
L5718
L5722
L5724
L5726
L5728
L5780
L5781
L5782

MAXIMUM
FEE
$265.90
$421.38
$438.84
$684.31
$676.35
$74.81
$102.46
$272.01
$664.84
$309.06
$750.94
$363.26
$531.69
$44.79
$625.76
$334.85
$1,319.76
$674.29
$1,319.76
$53.41
BR
$55.20
$71.11
$99.96
$159.74
$181.86
$163.49
$197.99
$80.48
$116.25
$186.91
$3,378.34
$3,974.83
$5,787.01
$623.25
$1,023.19
$1,014.11
$1,441.56
$408.65
$573.93
$435.40
$477.76
$820.18
$1,217.61
$1,081.89
$1,835.25
$2,032.15
$2,538.86
$1,530.30
$4,014.50
$4,232.21

HCPCS
CODE
L5785
L5790
L5795
L5810
L5811
L5812
L5814
L5816
L5818
L5822
L5824
L5826
L5828
L5830
L5840
L5845
L5848
L5850
L5855
L5856
L5857
L5910
L5920
L5925
L5930
L5940
L5950
L5960
L5962
L5964
L5966
L5968
L5970
L5972
L5974
L5975
L5976
L5978
L5979
L5980
L5981
L5982
L5984
L5985
L5986
L5987
L5988
L5990
L5995
L5999
L6000

MAXIMUM
FEE
$520.83
$740.61
$1,076.34
$488.06
$768.58
$608.11
$3,726.24
$852.54
$1,136.13
$1,707.09
$1,594.48
$3,133.33
$3,143.78
$2,081.73
$4,125.13
$1,798.34
$1,078.90
$128.24
$412.79
$24,080.26
$8,541.01
$363.06
$531.89
$445.73
$3,373.69
$666.93
$837.86
$1,071.61
$785.65
$1,153.10
$1,494.94
$3,646.03
$210.20
$391.05
$254.43
$465.13
$632.36
$390.06
$3,049.83
$4,136.69
$3,347.78
$675.36
$669.19
$283.03
$716.13
$7,217.73
$2,004.34
$1,820.24
BR
BR
$1,726.74

CPT only copyright 2004 American Medical Association. All Rights Reserved.

113

HCPCS
CODE
L6010
L6020
L6025
L6050
L6055
L6100
L6110
L6120
L6130
L6200
L6205
L6250
L6300
L6310
L6320
L6350
L6360
L6370
L6380
L6382
L6384
L6386
L6388
L6400
L6450
L6500
L6550
L6570
L6580
L6582
L6584
L6586
L6588
L6590
L6600
L6605
L6610
L6615
L6616
L6620
L6623
L6625
L6628
L6629
L6630
L6632
L6635
L6637
L6638
L6640
L6641

MAXIMUM
FEE
$1,928.26
$1,842.63
$8,029.01
$2,283.56
$2,794.11
$2,360.71
$2,556.18
$2,844.39
$2,973.13
$3,274.40
$3,750.00
$3,171.91
$4,205.48
$3,710.14
$2,284.19
$4,727.81
$3,220.83
$2,259.56
$1,283.33
$1,508.06
$1,911.30
$457.70
$474.28
$2,521.71
$3,491.13
$3,769.15
$4,110.80
$4,475.99
$1,686.19
$1,433.63
$2,080.50
$1,925.90
$3,049.84
$2,691.18
$189.21
$185.66
$185.45
$191.14
$65.03
$380.46
$728.08
$533.16
$589.66
$151.23
$216.05
$71.84
$198.33
$390.30
$2,509.08
$288.23
$195.59

MEDICAL EQUIPMENT AND SUPPLIES
HCPCS
CODE
L6642
L6645
L6646
L6647
L6648
L6650
L6655
L6660
L6665
L6670
L6672
L6675
L6676
L6680
L6682
L6684
L6686
L6687
L6688
L6689
L6690
L6691
L6692
L6693
L6694
L6695
L6696
L6697
L6698
L6700
L6705
L6710
L6715
L6720
L6725
L6730
L6735
L6740
L6745
L6750
L6755
L6765
L6770
L6775
L6780
L6790
L6795
L6800
L6805
L6806
L6807

MAXIMUM
FEE
$267.81
$339.16
$3,164.46
$520.96
$3,263.71
$339.33
$90.13
$114.49
$46.18
$58.03
$169.14
$120.39
$130.48
$241.54
$261.00
$349.43
$591.81
$578.23
$558.54
$697.14
$730.86
$411.69
$567.28
$2,848.46
BR
BR
BR
BR
BR
$565.24
$364.21
$403.31
$399.48
$889.90
$502.71
$742.91
$378.10
$499.51
$447.74
$416.34
$413.13
$466.96
$443.63
$487.03
$520.54
$476.39
$1,607.21
$1,161.31
$436.38
$1,622.70
$1,630.86

HCPCS
CODE
L6808
L6809
L6810
L6825
L6830
L6835
L6840
L6845
L6850
L6855
L6860
L6865
L6867
L6868
L6870
L6872
L6873
L6875
L6880
L6881
L6882
L6890
L6895
L6900
L6905
L6910
L6915
L6920
L6925
L6930
L6935
L6940
L6945
L6950
L6955
L6960
L6965
L6970
L6975
L7010
L7015
L7020
L7025
L7030
L7035
L7040
L7045
L7170
L7180
L7181
L7185

MAXIMUM
FEE
$1,268.78
$374.08
$204.06
$1,263.40
$1,521.59
$1,331.00
$897.10
$892.54
$790.60
$914.95
$810.33
$339.75
$1,122.50
$262.71
$260.75
$1,100.06
$494.40
$941.36
$601.18
$4,101.85
$3,111.45
$227.34
$641.15
$1,980.45
$1,572.74
$1,911.81
$830.18
$7,526.83
$8,280.63
$7,467.01
$8,443.36
$8,816.49
$10,232.33
$9,997.11
$11,972.91
$12,429.70
$14,399.20
$15,134.16
$17,063.03
$3,661.34
$5,818.14
$3,411.29
$3,442.49
$5,456.73
$3,525.51
$2,900.40
$1,620.31
$5,877.94
$36,225.78
BR
$5,952.20

CPT only copyright 2004 American Medical Association. All Rights Reserved.

114

HCPCS
CODE
L7186
L7190
L7191
L7260
L7261
L7266
L7272
L7274
L7360
L7362
L7364
L7366
L7367
L7368
L7499
L7500
L7510
L7520
L7900
L8000
L8001
L8002
L8010
L8015
L8020
L8030
L8035
L8039
L8040
L8040-KM
L8040-KN
L8041
L8041-KM
L8041-KN
L8042
L8042-KM
L8042-KN
L8043
L8043-KM
L8043-KN
L8044
L8044-KM
L8044-KN
L8045
L8045-KM
L8045-KN
L8046
L8046-KM
L8046-KN
L8047
L8047-KM

MAXIMUM
FEE
$10,920.18
$7,640.38
$10,631.40
$2,252.85
$4,061.84
$992.51
$2,078.09
$6,441.46
$228.90
$251.16
$472.21
$591.33
$390.61
$506.36
BR
BR
BR
BR
$532.88
$40.55
$125.84
$165.56
BR
$60.13
$238.80
$357.48
$3,675.83
BR
$2,303.04
$2,187.88
$921.21
$2,775.94
$2,637.13
$1,110.36
$3,119.03
$2,963.06
$1,247.60
$3,493.31
$3,318.65
$1,397.33
$3,867.58
$3,674.21
$1,547.04
$2,465.15
$2,341.90
$986.06
$2,495.21
$2,370.45
$998.09
$1,278.80
$1,214.85

MEDICAL EQUIPMENT AND SUPPLIES
HCPCS
CODE
L8047-KN
L8048
L8049
L8100
L8130
L8140
L8150
L8160
L8170
L8180
L8190
L8195
L8200
L8210
L8220
L8230
L8239
L8300
L8310
L8320
L8330
L8400
L8410
L8415
L8417
L8420
L8430
L8435
L8440
L8460
L8465
L8470
L8480
L8485
L8499
L8500
L8501
L8505
L8507
L8509
L8510
L8511
L8512
L8513
L8514
L8515
L8600
L8603
L8606
L8610
L8612

MAXIMUM
FEE
$511.53
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
$112.75
$170.74
$53.59
$49.49
$18.36
$21.23
$24.38
$75.45
$21.59
$24.49
$23.34
$42.03
$66.81
$48.90
$6.69
$9.23
$14.70
BR
$752.31
$121.10
BR
$42.05
$109.56
$253.55
$73.00
$2.16
$5.21
$94.63
$63.34
$625.99
$438.96
$219.99
$586.75
$609.54

HCPCS
CODE
L8613
L8614
L8615
L8616
L8617
L8618
L8619
L8620
L8621
L8622
L8630
L8631
L8641
L8642
L8658
L8659
L8670
L8699
L9900

MAXIMUM
FEE
$272.16
$19,019.69
$452.51
$105.39
$92.05
$26.33
$8,165.01
$64.93
$0.63
$0.33
$337.74
$2,178.11
$350.90
$379.50
$305.95
$1,936.13
$558.01
BR
BR

CPT only copyright 2004 American Medical Association. All Rights Reserved.

115

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