KX Modifier: HCPCS Codes - UHCprovider

HCPCS CodeAnkle-Foot/Knee-Ankle-Foot OrthosisDescriptionL2492Addition to knee joint, lift loop for drop lock ringL2500Addition to lower extremity, thigh/weight bearing, gluteal/ischial weight bearing, ringL2510Addition to lower extremity, thigh/weight bearing, quadri-lateral brim, molded to patient modelL2520Addition to lower extremity, thigh/weight bearing, quadri-lateral brim, custom fittedL2525Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim molded topatient modelL2526Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim, custom fittedL2530Addition to lower extremity, thigh/weight bearing, lacer, nonmoldedL2540Addition to lower extremity, thigh/weight bearing, lacer, molded to patient modelL2550Addition to lower extremity, thigh/weight bearing, high roll cuffL2750Addition to lower extremity orthosis, plating chrome or nickel, per barL2755Addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepregcomposite, per segment, for custom fabricated orthosis onlyL2760Addition to lower extremity orthosis, extension, per extension, per bar (for lineal adjustment forgrowth)L2768Orthotic side bar disconnect device, per barL2780Addition to lower extremity orthosis, non-corrosive finish, per barL2785Addition to lower extremity orthosis, drop lock retainer, eachL2795Addition to lower extremity orthosis, knee control, full kneecapL2800Addition to lower extremity orthosis, knee control, knee cap, medial or lateral pull, for use withcustom fabricated orthosis onlyL2810Addition to lower extremity orthosis, knee control, condylar padL2820Addition to lower extremity orthosis, soft interface for molded plastic, below knee sectionL2830Addition to lower extremity orthosis, soft interface for molded plastic, above knee sectionL2840Addition to lower extremity orthosis, tibial length sock, fracture or equal, eachL2850Addition to lower extremity orthosis, femoral length sock, fracture or equal, eachL4002Replacement strap, any orthosis, includes all components, any length, any typeL4010Replace trilateral socket brimL4020Replace quadrilateral socket brim, molded to patient modelL4030Replace quadrilateral socket brim, custom fittedL4040Replace molded thigh lacer, for custom fabricated orthosis onlyL4045Replace non-molded thigh lacer, for custom fabricated orthosis onlyL4050Replace molded calf lacer, for custom fabricated orthosis onlyL4055Replace non-molded calf lacer, for custom fabricated orthosis onlyL4060Replace high roll cuffL4070Replace proximal and distal upright for kafoL4080Replace metal bands kafo, proximal thighL4090Replace metal bands kafo-afo, calf or distal thighL4100Replace leather cuff kafo, proximal thighL4110Replace leather cuff kafo-afo, calf or distal thighL4130Replace pretibial shellL4205Repair of orthotic device, labor component, per 15 minutesKX Modifier: HCPCS CodesPage 4 of 26UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code ListApproval 06/09/2021Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc.

HCPCS CodeAnkle-Foot/Knee-Ankle-Foot OrthosisDescriptionL4210Repair of orthotic device, repair or replace minor partsL4350Ankle control orthosis, stirrup style, rigid, includes any type interface (e.g., pneumatic, gel),prefabricated, includes fitting and adjustmentL4360Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material,prefabricated, includes fitting and adjustmentL4361Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material,prefabricated, off-the-shelfL4370Pneumatic full leg splint, prefabricated, includes fitting and adjustmentL4386Walking boot, non-pneumatic, with or without joints, with or without interface material, prefabricated,includes fitting and adjustmentL4387Walking boot, non-pneumatic, with or without joints, with or without interface material, prefabricated,off-the-shelfL4392Replacement, soft interface material, static afoL4394Replace soft interface material, foot drop splintL4396Static or dynamic ankle foot orthosis, including soft interface material, adjustable for fit, forpositioning, may be used for minimal ambulation, prefabricated, includes fitting and adjustmentL4397Static or dynamic ankle foot orthosis, including soft interface material, adjustable for fit, forpositioning, may be used for minimal ambulation, prefabricated, off-the-shelfL4398Foot drop splint, recumbent positioning device, prefabricated, includes fitting and adjustmentL4631Ankle foot orthosis, walking boot type, varus/valgus correction, rocker bottom, anterior tibial shell,soft interface, custom arch support, plastic or other material, includes straps and closures, customfabricatedAutomatic External DefibrillatorsE0617External defibrillator with integrated electrocardiogram analysisK0606Automatic external defibrillator, with integrated electrocardiogram analysis, garment typeK0607Replacement battery for automated external defibrillator, garment type only, eachK0608Replacement garment for use with automated external defibrillator, eachK0609Replacement electrodes for use with automated external defibrillator, garment type only, eachCervical Traction DevicesE0849Traction equipment, cervical, free-standing stand/frame, pneumatic, applying traction force to otherthan mandibleE0855Cervical traction equipment not requiring additional stand or frameCommodesE0163Commode chair, mobile or stationary, with fixed armsE0165Commode chair, mobile or stationary, with detachable armsE0167Pail or pan for use with commode chair, replacement onlyE0168Commode chair, extra wide and/or heavy duty, stationary or mobile, with or without arms, any type,eachE0170Commode chair with integrated seat lift mechanism, electric, any typeE0171Commode chair with integrated seat lift mechanism, non-electric, any typeE0175Footrest, for use with commode chair, eachExternal Infusion PumpsE0784External ambulatory infusion pump, insulinKX Modifier: HCPCS CodesPage 5 of 26UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code ListApproval 06/09/2021Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc.

HCPCS CodeExternal Infusion PumpsDescriptionE0787External ambulatory infusion pump, insulin, dosage rate adjustment using therapeutic continuousglucose sensingJ1817Insulin for administration through DME (i.e., insulin pump) per 50 unitsHigh Frequency Chest Wall Oscillation DevicesA7025High frequency chest wall oscillation system vest, replacement for use with patient-owned equipment,eachA7026High frequency chest wall oscillation system hose, replacement for use with patient-ownedequipment, eachE0483High frequency chest wall oscillation air-pulse generator system, (includes hoses and vest), eachHospital Beds and AccessoriesE0250Hospital bed, fixed height, with any type side rails, with mattressE0251Hospital bed, fixed height, with any type side rails, without mattressE0255Hospital bed, variable height, hi-lo, with any type side rails, with mattressE0256Hospital bed, variable height, hi-lo, with any type side rails, without mattressE0260Hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattressE0261Hospital bed, semi-electric (head and foot adjustment), with any type side rails, without mattressE0265Hospital bed, total electric (head, foot and height adjustments), with any type side rails, with mattress(Non-covered) (NCD 280.7 Hospital Beds)E0266Hospital bed, total electric (head, foot and height adjustments), with any type side rails, withoutmattress (Non-covered) (NCD 280.7 Hospital Beds)E0271Mattress, innerspringE0272Mattress, foam rubberE0273Bed board (Non-covered) (NCD 280.7 Hospital Beds)E0274Over-bed table (Non-covered) (NCD 280.7 Hospital Beds)E0280Bed cradle, any typeE0290Hospital bed, fixed height, without side rails, with mattressE0291Hospital bed, fixed height, without side rails, without mattressE0292Hospital bed, variable height, hi-lo, without side rails, with mattressE0293Hospital bed, variable height, hi-lo, without side rails, without mattressE0294Hospital bed, semi-electric (head and foot adjustment), without side rails, with mattressE0295Hospital bed, semi-electric (head and foot adjustment), without side rails, without mattressE0296Hospital bed, total electric (head, foot and height adjustments). Without side rails, with mattress (Noncovered) (NCD 280.7 Hospital Beds)E0297Hospital bed, total electric (head, foot and height adjustments), without side rails, without mattress(Non-covered) (NCD 280.7 Hospital Beds)E0301Hospital bed, heavy duty, extra wide, with weight capacity greater than 350 pounds, but less than orequal to 600 pounds, with any type side rails, without mattressE0302Hospital bed, extra heavy duty, extra wide, with weight capacity greater than 600 pounds, with anytype side rails, without mattressE0303Hospital bed, heavy duty, extra wide, with weight capacity greater than 350 pounds, but less than orequal to 600 pounds, with any type side rails, with mattressE0304Hospital bed, extra heavy duty, extra wide, with weight capacity greater than 600 pounds, with anytype side rails, with mattressKX Modifier: HCPCS CodesPage 6 of 26UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code ListApproval 06/09/2021Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc.

HCPCS CodeHospital Beds and AccessoriesDescriptionE0305Bed side rails, half lengthE0310Bed side rails, full lengthE0315Bed accessory: board, table, or support device, any type (Non-covered) (NCD 280.7 Hospital Beds)E0316Safety enclosure frame/canopy for use with hospital bed, any typeE0328Hospital bed, pediatric, manual, 360 degree side enclosures, top of headboard, footboard and siderails up to 24 inches above the spring, includes mattressE0329Hospital bed, pediatric, electric or semi-electric, 360 degree side enclosures, top of headboard,footboard and side rails up to 24 inches above the spring, includes mattressE0910Trapeze bars, a/k/a patient helper, attached to bed, with grab barE0911Trapeze bar, heavy duty, for patient weight capacity greater than 250 pounds, attached to bed, withgrab barE0912Trapeze bar, heavy duty, for patient weight capacity greater than 250 pounds, free standing,complete with grab barE0940Trapeze bar, free standing, complete with grab barImmunosuppressive DrugsJ0485Injection, belatacept, 1 mgJ2920Injection, methylprednisolone sodium succinate, up to 40 mgJ2930Injection, methylprednisolone sodium succinate, up to 125 mgJ7500Azathioprine, oral, 50 mgJ7501Azathioprine, parenteral, 100 mgJ7502Cyclosporine, oral, 100 mgJ7504Lymphocyte immune globulin, antithymocyte globulin, equine, parenteral, 250 mgJ7505Muromonab-cd3, parenteral, 5 mgJ7506Prednisone, Oral, Per 5mgJ7507Tacrolimus, oral, per 1 mgJ7508Tacrolimus, extended release, (Astagraf XL), oral, 0.1 mgJ7509Methylprednisolone oral, per 4 mgJ7510Prednisolone oral, per 5 mgJ7511Lymphocyte Immune Globulin, Antithymocyte Globulin, Rabbit, Parenteral, 25mgJ7512Prednisone, immediate release or delayed release, oral, 1 mgJ7513Daclizumab, parenteral, 25 mgJ7515Cyclosporine, oral, 25 mgJ7516Cyclosporin, parenteral, 250 mgJ7517Mycophenolate mofetil, oral, 250 mgJ7518Mycophenolic acid, oral, 180 mgJ7520Sirolimus, oral, 1 mgJ7525Tacrolimus, parenteral, 5 mgJ7527Everolimus, oral, 0.25 mgJ7599Immunosuppressive drug, not otherwise classifiedJ8530Cyclophosphamide; oral, 25 mgJ8610Methotrexate; oral, 2.5 mgQ0510Pharmacy supply fee for initial immunosuppressive drug(s), first month following transplantKX Modifier: HCPCS CodesPage 7 of 26UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code ListApproval 06/09/2021Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc.

HCPCS CodeImmunosuppressive DrugsDescriptionQ0511Pharmacy supply fee for oral anti-cancer, oral anti-emetic or immunosuppressive drug(s); for the firstprescription in a 30-day periodQ0512Pharmacy supply fee for oral anti-cancer, oral anti-emetic or immunosuppressive drug(s); for asubsequent prescription in a 30-day periodKnee OrthosesK0672Addition to lower extremity orthosis, removable soft interface, all components, replacement only,eachL1810Knee orthosis, elastic with joints, prefabricated, includes fitting and adjustmentL1812Knee orthosis, elastic with joints, prefabricated, off-the-shelfL1820Knee orthosis, elastic with condylar pads and joints, with or without patellar control, prefabricated,includes fitting and adjustmentL1830Knee orthosis, immobilizer, canvas longitudinal, prefabricated, includes fitting and adjustmentL1831Knee orthosis, locking knee joint(s), positional orthosis, prefabricated, includes fitting and adjustmentL1832Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support,prefabricated, includes fitting and adjustmentL1833Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support,prefabricated, off-the shelfL1834Knee orthosis, without knee joint, rigid, custom-fabricatedL1836Knee orthosis, rigid, without joint(s), includes soft interface material, prefabricated, includes fittingand adjustmentL1840Knee orthosis, derotation, medial-lateral, anterior cruciate ligament, custom fabricatedL1843Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric orpolycentric), medial-lateral and rotation control, with or without varus/valgus adjustment,prefabricated, includes fitting and adjustmentL1844Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric orpolycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, customfabricatedL1845Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric orpolycentric), medial-lateral and rotation control, with or without varus/valgus adjustment,prefabricated, includes fitting and adjustmentL1846Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric orpolycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, customfabricatedL1847Knee orthosis, double upright with adjustable joint, with inflatable air support chamber(s),prefabricated, includes fitting and adjustmentL1848Knee orthosis, double upright with adjustable joint, with inflatable air support chamber(s),prefabricated, off-the-shelfL1850Knee orthosis, elcro type, prefabricated, includes fitting and adjustmentL1851Knee orthosis (KO), single upright, thigh and calf, with adjustable flexion and extension joint(unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgusadjustment, prefabricated, off-the-shelfL1852Knee orthosis (KO), double upright, thigh and calf, with adjustable flexion and extension joint(unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgusadjustment, prefabricated, off-the-shelfL1860Knee orthosis, modification of supracondylar prosthetic socket, custom-fabricated (sk)L2275Addition to lower extremity, varus/valgus correction, plastic modification, padded/linedKX Modifier: HCPCS CodesPage 8 of 26UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code ListApproval 06/09/2021Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc.

HCPCS CodeKnee OrthosesDescriptionL2320Addition to lower extremity, non-molded lacer, for custom fabricated orthosis onlyL2330Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis onlyL2385Addition to lower extremity, straight knee joint, heavy duty, each jointL2390Addition to lower extremity, offset knee joint, each jointL2395Addition to lower extremity, offset knee joint, heavy duty, each jointL2397Addition to lower extremity orthosis, suspension sleeveL2405Addition to knee joint, drop lock, eachL2415Addition to knee lock with integrated release mechanism ( bail, cable, or equal), any material, eachjointL2425Addition to knee joint, disc or dial lock for adjustable knee flexion, each jointL2430Addition to knee joint, ratchet lock for active and progressive knee extension, each jointL2492Addition to knee joint, lift loop for drop lock ringL2750Addition to lower extremity orthosis, plating chrome or nickel, per barL2755Addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepregcomposite, per segment, for custom fabricated orthosis onlyL2780Addition to lower extremity orthosis, non-corrosive finish, per barL2785Addition to lower extremity orthosis, drop lock retainer, eachL2795Addition to lower extremity orthosis, knee control, full kneecapL2800Addition to lower extremity orthosis, knee control, knee cap, medial or lateral pull, for use withcustom fabricated orthosis onlyL2810Addition to lower extremity orthosis, knee control, condylar padL2820Addition to lower extremity orthosis, soft interface for molded plastic, below knee sectionL2830Addition to lower extremity orthosis, soft interface for molded plastic, above knee sectionL4002Replacement strap, any orthosis, includes all components, any length, any typeL4205Repair of orthotic device, labor component, per 15 minutesL4210Repair of orthotic device, repair or replace minor partsManual Wheelchair BasesE1037Transport chair, pediatric sizeE1038Transport chair, adult size, patient weight capacity up to and including 300 poundsE1039Transport chair, adult size, heavy-duty, patient weight capacity greater than 300 poundsE1161Manual adult size wheelchair, includes tilt in spaceE1231Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, with seating systemE1232Wheelchair, pediatric size, tilt-in-space, folding, adjustable, with seating systemE1233Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, without seating systemE1234Wheelchair, pediatric size, tilt-in-space, folding, adjustable, without seating systemE1235Wheelchair, pediatric size, rigid, adjustable, with seating systemE1236Wheelchair, pediatric size, folding, adjustable, with seating systemE1237Wheelchair, pediatric size, rigid, adjustable, without seating systemE1238Wheelchair, pediatric size, folding, adjustable, without seating systemK0001Standard wheelchairK0002Standard hemi (low seat) wheelchairK0003Lightweight wheelchairKX Modifier: HCPCS CodesPage 9 of 26UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code ListApproval 06/09/2021Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc.

HCPCS CodeManual Wheelchair BasesK0004High strength, lightweight wheelchairK0005Ultralightweight wheelchairK0006Heavy duty wheelchairK0007Extra heavy duty wheelchairK0008Custom manual wheelchair/baseK0009Other manual wheelchair/baseK0013Custom motorized/power wheelchair c aerosol generator with small volume nebulizerJ7686Treprostinil, inhalation solution, fda-approved final product, non-compounded, administered throughdme, unit dose form, 1.74 mgK0730Controlled dose inhalation drug delivery systemQ4074Iloprost, inhalation solution, fda-approved final product, non-compounded, administered throughdme, unit dose form, up to 20 microgramsNegative Pressure Wound Therapy PumpsA6550Wound care set, for negative pressure wound therapy electrical pump, includes all supplies andaccessoriesE2402Negative pressure wound therapy electrical pump, stationary or portableOral Antiemetic Drugs (Replacement for Intravenous Antiemetics)J8501Aprepitant, oral, 5 mgJ8540Dexamethasone, oral, 0.25 mgJ8655Netupitant 300 mg and palono

Ankle-foot orthotic (AFO), multiligamentus ankle support, prefabricated, includes fitting and adjustment : L1907 . Ankle-foot orthotic (AFO), supramalleolar with straps, with or without interface/pads, custom fabricated : L1910 . Ankle-foot orthotic (AFO), posterior, single bar,