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 Replacement of facial prosthesis including new impression/moulage.

-KN 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.

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 MEDICAL EQUIPMENT AND SUPPLIES
HCPCS MAXIMUM HCPCS MAXIMUM HCPCS MAXIMUM
CODE FEE CODE FEE CODE FEE
L0100 $703.10 L0999 BR L1800 $67.33
L0110 $174.09 L1000 $1,998.04 L1810 $94.19
L0112 $1,401.54 L1005 $3,205.04 L1815 $111.98
L0120 $33.29 L1010 $70.48 L1820 $124.91
L0130 $153.51 L1020 $81.33 L1825 $51.74
L0140 $80.31 L1025 $117.34 L1830 $85.75
L0150 $134.85 L1030 $59.86 L1831 $294.73
L0160 $163.86 L1040 $74.20 L1832 $572.06
L0170 $618.41 L1050 $78.34 L1834 $788.83
L0172 $120.79 L1060 $92.58 L1836 $133.63
L0174 $273.61 L1070 $84.66 L1840 $886.40
L0180 $351.23 L1080 $52.08 L1843 $898.51
L0190 $493.76 L1085 $144.84 L1844 $1,893.38
L0200 $592.80 L1090 $87.13 L1845 $769.09
L0210 $42.26 L1100 $164.58 L1846 $999.00
L0220 $128.41 L1110 $302.76 L1847 $575.95
L0430 $1,313.95 L1120 $37.38 L1850 $280.73
L0450 $184.11 L1200 $1,707.53 L1855 $1,033.99
L0452 BR L1210 $246.21 L1858 $1,127.49
L0454 $347.31 L1220 $215.81 L1860 $1,282.89
L0456 $995.95 L1230 $534.89 L1870 $1,062.58
L0458 $893.06 L1240 $73.06 L1880 $720.64
L0460 $1,005.20 L1250 $67.98 L1900 $264.34
L0462 $1,250.31 L1260 $71.19 L1901 $17.71
L0464 $1,488.45 L1270 $72.90 L1902 $79.26
L0466 $367.24 L1280 $81.18 L1904 $444.79
L0468 $466.41 L1290 $73.96 L1906 $113.16
L0470 $643.25 L1300 $1,692.36 L1907 $563.44
L0472 $405.34 L1310 $1,803.88 L1910 $251.63
L0480 $1,735.26 L1499 BR L1920 $328.95
L0482 $1,624.01 L1500 $2,231.20 L1930 $260.15
L0484 $1,691.40 L1510 $1,297.08 L1932 $893.59
L0486 $1,774.10 L1520 $2,618.39 L1940 $509.60
L0488 $1,005.20 L1600 $121.25 L1945 $871.03
L0490 $283.26 L1610 $48.64 L1950 $732.43
L0700 $2,536.41 L1620 $130.10 L1951 $840.99
L0710 $2,104.45 L1630 $174.56 L1960 $521.55
L0810 $2,589.55 L1640 $490.10 L1970 $800.29
L0820 $2,070.60 L1650 $229.45 L1971 $469.36
L0830 $3,048.75 L1652 $356.98 L1980 $383.08
L0860 $1,146.29 L1660 $161.03 L1990 $484.15
L0861 $215.81 L1680 $1,396.21 L2000 $954.39
L0960 $67.43 L1685 $1,119.24 L2005 $3,604.61
L0970 $107.54 L1686 $858.33 L2010 $874.69
L0972 $98.48 L1690 $1,936.39 L2020 $1,098.70
L0974 $179.49 L1700 $1,572.64 L2030 $1,015.18
L0976 $167.63 L1710 $1,682.08 L2035 $173.45
L0978 $240.11 L1720 $1,456.38 L2036 $1,745.76
L0980 $16.43 L1730 $1,170.50 L2037 $1,567.24
L0982 $17.59 L1750 $185.13 L2038 $1,345.30
L0984 $65.58 L1755 $1,524.38 L2039 $2,225.45
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 MEDICAL EQUIPMENT AND SUPPLIES
HCPCS MAXIMUM HCPCS MAXIMUM HCPCS MAXIMUM
CODE FEE CODE FEE CODE FEE
L2040 $167.06 L2415 $121.64 L3208 BR
L2050 $448.24 L2425 $143.53 L3209 BR
L2060 $565.63 L2430 $143.53 L3211 BR
L2070 $131.01 L2492 $95.95 L3212 BR
L2080 $367.79 L2500 $297.55 L3213 BR
L2090 $457.03 L2510 $739.53 L3214 BR
L2106 $639.76 L2520 $433.48 L3215 BR
L2108 $1,005.36 L2525 $1,256.58 L3216 BR
L2112 $439.00 L2526 $644.50 L3217 BR
L2114 $576.98 L2530 $243.01 L3219 BR
L2116 $709.11 L2540 $397.81 L3221 BR
L2126 $1,126.74 L2550 $270.24 L3222 BR
L2128 $1,613.46 L2570 $515.61 L3224 $67.63
L2132 $759.04 L2580 $436.70 L3225 $78.66
L2134 $910.06 L2600 $193.25 L3230 BR
L2136 $1,123.51 L2610 $228.51 L3250 BR
L2180 $111.03 L2620 $317.65 L3251 BR
L2182 $103.46 L2622 $303.38 L3252 BR
L2184 $116.56 L2624 $367.54 L3253 BR
L2186 $146.95 L2627 $1,613.05 L3254 BR
L2188 $281.80 L2628 $1,576.45 L3255 BR
L2190 $86.85 L2630 $233.00 L3257 BR
L2192 $425.03 L2640 $316.21 L3260 BR
L2200 $44.74 L2650 $139.39 L3265 BR
L2210 $63.25 L2660 $175.38 L3320 BR
L2220 $79.00 L2670 $163.11 L3485 BR
L2230 $74.34 L2680 $165.00 L3649 BR
L2232 BR L2750 $86.86 L3650 $64.81
L2240 $82.91 L2755 $130.85 L3651 $60.01
L2250 $393.91 L2760 $57.16 L3652 $180.86
L2260 $188.63 L2768 $130.50 L3660 $118.51
L2265 $113.09 L2770 $58.10 L3670 $138.83
L2270 $50.54 L2780 $63.68 L3675 $159.91
L2275 $150.05 L2785 $31.83 L3677 BR
L2280 $426.08 L2795 $79.95 L3700 $79.26
L2300 $263.06 L2800 $100.36 L3701 $18.59
L2310 $115.75 L2810 $73.49 L3710 $113.83
L2320 $207.00 L2820 $81.71 L3720 $630.55
L2330 $391.58 L2830 $88.40 L3730 $988.40
L2335 $285.01 L2840 $42.54 L3740 $1,045.46
L2340 $423.23 L2850 $77.69 L3760 $455.75
L2350 $917.26 L2860 BR L3762 $98.00
L2360 $52.09 L2999 BR L3800 $202.10
L2370 $322.06 L3031 BR L3805 $319.98
L2375 $114.68 L3160 BR L3807 $227.88
L2380 $140.04 L3201 BR L3810 $66.38
L2385 $128.15 L3202 BR L3815 $55.74
L2390 $103.00 L3203 BR L3820 $122.25
L2395 $154.86 L3204 BR L3825 $60.55
L2397 $126.78 L3206 BR L3830 $94.53
L2405 $87.29 L3207 BR L3835 $106.00
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 MEDICAL EQUIPMENT AND SUPPLIES
HCPCS MAXIMUM HCPCS MAXIMUM HCPCS MAXIMUM
CODE FEE CODE FEE CODE FEE
L3840 $68.85 L4002 BR L5450 $493.43
L3845 $74.75 L4010 $707.43 L5460 $647.20
L3850 $124.55 L4020 $911.13 L5500 $1,686.56
L3855 $142.04 L4030 $490.26 L5505 $1,974.39
L3860 $189.25 L4040 $404.88 L5510 $1,732.25
L3890 BR L4045 $332.34 L5520 $1,759.51
L3900 $1,490.46 L4050 $438.46 L5530 $1,844.14
L3901 $1,727.11 L4055 $268.95 L5535 $2,041.00
L3904 $2,696.40 L4060 $307.96 L5540 $2,263.26
L3906 $368.05 L4070 $301.14 L5560 $2,176.90
L3907 $467.73 L4080 $115.28 L5570 $2,407.86
L3908 $56.06 L4090 $108.96 L5580 $2,613.75
L3909 $12.90 L4100 $103.50 L5585 $2,787.33
L3910 $430.85 L4110 $84.78 L5590 $2,816.11
L3911 $22.60 L4130 $514.66 L5595 $4,036.41
L3912 $108.03 L4205 BR L5600 $4,498.53
L3914 $104.11 L4210 BR L5610 $2,767.31
L3916 $134.90 L4350 $84.11 L5611 $1,851.50
L3917 $96.25 L4360 $260.54 L5613 $2,991.00
L3918 $81.73 L4370 $177.64 L5614 $1,693.09
L3920 $106.35 L4380 $101.06 L5616 $1,594.11
L3922 $107.44 L4386 $158.78 L5617 $560.79
L3923 $35.48 L4392 $22.74 L5618 $298.15
L3924 $120.21 L4394 $16.56 L5620 $283.74
L3926 $110.63 L4396 $162.08 L5622 $365.58
L3928 $68.46 L4398 $74.61 L5624 $364.45
L3930 $72.81 L5000 $529.11 L5626 $488.79
L3932 $57.70 L5010 $1,413.19 L5628 $507.31
L3934 $58.40 L5020 $1,986.63 L5629 $318.59
L3936 $97.46 L5050 $2,319.14 L5630 $577.89
L3938 $100.73 L5060 $3,055.60 L5631 $440.46
L3940 $121.83 L5100 $2,640.38 L5632 $252.43
L3942 $78.10 L5105 $3,730.51 L5634 $327.89
L3944 $120.58 L5150 $4,109.24 L5636 $258.58
L3946 $108.80 L5160 $4,366.66 L5637 $289.60
L3948 $58.93 L5200 $3,535.83 L5638 $487.86
L3950 $181.34 L5210 $2,611.18 L5639 $1,123.94
L3952 $180.43 L5220 $3,056.81 L5640 $670.29
L3954 $102.53 L5230 $4,069.51 L5642 $636.41
L3956 BR L5250 $5,845.73 L5643 $1,560.28
L3960 $741.69 L5270 $6,123.48 L5644 $647.23
L3962 $771.10 L5280 $6,010.25 L5645 $799.85
L3963 $1,536.13 L5301 $2,608.01 L5646 $549.26
L3980 $338.99 L5311 $3,925.33 L5647 $1,063.23
L3982 $358.13 L5321 $3,294.79 L5648 $722.21
L3984 $381.44 L5331 $5,569.59 L5649 $1,908.63
L3985 $538.16 L5341 $5,692.90 L5650 $489.39
L3986 $546.36 L5400 $1,356.96 L5651 $1,203.88
L3995 $30.11 L5410 $504.40 L5652 $437.05
L3999 BR L5420 $1,828.18 L5653 $675.36
L4000 $1,334.49 L5430 $598.80 L5654 $355.34
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 MEDICAL EQUIPMENT AND SUPPLIES
HCPCS MAXIMUM HCPCS MAXIMUM HCPCS MAXIMUM
CODE FEE CODE FEE CODE FEE
L5655 $265.90 L5785 $520.83 L6010 $1,928.26
L5656 $421.38 L5790 $740.61 L6020 $1,842.63
L5658 $438.84 L5795 $1,076.34 L6025 $8,029.01
L5661 $684.31 L5810 $488.06 L6050 $2,283.56
L5665 $676.35 L5811 $768.58 L6055 $2,794.11
L5666 $74.81 L5812 $608.11 L6100 $2,360.71
L5668 $102.46 L5814 $3,726.24 L6110 $2,556.18
L5670 $272.01 L5816 $852.54 L6120 $2,844.39
L5671 $664.84 L5818 $1,136.13 L6130 $2,973.13
L5672 $309.06 L5822 $1,707.09 L6200 $3,274.40
L5673 $750.94 L5824 $1,594.48 L6205 $3,750.00
L5676 $363.26 L5826 $3,133.33 L6250 $3,171.91
L5677 $531.69 L5828 $3,143.78 L6300 $4,205.48
L5678 $44.79 L5830 $2,081.73 L6310 $3,710.14
L5679 $625.76 L5840 $4,125.13 L6320 $2,284.19
L5680 $334.85 L5845 $1,798.34 L6350 $4,727.81
L5681 $1,319.76 L5848 $1,078.90 L6360 $3,220.83
L5682 $674.29 L5850 $128.24 L6370 $2,259.56
L5683 $1,319.76 L5855 $412.79 L6380 $1,283.33
L5684 $53.41 L5856 $24,080.26 L6382 $1,508.06
L5685 BR L5857 $8,541.01 L6384 $1,911.30
L5686 $55.20 L5910 $363.06 L6386 $457.70
L5688 $71.11 L5920 $531.89 L6388 $474.28
L5690 $99.96 L5925 $445.73 L6400 $2,521.71
L5692 $159.74 L5930 $3,373.69 L6450 $3,491.13
L5694 $181.86 L5940 $666.93 L6500 $3,769.15
L5695 $163.49 L5950 $837.86 L6550 $4,110.80
L5696 $197.99 L5960 $1,071.61 L6570 $4,475.99
L5697 $80.48 L5962 $785.65 L6580 $1,686.19
L5698 $116.25 L5964 $1,153.10 L6582 $1,433.63
L5699 $186.91 L5966 $1,494.94 L6584 $2,080.50
L5700 $3,378.34 L5968 $3,646.03 L6586 $1,925.90
L5701 $3,974.83 L5970 $210.20 L6588 $3,049.84
L5702 $5,787.01 L5972 $391.05 L6590 $2,691.18
L5704 $623.25 L5974 $254.43 L6600 $189.21
L5705 $1,023.19 L5975 $465.13 L6605 $185.66
L5706 $1,014.11 L5976 $632.36 L6610 $185.45
L5707 $1,441.56 L5978 $390.06 L6615 $191.14
L5710 $408.65 L5979 $3,049.83 L6616 $65.03
L5711 $573.93 L5980 $4,136.69 L6620 $380.46
L5712 $435.40 L5981 $3,347.78 L6623 $728.08
L5714 $477.76 L5982 $675.36 L6625 $533.16
L5716 $820.18 L5984 $669.19 L6628 $589.66
L5718 $1,217.61 L5985 $283.03 L6629 $151.23
L5722 $1,081.89 L5986 $716.13 L6630 $216.05
L5724 $1,835.25 L5987 $7,217.73 L6632 $71.84
L5726 $2,032.15 L5988 $2,004.34 L6635 $198.33
L5728 $2,538.86 L5990 $1,820.24 L6637 $390.30
L5780 $1,530.30 L5995 BR L6638 $2,509.08
L5781 $4,014.50 L5999 BR L6640 $288.23
L5782 $4,232.21 L6000 $1,726.74 L6641 $195.59
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 MEDICAL EQUIPMENT AND SUPPLIES
HCPCS MAXIMUM HCPCS MAXIMUM HCPCS MAXIMUM
CODE FEE CODE FEE CODE FEE
L6642 $267.81 L6808 $1,268.78 L7186 $10,920.18
L6645 $339.16 L6809 $374.08 L7190 $7,640.38
L6646 $3,164.46 L6810 $204.06 L7191 $10,631.40
L6647 $520.96 L6825 $1,263.40 L7260 $2,252.85
L6648 $3,263.71 L6830 $1,521.59 L7261 $4,061.84
L6650 $339.33 L6835 $1,331.00 L7266 $992.51
L6655 $90.13 L6840 $897.10 L7272 $2,078.09
L6660 $114.49 L6845 $892.54 L7274 $6,441.46
L6665 $46.18 L6850 $790.60 L7360 $228.90
L6670 $58.03 L6855 $914.95 L7362 $251.16
L6672 $169.14 L6860 $810.33 L7364 $472.21
L6675 $120.39 L6865 $339.75 L7366 $591.33
L6676 $130.48 L6867 $1,122.50 L7367 $390.61
L6680 $241.54 L6868 $262.71 L7368 $506.36
L6682 $261.00 L6870 $260.75 L7499 BR
L6684 $349.43 L6872 $1,100.06 L7500 BR
L6686 $591.81 L6873 $494.40 L7510 BR
L6687 $578.23 L6875 $941.36 L7520 BR
L6688 $558.54 L6880 $601.18 L7900 $532.88
L6689 $697.14 L6881 $4,101.85 L8000 $40.55
L6690 $730.86 L6882 $3,111.45 L8001 $125.84
L6691 $411.69 L6890 $227.34 L8002 $165.56
L6692 $567.28 L6895 $641.15 L8010 BR
L6693 $2,848.46 L6900 $1,980.45 L8015 $60.13
L6694 BR L6905 $1,572.74 L8020 $238.80
L6695 BR L6910 $1,911.81 L8030 $357.48
L6696 BR L6915 $830.18 L8035 $3,675.83
L6697 BR L6920 $7,526.83 L8039 BR
L6698 BR L6925 $8,280.63 L8040 $2,303.04
L6700 $565.24 L6930 $7,467.01 L8040-KM $2,187.88
L6705 $364.21 L6935 $8,443.36 L8040-KN $921.21
L6710 $403.31 L6940 $8,816.49 L8041 $2,775.94
L6715 $399.48 L6945 $10,232.33 L8041-KM $2,637.13
L6720 $889.90 L6950 $9,997.11 L8041-KN $1,110.36
L6725 $502.71 L6955 $11,972.91 L8042 $3,119.03
L6730 $742.91 L6960 $12,429.70 L8042-KM $2,963.06
L6735 $378.10 L6965 $14,399.20 L8042-KN $1,247.60
L6740 $499.51 L6970 $15,134.16 L8043 $3,493.31
L6745 $447.74 L6975 $17,063.03 L8043-KM $3,318.65
L6750 $416.34 L7010 $3,661.34 L8043-KN $1,397.33
L6755 $413.13 L7015 $5,818.14 L8044 $3,867.58
L6765 $466.96 L7020 $3,411.29 L8044-KM $3,674.21
L6770 $443.63 L7025 $3,442.49 L8044-KN $1,547.04
L6775 $487.03 L7030 $5,456.73 L8045 $2,465.15
L6780 $520.54 L7035 $3,525.51 L8045-KM $2,341.90
L6790 $476.39 L7040 $2,900.40 L8045-KN $986.06
L6795 $1,607.21 L7045 $1,620.31 L8046 $2,495.21
L6800 $1,161.31 L7170 $5,877.94 L8046-KM $2,370.45
L6805 $436.38 L7180 $36,225.78 L8046-KN $998.09
L6806 $1,622.70 L7181 BR L8047 $1,278.80
L6807 $1,630.86 L7185 $5,952.20 L8047-KM $1,214.85
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 MEDICAL EQUIPMENT AND SUPPLIES
HCPCS MAXIMUM HCPCS MAXIMUM
CODE FEE CODE FEE
L8047-KN $511.53 L8613 $272.16
L8048 BR L8614 $19,019.69
L8049 BR L8615 $452.51
L8100 BR L8616 $105.39
L8130 BR L8617 $92.05
L8140 BR L8618 $26.33
L8150 BR L8619 $8,165.01
L8160 BR L8620 $64.93
L8170 BR L8621 $0.63
L8180 BR L8622 $0.33
L8190 BR L8630 $337.74
L8195 BR L8631 $2,178.11
L8200 BR L8641 $350.90
L8210 BR L8642 $379.50
L8220 BR L8658 $305.95
L8230 BR L8659 $1,936.13
L8239 BR L8670 $558.01
L8300 $112.75 L8699 BR
L8310 $170.74 L9900 BR
L8320 $53.59
L8330 $49.49
L8400 $18.36
L8410 $21.23
L8415 $24.38
L8417 $75.45
L8420 $21.59
L8430 $24.49
L8435 $23.34
L8440 $42.03
L8460 $66.81
L8465 $48.90
L8470 $6.69
L8480 $9.23
L8485 $14.70
L8499 BR
L8500 $752.31
L8501 $121.10
L8505 BR
L8507 $42.05
L8509 $109.56
L8510 $253.55
L8511 $73.00
L8512 $2.16
L8513 $5.21
L8514 $94.63
L8515 $63.34
L8600 $625.99
L8603 $438.96
L8606 $219.99
L8610 $586.75
L8612 $609.54
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