Notification



Notification Issue Date:



Policy Attachment



Attachment to Policy # 05.00.59j


Attachment:A

Policy #:05.00.59j

Description:HCPCS Level II Code Number(s) and Narrative(s)

Title:Lower Limb Prostheses


Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.



HCPCS Level II Code Number(s) and Narrative(s)

L3250 Orthopedic footwear, custom molded shoe, removable inner mold, prosthetic shoe, each

L5000 Partial foot, shoe insert with longitudinal arch, toe filler

L5010 Partial foot, molded socket, ankle height, with toe filler

L5020 Partial foot, molded socket, tibial tubercle height, with toe filler

L5050 Ankle, Symes, molded socket, SACH foot

L5060 Ankle, Symes, metal frame, molded leather socket, articulated ankle/foot

L5100 Below knee, molded socket, shin, SACH foot

L5105 Below knee, plastic socket, joints and thigh lacer, SACH foot

L5150 Knee disarticulation (or through knee), molded socket, external knee joints, shin, SACH foot

L5160 Knee disarticulation (or through knee), molded socket, bent knee configuration, external knee joints, shin, SACH foot

L5200 Above knee, molded socket, single axis constant friction knee, shin, SACH foot

L5210 Above knee, short prosthesis, no knee joint (stubbies), with foot blocks, no ankle joints, each

L5220 Above knee, short prosthesis, no knee joint (stubbies), with articulated ankle/foot, dynamically aligned, each

L5230 Above knee, for proximal femoral focal deficiency, constant friction knee, shin, SACH foot

L5250 Hip disarticulation, Canadian type; molded socket, hip joint, single axis constant friction knee, shin, SACH foot

L5270 Hip disarticulation, tilt table type; molded socket, locking hip joint, single axis constant friction knee, shin, SACH foot

L5280 Hemipelvectomy, Canadian type; molded socket, hip joint, single axis constant friction knee, shin, SACH foot

L5301 Below knee, molded socket, shin, SACH foot, endoskeletal system

L5312 Knee disarticulation (or through knee), molded socket, single axis knee, pyson, sach foot, endoskeletal system

L5321 Above knee, molded socket, open end, SACH foot, endoskeletal system, single axis knee

L5331 Hip disarticulation, Canadian type, molded socket, endoskeletal system, hip joint, single axis knee, SACH foot

L5341 Hemipelvectomy, Canadian type, molded socket, endoskeletal system, hip joint, single axis knee, SACH foot

L5400 Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting, alignment, suspension, and one cast change, below knee

L5410 Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension, below knee, each additional cast change and realignment

L5420 Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension and one cast change AK or knee disarticulation

L5430 Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension, AK or knee disarticulation, each additional cast change and realignment

L5450 Immediate postsurgical or early fitting, application of nonweight bearing rigid dressing, below knee

L5460 Immediate postsurgical or early fitting, application of nonweight bearing rigid dressing, above knee

L5500 Initial, below knee PTB type socket, nonalignable system, pylon, no cover, SACH foot, plaster socket, direct formed

L5505 Initial, above knee - knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, SACH foot plaster socket, direct formed

L5510 Preparatory, below knee PTB type socket, nonalignable system, pylon, no cover, SACH foot, plaster socket, molded to model

L5520 Preparatory, below knee PTB type socket, nonalignable system, pylon, no cover, SACH foot, thermoplastic or equal, direct formed

L5530 Preparatory, below knee PTB type socket, nonalignable system, pylon, no cover, SACH foot, thermoplastic or equal, molded to model

L5535 Preparatory, below knee PTB type socket, nonalignable system, pylon, no cover, SACH foot, prefabricated, adjustable open end socket

L5540 Preparatory, below knee PTB type socket, nonalignable system, pylon, no cover, SACH foot, laminated socket, molded to model

L5560 Preparatory, above knee - knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, SACH foot, plaster socket, molded to model

L5570 Preparatory, above knee - knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, SACH foot, thermoplastic or equal, direct formed

L5580 Preparatory, above knee - knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, SACH foot, thermoplastic or equal, molded to model

L5585 Preparatory, above knee - knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, SACH foot, prefabricated adjustable open end socket

L5590 Preparatory, above knee - knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, SACH foot, laminated socket, molded to model

L5595 Preparatory, hip disarticulation - hemipelvectomy, pylon, no cover, SACH foot, thermoplastic or equal, molded to patient model

L5600 Preparatory, hip disarticulation - hemipelvectomy, pylon, no cover, SACH foot, laminated socket, molded to patient model

L5610 Addition to lower extremity, endoskeletal system, above knee, hydracadence system

L5611 Addition to lower extremity, endoskeletal system, above knee - knee disarticulation, 4-bar linkage, with friction swing phase control

L5613 Addition to lower extremity, endoskeletal system, above knee - knee disarticulation, 4-bar linkage, with hydraulic swing phase control

L5614 Addition to lower extremity, endoskeletal system, above knee - knee disarticulation, 4-bar linkage, with pneumatic swing phase control

L5616 Addition to lower extremity, endoskeletal system, above knee, universal multiplex system, friction swing phase control

L5617 Addition to lower extremity, quick change self-aligning unit, above or below knee, each

L5618 Addition to lower extremity, test socket, Symes

L5620 Addition to lower extremity, test socket, below knee

L5622 Addition to lower extremity, test socket, knee disarticulation

L5624 Addition to lower extremity, test socket, above knee

L5626 Addition to lower extremity, test socket, hip disarticulation

L5628 Addition to lower extremity, test socket, hemipelvectomy

L5629 Addition to lower extremity, below knee, acrylic socket

L5630 Addition to lower extremity, Symes type, expandable wall socket

L5631 Addition to lower extremity, above knee or knee disarticulation, acrylic socket

L5632 Addition to lower extremity, Symes type, PTB brim design socket

L5634 Addition to lower extremity, Symes type, posterior opening (Canadian) socket

L5636 Addition to lower extremity, Symes type, medial opening socket

L5637 Addition to lower extremity, below knee, total contact

L5638 Addition to lower extremity, below knee, leather socket

L5639 Addition to lower extremity, below knee, wood socket

L5640 Addition to lower extremity, knee disarticulation, leather socket

L5642 Addition to lower extremity, above knee, leather socket

L5643 Addition to lower extremity, hip disarticulation, flexible inner socket, external frame

L5644 Addition to lower extremity, above knee, wood socket

L5645 Addition to lower extremity, below knee, flexible inner socket, external frame

L5646 Addition to lower extremity, below knee, air, fluid, gel or equal, cushion socket

L5647 Addition to lower extremity, below knee, suction socket

L5648 Addition to lower extremity, above knee, air, fluid, gel or equal, cushion socket

L5649 Addition to lower extremity, ischial containment/narrow M-L socket

L5650 Addition to lower extremity, total contact, above knee or knee disarticulation socket

L5651 Addition to lower extremity, above knee, flexible inner socket, external frame

L5652 Addition to lower extremity, suction suspension, above knee or knee disarticulation socket

L5653 Addition to lower extremity, knee disarticulation, expandable wall socket

L5654 Addition to lower extremity, socket insert, Symes (Kemblo, Pelite, Aliplast, Plastazote or equal)

L5655 Addition to lower extremity, socket insert, below knee (Kemblo, Pelite, Aliplast, Plastazote or equal)

L5656 Addition to lower extremity, socket insert, knee disarticulation (Kemblo, Pelite, Aliplast, Plastazote or equal)

L5658 Addition to lower extremity, socket insert, above knee (Kemblo, Pelite, Aliplast, Plastazote or equal)

L5661 Addition to lower extremity, socket insert, multidurometer, Symes

L5665 Addition to lower extremity, socket insert, multidurometer, below knee

L5666 Addition to lower extremity, below knee, cuff suspension

L5668 Addition to lower extremity, below knee, molded distal cushion

L5670 Addition to lower extremity, below knee, molded supracondylar suspension (PTS or similar)

L5671 Addition to lower extremity, below knee/above knee suspension locking mechanism (shuttle, lanyard or equal), excludes socket insert

L5672 Addition to lower extremity, below knee, removable medial brim suspension

L5673 Addition to lower extremity, below knee/above knee, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, for use with locking mechanism

L5676 Addition to lower extremity, below knee, knee joints, single axis, pair

L5677 Addition to lower extremity, below knee, knee joints, polycentric, pair

L5678 Addition to lower extremity, below knee joint covers, pair

L5679 Addition to lower extremity, below knee/above knee, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, not for use with locking mechanism

L5680 Addition to lower extremity, below knee, thigh lacer, nonmolded

L5681 Addition to lower extremity, below knee/above knee, custom fabricated socket insert for congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only (for other than initial, use code L5673 or L5679)

L5682 Addition to lower extremity, below knee, thigh lacer, gluteal/ischial, molded

L5683 Addition to lower extremity, below knee/above knee, custom fabricated socket insert for other than congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only (for other than initial, use code L5673 or L5679)

L5684 Addition to lower extremity, below knee, fork strap

L5685 Addition to lower extremity prosthesis, below knee, suspension/sealing sleeve, with or without valve, any material, each

L5686 Addition to lower extremity, below knee, back check (extension control)

L5688 Addition to lower extremity, below knee, waist belt, webbing

L5690 Addition to lower extremity, below knee, waist belt, padded and lined

L5692 Addition to lower extremity, above knee, pelvic control belt, light

L5694 Addition to lower extremity, above knee, pelvic control belt, padded and lined

L5695 Addition to lower extremity, above knee, pelvic control, sleeve suspension, neoprene or equal, each

L5696 Addition to lower extremity, above knee or knee disarticulation, pelvic joint

L5697 Addition to lower extremity, above knee or knee disarticulation, pelvic band

L5698 Addition to lower extremity, above knee or knee disarticulation, Silesian bandage

L5699 All lower extremity prostheses, shoulder harness

L5700 Replacement, socket, below knee, molded to patient model

L5701 Replacement, socket, above knee/knee disarticulation, including attachment plate, molded to patient model

L5702 Replacement, socket, hip disarticulation, including hip joint, molded to patient model

L5703 Ankle, Symes, molded to patient model, socket without solid ankle cushion heel (SACH) foot, replacement only

L5704 Custom shaped protective cover, below knee

L5705 Custom shaped protective cover, above knee

L5706 Custom shaped protective cover, knee disarticulation

L5707 Custom shaped protective cover, hip disarticulation

L5710 Addition, exoskeletal knee-shin system, single axis, manual lock

L5711 Addition, exoskeletal knee-shin system, single axis, manual lock, ultra-light material

L5712 Addition, exoskeletal knee-shin system, single axis, friction swing and stance phase control (safety knee)

L5714 Addition, exoskeletal knee-shin system, single axis, variable friction swing phase control

L5716 Addition, exoskeletal knee-shin system, polycentric, mechanical stance phase lock

L5718 Addition, exoskeletal knee-shin system, polycentric, friction swing and stance phase control

L5722 Addition, exoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase control

L5724 Addition, exoskeletal knee-shin system, single axis, fluid swing phase control

L5726 Addition, exoskeletal knee-shin system, single axis, external joints, fluid swing phase control

L5728 Addition, exoskeletal knee-shin system, single axis, fluid swing and stance phase control

L5780 Addition, exoskeletal knee-shin system, single axis, pneumatic/hydra pneumatic swing phase control

L5781 Addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system

L5782 Addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system, heavy duty

L5785 Addition, exoskeletal system, below knee, ultra-light material (titanium, carbon fiber or equal)

L5790 Addition, exoskeletal system, above knee, ultra-light material (titanium, carbon fiber or equal)

L5795 Addition, exoskeletal system, hip disarticulation, ultra-light material (titanium, carbon fiber or equal)

L5810 Addition, endoskeletal knee-shin system, single axis, manual lock

L5811 Addition, endoskeletal knee-shin system, single axis, manual lock, ultra-light material

L5812 Addition, endoskeletal knee-shin system, single axis, friction swing and stance phase control (safety knee)

L5814 Addition, endoskeletal knee-shin system, polycentric, hydraulic swing phase control, mechanical stance phase lock

L5816 Addition, endoskeletal knee-shin system, polycentric, mechanical stance phase lock

L5818 Addition, endoskeletal knee-shin system, polycentric, friction swing and stance phase control

L5822 Addition, endoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase control

L5824 Addition, endoskeletal knee-shin system, single axis, fluid swing phase control

L5826 Addition, endoskeletal knee-shin system, single axis, hydraulic swing phase control, with miniature high activity frame

L5828 Addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control

L5830 Addition, endoskeletal knee-shin system, single axis, pneumatic/swing phase control

L5840 Addition, endoskeletal knee-shin system, 4-bar linkage or multiaxial, pneumatic swing phase control

L5845 Addition, endoskeletal knee-shin system, stance flexion feature, adjustable

L5848 Addition to endoskeletal knee-shin system, fluid stance extension, dampening feature, with or without adjustability

L5850 Addition, endoskeletal system, above knee or hip disarticulation, knee extension assist

L5855 Addition, endoskeletal system, hip disarticulation, mechanical hip extension assist

L5910 Addition, endoskeletal system, below knee, alignable system

L5920 Addition, endoskeletal system, above knee or hip disarticulation, alignable system

L5925 Addition, endoskeletal system, above knee, knee disarticulation or hip disarticulation, manual lock

L5930 Addition, endoskeletal system, high activity knee control frame

L5940 Addition, endoskeletal system, below knee, ultra-light material (titanium, carbon fiber or equal)

L5950 Addition, endoskeletal system, above knee, ultra-light material (titanium, carbon fiber or equal)

L5960 Addition, endoskeletal system, hip disarticulation, ultra-light material (titanium, carbon fiber or equal)

L5961 Addition, endoskeletal system, polycentric hip joint, pneumatic or hydraulic control, rotation control, with or without flexion and/or extension control

L5962 Addition, endoskeletal system, below knee, flexible protective outer surface covering system

L5964 Addition, endoskeletal system, above knee, flexible protective outer surface covering system

L5966 Addition, endoskeletal system, hip disarticulation, flexible protective outer surface covering system

L5968 Addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature

L5970 All lower extremity prostheses, foot, external keel, SACH foot

L5971 All lower extremity prosthesis, solid ankle cushion heel (SACH) foot, replacement only

L5972 All lower extremity prostheses, flexible keel foot (SAFE, STEN, Bock Dynamic or equal)

L5974 All lower extremity prostheses, foot, single axis ankle/foot

L5975 All lower extremity prosthesis, combination single axis ankle and flexible keel foot

L5976 All lower extremity prostheses, energy storing foot (Seattle Carbon Copy II or equal)

L5978 All lower extremity prostheses, foot, multiaxial ankle/foot

L5979 All lower extremity prostheses, multiaxial ankle, dynamic response foot, one piece system

L5980 All lower extremity prostheses, flex-foot system

L5981 All lower extremity prostheses, flex-walk system or equal

L5982 All exoskeletal lower extremity prostheses, axial rotation unit

L5984 All endoskeletal lower extremity prosthesis, axial rotation unit, with or without adjustability

L5985 All endoskeletal lower extremity prostheses, dynamic prosthetic pylon

L5986 All lower extremity prostheses, multiaxial rotation unit (MCP or equal)

L5987 All lower extremity prosthesis, shank foot system with vertical loading pylon

L5988 Addition to lower limb prosthesis, vertical shock reducing pylon feature

L5990 Addition to lower extremity prosthesis, user adjustable heel height

L5999 Lower extremity prosthesis, not otherwise specified

L7367 Lithium ion battery, rechargeable, replacement

L7368 Lithium ion battery charger, replacement only

L7510 Repair of prosthetic device, repair or replace minor parts

L7520 Repair prosthetic device, labor component, per 15 minutes

L7600 Prosthetic donning sleeve, any material, each

L7700 Gasket or seal, for use with prosthetic socket insert, any type, each

L8400 Prosthetic sheath, below knee, each

L8410 Prosthetic sheath, above knee, each

L8417 Prosthetic sheath/sock, including a gel cushion layer, below knee or above knee, each

L8420 Prosthetic sock, multiple ply, below knee, each

L8430 Prosthetic sock, multiple ply, above knee, each

L8440 Prosthetic shrinker, below knee, each

L8460 Prosthetic shrinker, above knee, each

L8470 Prosthetic sock, single ply, fitting, below knee, each

L8480 Prosthetic sock, single ply, fitting, above knee, each



Version Effective Date: 06/17/2019
Version Issued Date: 06/17/2019
Version Reissued Date: 04/09/2020



2017 AmeriHealth.