RETIRED - Upper Limb Prostheses - Correct Coding - JA DME

Joint DME MAC and PDAC Publication
Posted March 31, 2022

Based on recent analysis of claims submitted to the Durable Medical Equipment Medicare Administrative Contractors (DME MACs) for upper extremity prostheses, the DME MACs and the Pricing, Data Analysis and Coding (PDAC) Contractor want to remind Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) suppliers about the correct coding for these products.

The Medicare Program Integrity Manual (CMS Pub. 100-08), Chapter 3, Sections 3.3.B and 3.6.2.4 specify that for Medicare claims, only CMS and the DME MACs have the authority to establish HCPCS Level II Coding Guidelines.

Correct HCPCS coding is a determination that the item provided to a beneficiary is billed using the appropriate HCPCS code for that item. Suppliers are required to correctly code for the item billed. An item/service is correctly coded when it meets all the coding guidelines listed in CMS HCPCS guidelines, Local Coverage Determinations (LCDs), LCD-related Policy Articles, or DME MAC articles.

Upper Extremity Prosthetic Limbs are generally categorized and described by the level of amputation and the type of power source utilized to operate the limb. There are three types of upper extremity prostheses that reference the power source:

1. Body power - Body power prostheses rely on a system of mechanisms such as cable(s)/linkage(s)/anchor point(s) and upon the coordination of contracting muscles create motion of the prosthetic limb's joints via the control mechanism.
2. External (i.e., electrical) power - External power prostheses are controlled by the use of electric signals from the body's muscles which are translated and amplified via battery power to eventual control of the prosthetic components.
3. Passive/restorative - Passive (restorative) prostheses do not have active motion within the prosthesis. Passive prostheses may allow motion of the next proximal joint; without controlling a motion within the prosthesis. Motion of the passive prosthesis is not described as external or body power.

Two of the three types of prosthetic limb systems are described by the primary mechanism or source of motive power which then causes a functional motion at a joint(s) within the prosthesis.

A prosthesis described as a hybrid- type typically combines body power and external power components into one prosthetic limb. A beneficiary may receive a hybrid limb which combines power sources such as body power and external power.

Coding Guidelines

Correct coding of an upper extremity prosthetic limb is based on the amputation level, using appropriate code(s) that are limited based on the level of amputation described in the code narrative. Upper extremity codes without a limb amputation level may be appropriate when it conforms to the coding guideline for that specific code.

INTERSCAPULAR THORACIC

Codes L6350, L6360, L6370, L6570, L6970, and L6975 are base codes which describe a prosthetic limb used for an interscapular thoracic level amputation device. The base codes are further delineated by the type of power source. The use of the base code is determined by the level of amputation and the mechanism of function.

Codes L6350 and L6570 are described as a body-powered interscapular thoracic device.

Codes L6970 and L6975 are described as an external powered interscapular thoracic device.

Codes L6360 and L6370 are described as passive/restorative interscapular thoracic devices.

SHOULDER DISARTICULATION

Codes L6300, L6310, L6320, L6550, L6960, and L6965 are considered base codes which describe a prosthetic limb used for a shoulder disarticulation level amputation device. The base codes are further delineated by the type of power source. The use of the base code is determined by the level of amputation and the mechanism of function.

Codes L6300 and L6550 are described as a body-powered shoulder disarticulation device.

Codes L6960 and L6965 are described as an external powered shoulder disarticulation device.

Codes L6310 and L6320 are described as passive/restorative shoulder disarticulation devices.

TRANS-HUMERAL (ABOVE ELBOW)

Codes L6200, L6205, L6250, L6450, L6500, L6940, L6945, L6950, and L6955 are base codes which describe a prosthetic limb used for a trans-humeral (above elbow) or elbow disarticulation devices. The base codes are further delineated by the type of power source. The use of the base code is determined by the level of amputation and the mechanism of function.

Codes L6200, L6205, L6250, L6450, and L6500 are described as body-powered trans-humeral (above elbow) or elbow disarticulation level amputation devices.

Codes L6940, L6945, L6950, and L6955 are described as an external powered trans-humeral (above elbow) or elbow disarticulation level amputation devices.

TRANS-RADIAL (BELOW ELBOW)

Codes L6100, L6110, L6120, L6130, L6400, L6930, and L6935 are base codes which describe a prosthetic limb used for a trans-radial (below elbow) device. The base codes are further delineated by the type of power source. The use of the base code is determined by the level of amputation and the mechanism of function.

Codes L6100, L6110, L6120, L6130, and L6400 are described as a body-powered trans-radial (below elbow) amputation device.

Codes L6930 and L6935 are described as an external powered trans-radial (below elbow) amputation device.

WRIST DISARTICULTION

Codes L6050, L6055, L6920, and L6925 are base codes which describe a prosthetic limb used for a wrist disarticulation device. The base codes are further delineated by the type of power source. The use of the base code is determined by the level of amputation and the mechanism of function.

Codes L6050 and L6055 are described as a body-powered wrist disarticulation amputation device.

Codes L6920 and L6925 are described as an external powered wrist disarticulation amputation device.

PARTIAL HAND

Codes L6000, L6010, L6020, and L6026 are base codes which describe a prosthetic limb used for a partial hand device. The base codes are further delineated by the type of power source. The use of the base code is determined by the level of amputation and the mechanism of function. Allowable addition codes are either amputation level-specific or have no amputation level specified.

Code L6000 (PARTIAL HAND, THUMB REMAINING) describes a base code for a cable/spring driven body-powered transcarpal /metacarpal partial hand prosthesis with the anatomical thumb still remaining. L6000 includes the standard friction wrist and control cable system. This code describes a complete terminal device, and thus the use of more than one terminal device code is considered incorrect coding.

Code L6010 (PARTIAL HAND, LITTLE AND/OR RING FINGER REMAINING) describes a base code for a cable/spring driven body-powered transcarpal /metacarpal partial hand prosthesis with the anatomical little and/or ring finger still remaining. L6010 includes the standard friction wrist and control cable system. This code fully describes a complete terminal device, and thus the use of more than one terminal device code is considered incorrect coding

Code L6020 (PARTIAL HAND, NO FINGER REMAINING) describes a base code for a cable/spring driven body-powered transcarpal /metacarpal partial hand prosthesis with no anatomical fingers remaining. L6020 includes the standard friction wrist and control cable system. This code fully describes a complete terminal device, and thus the use of more than one terminal device code is considered incorrect coding.

Code L6026 (TRANSCARPAL/METACARPAL OR PARTIAL HAND DISARTICULATION PROSTHESIS, EXTERNAL POWER, SELF-SUSPENDED, INNER SOCKET WITH REMOVABLE FOREARM SECTION, ELECTRODES AND CABLES, TWO BATTERIES, CHARGER, MYOELECTRIC CONTROL OF TERMINAL DEVICE, EXCLUDES TERMINAL DEVICE(S)) describes a base code for a transcarpal/metacarpal or a partial hand disarticulation, myoelectric-controlled prosthesis which includes all necessary components besides the terminal device.

Partial hand prostheses that utilize body powered individually articulating digits must be submitted to the DME MACs with HCPCS code L7499. Code L7499 should be used to describe the complete device, and thus the use of more than one code is considered incorrect coding not separately payable (unbundling).

SOCKET FABRICATION

Codes L7400, L7401, L7402, L7403, L7404, and L7405 are used for ultra-light or acrylic materials and may only be used when materials such as carbon fiber, fiberglass, Kevlar®, or other advanced composite lamination materials are used in the fabrication of a socket for an upper limb prosthesis. They are not used for ultralight materials used in other components of a prosthesis - e.g., shoulders, elbows, wrists or terminal devices, etc. For codes L7400, L7401, 7402, L7403, L7404 and L7405, the unit of service (UOS) is per limb.

TEST SOCKETS

Codes L6680, L6682, and L6684 describe plastic sockets to evaluate the socket fit. Test sockets are part of an intermediate fabrication process and are not a component of the final prosthesis delivered to the beneficiary. Each code describes the level of amputation for the respective test socket procedure.

SUSPENSION

Code L6686 (UPPER EXTREMITY ADDITION, SUCTION SOCKET) describes a modification to the socket using a suction valve component along with positive model rectifications specific to the suction socket design as compared to a non-suction socket design. Suction will provide a suspensory function for the prosthesis. When a suction valve is integral to another product such as L6698 the suction valve is considered not separately payable (unbundling).

Codes L6687, L6688, L6689, and L6690 describe amputation level-specific sockets fabricated with fenestrations (frame type socket) and when clinically appropriate, include inner sockets made of a more flexible material. The flexible inner socket is included with the "frame-type socket" and, billing of a flexible inner socket is considered not separately payable (unbundling).

Socket inserts described by codes L6691, L6692, L6694, L6695, L6696, or L6697, should not be equated to the flexible inner socket included with codes L6687 or L6688 and L6689 or L6690. The socket inserts used in conjunction with a suspension locking mechanism are billed with codes L6694, L6696, and L6697 as appropriate. These codes include socket inserts with a distal umbrella adapter for attaching the locking mechanism. Code L6695 is a socket insert that does not include a locking mechanism.

Codes L6696 and L6697 are for use only with the initial issue of a custom fabricated socket insert. Additional inserts (either custom fabricated or prefabricated) provided at the time of initial issue or replacement socket inserts are coded L6694 and L6695, whichever is applicable.

Body powered harness systems are required additions for the suspension and function of the body powered prosthesis. Codes L6672, L6675, L6676, and L6677 describe the specific control design of the body-powered system and fully describe a complete harness, and thus the use of more than one code is considered incorrect coding.

Code L7700 (GASKET OR SEAL, FOR USE WITH PROSTHETIC SOCKET INSERT, ANY TYPE, EACH) describes a stand-alone (i.e., not integrated into or a part of a prosthetic socket insert) sealing ring that is added to a socket insert to assist in providing or maintaining negative pressure for socket suspension. The ring creates a seal against the outer surface of the insert and against the inner wall of the socket. L7700 is not intended for use with mechanical socket suspensions such as a pin-lock system. It may be made of any suitable material. L7700 may be used with upper or lower extremity sockets. The UOS is 1 (one) item. This code is not to be used to bill for gaskets, seals, or other sealing materials that are included as part of an insert. Integrated seals are included in the code for the insert. Separate billing of integrated gaskets or seals such as L7700, is considered not separately payable (unbundling).

CABLE SYSTEMS

Cables and cable additions are appropriate with body-powered prostheses. Codes L6655 and L6660 fully describe a complete cable, and thus the use of more than one cable code is considered incorrect coding. Addition codes L6665, L6670, L6641, and L6642 are available if not described in the features or functions found in other L-codes of the prosthetic device.

SHOULDER UNITS

Body powered shoulder units are not included in the base codes identified as L6300, L6310, L6320, L6960, and L6965.

Codes L6640, L6645, L6646, L6647, L6648, and L6650 describe shoulder joints that are additions to the prosthesis for the function of the shoulder disarticulation prosthesis.

ELBOW UNITS AND ADDITIONS

Body powered elbow units are included in the base code identified as L6200, L6205, and L6250. Addition codes L6600, L6605, and L6610 describe elbow hinges for the body powered elbow disarticulation or above elbow prostheses are considered an upgrade to the prosthesis.

Additional features to the elbow unit, such as codes L6635, L6637, L6638, and L6693, are available if not described in the features or functions found in other L-codes of the prosthetic device.

Codes L7170, L7180, L7181, L7185, L7186, L7190, and L7191 describe electric powered elbow units that are additions to the base socket design. A single addition code can fully describe a complete elbow unit, and thus the use of more than one elbow unit code is considered incorrect coding.

WRIST UNITS AND ADDITIONS

Wrist unit codes L6615, L6616, L6620, L6623, L6624, L6625, L6628, L6629, and L6630 are not applicable for partial hand and distal amputations. Codes L6616 and L6630 are additions to the wrist units that are available if not described in the features or functions found in other L-codes describing the prosthetic device.

Wrist unit codes L7259 and L6621 are not applicable for partial hand and distal amputations.

Code L6621 (UPPER EXTREMITY PROSTHESIS ADDITION, FLEXION/EXTENSION WRIST WITH OR WITHOUT FRICTION, FOR USE WITH EXTERNAL POWERED TERMINAL DEVICE) describes a complete product that allows the wrist to move in a wide range of motion and incorporates a locking feature in multiple flexion and extensions positions. L6621 is utilized with an external powered terminal device.

Code L7259 (ELECTRONIC WRIST ROTATOR, ANY TYPE) describes a complete product as an electronic wrist rotator, any type.

TERMINAL DEVICES AND ADDITIONS

Codes L6703, L6704, L6708, L6709, L6713, L6714, L6706, L6707, L6721, and L6722 describe body powered terminal devices (hand or hook type) that are additions to the base prosthetic limb design. A single addition code can fully describe a complete terminal device, and thus the use of more than one terminal device code is considered incorrect coding.

Codes L6805 and L6810 are additional features to a body powered terminal device and are available if not described in the features or functions found in other L-codes describing the prosthetic device.

Codes L6880, L7007, L7008, L7009, and L7040 describe external powered terminal (hand or hook type) devices that are additions to the base prosthetic limb design. A single addition code can fully describe a complete terminal device, and thus the use of more than one terminal device code is considered incorrect coding.

Code L6880 (ELECTRIC HAND, SWITCH OR MYOLELECTRIC CONTROLLED, INDEPENDENTLY ARTICULATING DIGITS, ANY GRASP PATTERN OR COMBINATION OF GRASP PATTERNS, INCLUDES MOTOR(S)) has the following characteristics:

1. Includes all necessary components;
2. Is all-inclusive;
3. Is comprised of five (5) articulating digits and the necessary motors; and,
4. Includes all grasp patterns

The use of codes L6881 (AUTOMATIC GRASP FEATURE, ADDITION TO UPPER LIMB ELECTRIC PROSTHETIC TERMINAL DEVICE) and L6882 (MICROPROCESSOR CONTROL FEATURE, ADDITION TO UPPER LIMB PROSTHETIC TERMINAL DEVICE) are considered not separately payable (unbundling) with L6880. Billing of any additional features or functions used to describe a manufacturer's terminal device is considered not separately payable (unbundling).

Code L6715 (TERMINAL DEVICE, MULTIPLE ARTICULATING DIGIT, INCLUDES MOTOR(S), INITIAL ISSUE OR REPLACEMENT) describes multiple articulating digit(s) (fingers and/or thumb) which are used with initial use, when paired with a partial hand base, L6026. The articulating digit(s) can also be used as a "replacement" digit(s)" with the use of the RB modifier as part of a prosthetic repair.

Effective for claims with dates of service on or after January 1, 2022, the only products that may be billed using HCPCS codes L6715 and/or L6880 are those that have received mandatory code verification review and are listed on the Product Classification List (PCL) of the Pricing, Data Analysis, and Coding (PDAC) contractor website.

EXTERNAL POWERED ADDITIONS

Codes L6638, L6881, L6882, L7180, and L7181 describe additional features to an externally powered terminal device and are available if not described in the features or functions found in other L-codes describing the prosthetic device. For codes L6638, L6881, L6882, L7180, and L7181, billing of any additional features or functions used to describe a manufacturer's terminal device is considered not separately payable (unbundling).

Code L6638 (UPPER EXTREMITY ADDITION TO PROSTHESIS, ELECTRIC LOCKING FEATURE, ONLY FOR USE WITH MANUALLY POWERED ELBOW) describes an addition for an electric locking mechanism that is used with a manually powered elbow unit. The UOS is per limb.

Code L6881 (AUTOMATIC GRASP FEATURE, ADDITION TO UPPER LIMB ELECTRIC PROSTHETIC TERMINAL DEVICE) describes slip detection through special sensors built into the thumb and fingers of the prosthetic hand (terminal device) that allows the device to detect changes in the position and weight of grasped objects in anticipation of when the object will slip. The slip detection causes the hand to automatically increase the gripping force applied to the object. The UOS is per limb.

Code L6882 (MICROPROCESSOR CONTROL FEATURE, ADDITION TO UPPER LIMB PROSTHETIC TERMINAL DEVICE) describes an on-board microprocessor that automates monitoring and compensatory control functions of an external powered terminal device. Terminal devices and wrist units are susceptible to performance degradation and this product provides a function to lessen the resulting dysfunction from the user's input and functional output. This additional electronic control is separate from the electronic control described in the base codes for external power such as L6925, L6935, L6950, L6955, L6965, or L6975. The UOS is per limb.

Code L7180 (ELECTRONIC ELBOW, MICROPROCESSOR SEQUENTIAL CONTROL OF ELBOW AND TERMINAL DEVICE) describes an on-board microprocessor providing input to an external powered device one device at a time, that follows a logical sequence for functional activities. The UOS is per limb.

Code L7181 (ELECTRONIC ELBOW, MICROPROCESSOR SIMULTANEOUS CONTROL OF ELBOW AND TERMINAL DEVICE) describes an on-board microprocessor that provides simultaneous control of an external powered elbow and external powered terminal device. This simultaneous control uses two separate microprocessors located in the elbow unit. One processor provides automated adjustment for controlling the electrically powered elbow and other processor provides automated adjustment for controlling the electrically powered terminal device and electrically powered wrist unit. The UOS is per limb.

PASSIVE-RESTORATIVE DEVICES

Codes L6900, L6905, L6910, and L6915 are complete products and afford shape, protection, and water resistance for normal daily usage of the prosthesis.

IMMEDIATE POST-SURGICAL/PREPARATORY

Immediate post-surgical prosthetic codes L6380, L6382, L6384, L6386, and L6388 are complete products and no additions are allowed.

Preparatory prosthetic codes L6580, L6582, L6584, L6586, L6588, and L6590 include the complete control mechanism and socket for the preparatory prosthesis. They do not include the body-powered terminal device necessary for the functional prosthesis.

NOT OTHERWISE SPECIFIED

Code L7499 (UPPER EXTREMITY PROSTHESIS, NOT OTHERWISE SPECIFIED (NOS)), belongs to a group of codes which share the phrase "Not Otherwise Specified" (NOS) and are

commonly referred to as NOC codes, is intended to describe a unique product which is not described by a specific L-code(s). It is used to describe a complete product not included in the functions or features of another code. Therefore, the NOC code must not be used to bill for any features or functions already included in one or more L-codes. Examples (not all-inclusive) of items not to be billed with a NOC code are, equipment or supplier time used in the fabrication, modification, or delivery.

BATTERIES AND BATTERY CHARGERS

Refer to Billing of Powered L-Coded Items - Correct Coding - Revised for the correct coding of batteries and chargers related to upper extremity prostheses.

MODIFIERS

The right (RT) and left (LT) modifiers must be used with prosthesis codes. Effective for claims with dates of service on or after 3/1/2019, when the same code for prostheses, sockets, or other components for bilateral amputees are billed on the same date of service, bill each item on two separate claim lines using the RT and LT modifiers and 1 unit of service (UOS) on each claim line. Do not bill the RTLT modifier as 2 UOS on the same claim line. Claim lines billed without the RT and/or LT modifiers, or as 2 UOS with RTLT on the same claim line, will be rejected as incorrect coding.

Correct coding is an essential element for correct claim payment. The PDAC contractor maintains a variety of resources to assist suppliers in determining the appropriate code for Medicare billing. For questions about correct coding, contact the PDAC HCPCS Helpline at (877) 735-1326 during the hours of 9:30 am to 5:00 pm ET, Monday through Friday. You may also visit the PDAC website to chat with a representative or select the Contact Us button at the top of the PDAC website for email, FAX, or postal mail information.

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