Notification



Notification Issue Date:



Policy Attachment


Attachment to Policy # 05.00.72f


Attachment:A

Policy #:05.00.72f

Description:HCPCS Codes

Title:Upper 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 CODES

MEDICALLY NECESSARY

L6000 Partial hand, thumb remaining

L6010 Partial hand, little and/or ring finger remaining

L6020 Partial hand, no finger remaining

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)

L6050 Wrist disarticulation, molded socket, flexible elbow hinges, triceps pad

L6055 Wrist disarticulation, molded socket with expandable interface, flexible elbow hinges, triceps pad

L6100 Below elbow, molded socket, flexible elbow hinge, triceps pad

L6110 Below elbow, molded socket (Muenster or Northwestern suspension types)

L6120 Below elbow, molded double wall split socket, step-up hinges, half cuff

L6130 Below elbow, molded double wall split socket, stump activated locking hinge, half cuff

L6200 Elbow disarticulation, molded socket, outside locking hinge, forearm

L6205 Elbow disarticulation, molded socket with expandable interface, outside locking hinges, forearm

L6250 Above elbow, molded double wall socket, internal locking elbow, forearm

L6300 Shoulder disarticulation, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearm

L6310 Shoulder disarticulation, passive restoration (complete prosthesis)

L6320 Shoulder disarticulation, passive restoration (shoulder cap only)

L6350 Interscapular thoracic, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearm

L6360 Interscapular thoracic, passive restoration (complete prosthesis)

L6370 Interscapular thoracic, passive restoration (shoulder cap only)

L6380 Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting alignment and suspension of components, and one cast change, wrist disarticulation or below elbow

L6382 Immediate postsurgical or early fitting, application of initial rigid dressing including fitting alignment and suspension of components, and one cast change, elbow disarticulation or above elbow

L6384 Immediate postsurgical or early fitting, application of initial rigid dressing including fitting alignment and suspension of components, and one cast change, shoulder disarticulation or interscapular thoracic

L6386 Immediate postsurgical or early fitting, each additional cast change and realignment

L6388 Immediate postsurgical or early fitting, application of rigid dressing only

L6400 Below elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping

L6450 Elbow disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue shaping

L6500 Above elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping

L6550 Shoulder disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue shaping

L6570 Interscapular thoracic, molded socket, endoskeletal system, including soft prosthetic tissue shaping

L6580 Preparatory, wrist disarticulation or below elbow, single wall plastic socket, friction wrist, flexible elbow hinges, figure of eight harness, humeral cuff, Bowden cable control, USMC or equal pylon, no cover, molded to patient model

L6582 Preparatory, wrist disarticulation or below elbow, single wall socket, friction wrist, flexible elbow hinges, figure of eight harness, humeral cuff, Bowden cable control, USMC or equal pylon, no cover, direct formed

L6584 Preparatory, elbow disarticulation or above elbow, single wall plastic socket, friction wrist, locking elbow, figure of eight harness, fair lead cable control, USMC or equal pylon, no cover, molded to patient model

L6586 Preparatory, elbow disarticulation or above elbow, single wall socket, friction wrist, locking elbow, figure of eight harness, fair lead cable control, USMC or equal pylon, no cover, direct formed

L6588 Preparatory, shoulder disarticulation or interscapular thoracic, single wall plastic socket, shoulder joint, locking elbow, friction wrist, chest strap, fair lead cable control, USMC or equal pylon, no cover, molded to patient model

L6590 Preparatory, shoulder disarticulation or interscapular thoracic, single wall socket, shoulder joint, locking elbow, friction wrist, chest strap, fair lead cable control, USMC or equal pylon, no cover, direct formed

L6600 Upper extremity additions, polycentric hinge, pair

L6605 Upper extremity additions, single pivot hinge, pair

L6610 Upper extremity additions, flexible metal hinge, pair

L6611 Addition to upper extremity prosthesis, external powered, additional switch, any type

L6615 Upper extremity addition, disconnect locking wrist unit

L6616 Upper extremity addition, additional disconnect insert for locking wrist unit, each

L6620 Upper extremity addition, flexion/extension wrist unit, with or without friction

L6621 Upper extremity prosthesis addition, flexion/extension wrist with or without friction, for use with external powered terminal device

L6623 Upper extremity addition, spring assisted rotational wrist unit with latch release

L6624 Upper extremity addition, flexion/extension and rotation wrist unit

L6625 Upper extremity addition, rotation wrist unit with cable lock

L6628 Upper extremity addition, quick disconnect hook adapter, Otto Bock or equal

L6629 Upper extremity addition, quick disconnect lamination collar with coupling piece, Otto Bock or equal

L6630 Upper extremity addition, stainless steel, any wrist

L6632 Upper extremity addition, latex suspension sleeve, each

L6635 Upper extremity addition, lift assist for elbow

L6637 Upper extremity addition, nudge control elbow lock

L6638 Upper extremity addition to prosthesis, electric locking feature, only for use with manually powered elbow

L6640 Upper extremity additions, shoulder abduction joint, pair

L6641 Upper extremity addition, excursion amplifier, pulley type

L6642 Upper extremity addition, excursion amplifier, lever type

L6645 Upper extremity addition, shoulder flexion-abduction joint, each

L6646 Upper extremity addition, shoulder joint, multipositional locking, flexion, adjustable abduction friction control, for use with body powered or external powered system

L6647 Upper extremity addition, shoulder lock mechanism, body powered actuator

L6648 Upper extremity addition, shoulder lock mechanism, external powered actuator

L6650 Upper extremity addition, shoulder universal joint, each

L6655 Upper extremity addition, standard control cable, extra

L6660 Upper extremity addition, heavy-duty control cable

L6665 Upper extremity addition, Teflon, or equal, cable lining

L6670 Upper extremity addition, hook to hand, cable adapter

L6672 Upper extremity addition, harness, chest or shoulder,

saddle type

L6675 Upper extremity addition, harness, (e.g., figure of eight type), single cable design

L6676 Upper extremity addition, harness, (e.g., figure of eight type), dual cable design

L6677 Upper extremity addition, harness, triple control, simultaneous operation of terminal device and elbow

L6680 Upper extremity addition, test socket, wrist disarticulation or below elbow

L6682 Upper extremity addition, test socket, elbow disarticulation or above elbow

L6684 Upper extremity addition, test socket, shoulder disarticulation or interscapular thoracic

L6686 Upper extremity addition, suction socket

L6687 Upper extremity addition, frame type socket, below elbow or wrist disarticulation

L6688 Upper extremity addition, frame type socket, above elbow or elbow disarticulation

L6689 Upper extremity addition, frame type socket, shoulder disarticulation

L6690 Upper extremity addition, frame type socket, interscapular-thoracic

L6691 Upper extremity addition, removable insert, each

L6692 Upper extremity addition, silicone gel insert or equal, each

L6693 Upper extremity addition, locking elbow, forearm counterbalance

L6694 Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, for use with locking mechanism

L6695 Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, not for use with locking mechanism

L6696 Addition to upper extremity prosthesis, below elbow/above elbow, 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 L6694 or L6695)

L6697 Addition to upper extremity prosthesis, below elbow/above elbow, 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 L6694 or L6695)

L6698 Addition to upper extremity prosthesis, below elbow/above elbow, lock mechanism, excludes socket insert

L6703 Terminal device, passive hand/mitt, any material, any size

L6706 Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined

L6707 Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined

L6708 Terminal device, hand, mechanical, voluntary opening, any material, any size

L6709 Terminal device, hand, mechanical, voluntary closing, any material, any size

L6711 Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined, pediatric

L6712 Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined, pediatric

L6713 Terminal device, hand, mechanical, voluntary opening, any material, any size, pediatric

L6714 Terminal device, hand, mechanical, voluntary closing, any material, any size, pediatric

L6721 Terminal device, hook or hand, heavy-duty, mechanical, voluntary opening, any material, any size, lined or unlined

L6722 Terminal device, hook or hand, heavy-duty, mechanical, voluntary closing, any material, any size, lined or unlined

L6805 Addition to terminal device, modifier wrist unit

L6810 Addition to terminal device, precision pinch device

L6881 Automatic grasp feature, addition to upper limb electric prosthetic terminal device

L6882 Microprocessor control feature, addition to upper limb prosthetic terminal device

L6883 Replacement socket, below elbow/wrist disarticulation, molded to patient model, for use with or without external power

L6884 Replacement socket, above elbow/elbow disarticulation, molded to patient model, for use with or without external power

L6885 Replacement socket, shoulder disarticulation/interscapular thoracic, molded to patient model, for use with or without external power

L6890 Addition to upper extremity prosthesis, glove for terminal device, any material, prefabricated, includes fitting and adjustment

L6895 Addition to upper extremity prosthesis, glove for terminal device, any material, custom fabricated

L6900 Hand restoration (casts, shading and measurements included), partial hand, with glove, thumb or one finger remaining

L6905 Hand restoration (casts, shading and measurements included), partial hand, with glove, multiple fingers remaining

L6910 Hand restoration (casts, shading and measurements included), partial hand, with glove, no fingers remaining

L6915 Hand restoration (shading and measurements included), replacement glove for above

L6920 Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal switch, cables, 2 batteries and 1 charger, switch control of terminal device

L6925 Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal electrodes, cables, 2 batteries and one charger, myoelectronic control of terminal device

L6930 Below elbow, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal switch, cables, 2 batteries and one charger, switch control of terminal device

L6935 Below elbow, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal electrodes, cables, 2 batteries and one charger, myoelectronic control of terminal device

L6940 Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, Otto Bock or equal switch, cables, 2 batteries and one charger, switch control of terminal device

L6945 Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, Otto Bock or equal electrodes, cables, 2 batteries and one charger, myoelectronic control of terminal device

L6950 Above elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, Otto Bock or equal switch, cables, 2 batteries and one charger, switch control of terminal device

L6955 Above elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, Otto Bock or equal electrodes, cables, 2 batteries and one charger, myoelectronic control of terminal device

L6960 Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal switch, cables, 2 batteries and one charger, switch control of terminal device

L6965 Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal electrodes, cables, 2 batteries and one charger, myoelectronic control of terminal device

L6970 Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal switch, cables, 2 batteries and one charger, switch control of terminal device

L6975 Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal electrodes, cables, 2 batteries and one charger, myoelectronic control of terminal device

L7007 Electric hand, switch or myoelectric controlled, adult

L7008 Electric hand, switch or myoelectric, controlled, pediatric

L7009 Electric hook, switch or myoelectric controlled, adult

L7040 Prehensile actuator, switch controlled

L7045 Electric hook, switch or myoelectric controlled, pediatric

L7170 Electronic elbow, Hosmer or equal, switch controlled

L7180 Electronic elbow, microprocessor sequential control of elbow and terminal device

L7181 Electronic elbow, microprocessor simultaneous control of elbow and terminal device

L7185 Electronic elbow, adolescent, Variety Village or equal, switch controlled

L7186 Electronic elbow, child, Variety Village or equal, switch controlled

L7190 Electronic elbow, adolescent, Variety Village or equal, myoelectronically controlled

L7191 Electronic elbow, child, Variety Village or equal, myoelectronically controlled

L7259 Electronic wrist rotator, any type

L7360 Six volt battery, each

L7362 Battery charger, 6 volt, each

L7364 Twelve volt battery, each

L7366 Battery charger, twelve volt, each

L7367 Lithium ion battery, rechargeable, replacement

L7400 Addition to upper extremity prosthesis, below elbow/wrist disarticulation, ultralight material (titanium, carbon fiber or equal)

L7401 Addition to upper extremity prosthesis, above elbow disarticulation, ultralight material (titanium, carbon fiber or equal)

L7402 Addition to upper extremity prosthesis, shoulder disarticulation/interscapular thoracic, ultralight material (titanium, carbon fiber or equal)

L7403 Addition to upper extremity prosthesis, below elbow/wrist disarticulation, acrylic material

L7404 Addition to upper extremity prosthesis, above elbow disarticulation, acrylic material

L7405 Addition to upper extremity prosthesis, shoulder disarticulation/interscapular thoracic, acrylic material

L7499 Upper extremity prosthesis, not otherwise specified

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

L8415 Prosthetic sheath, upper limb, each

L8435 Prosthetic sock, multiple ply, upper limb, each

L8465 Prosthetic shrinker, upper limb, each

L8485 Prosthetic sock, single ply, fitting, upper limb, each

NOT MEDICALLY NECESSARY

L6704 Terminal device, sport/recreational/work attachment, any material, any size

EXPERIMENTAL/INVESTIGATIONAL

L6715 Terminal device, multiple articulating digit, includes motor(s), initial issue or replacement

L6880 Electric hand, switch or myolelectric controlled, independently articulating digits, any grasp pattern or combination of grasp patterns, includes motor(s)

Version Effective Date: 04/15/2019
Version Issued Date: 04/15/2019
Version Reissued Date: N/A

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