6/21/2018: Article retired. Please refer to Durable Medical Equipment Coding System (DMECS) for coding recommendations.
Joint DME MAC Publication
This article revises the Correct Coding article published March 10, 2016, to provide specific HCPCS codes for Medicare billing. HCPCS code L5999 (LOWER EXTREMITY PROSTHESIS, NOT OTHERWISE SPECIFIED), which is currently used for billing purposes, is being replaced with specific L-codes. The revised coding requirements are effective for claims with dates of service on or after June 1, 2016.
The Socket-less Socket™ (Martin Bionics) is an open frame above-knee socket design. This product uses a combination of fixed and floating struts attached to a base and connected by adjustable straps to form the structure of the socket. The product is supplied as a prefabricated kit and fit directly to the beneficiary.
Existing HCPCS L-codes used for above-knee lower limb prosthesis sockets describe items which enclose the residual limb to provide the stability, proprioception, and suspension necessary for the effective use of an artificial limb. Although the Socket-less Socket™ is different in design from traditional sockets described by the existing L-codes, we have determined that this product is an effective alternative, and that existing HCPCS codes appropriately describe the product. The correct combination of codes to bill Medicare for this item are:
Base code:
If this product is included as part of a complete prosthesis, the base socket is included as part of the prosthesis base code. Chose the appropriate base code depending upon the type provided.
L5321 – SOCKET ABOVE KNEE, MOLDED SOCKET, OPEN END, SACH FOOT, ENDOSKELETAL SYSTEM, SINGLE AXIS KNEE.
L5590 – PREPARATORY, ABOVE KNEE – KNEE DISARTICULATION ISCHIAL LEVEL SOCKET, NON-ALIGNABLE SYSTEM, PYLON NO COVER, SACH FOOT, LAMINATED SOCKET, MOLDED TO MODEL
The addition codes discussed below (L5631, L5649, L5950) and choice of suspension must be included on the same claim for the complete prosthesis i.e., the claim that includes one of the above codes.
If this product is provided as a replacement to an existing socket, in addition to the add-on codes below (L5631, L5649, L5950) and choice of suspension, for the base code, use:
L5701 – REPLACEMENT, SOCKET, ABOVE KNEE/KNEE DISARTICULATION, INCLUDING ATTACHMENT PLATE, MOLDED TO PATIENT MODEL.
Do not use L5321 or L5590 for billing a replacement socket for an existing prosthesis.
Addition codes:
Use these codes on all claims in addition to the base code:
L5631 – ADDITION TO LOWER EXTREMITY, ABOVE KNEE OR KNEE DISARTICULATION, ACRYLIC SOCKET.
L5649 – ADDITION TO LOWER EXTREMITY, ISCHIAL CONTAINMENT/NARROW M-L SOCKET.
L5950 – ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNEE, ULTRALIGHT MATERIAL (TITANIUM, CARBON FIBER OR EQUAL).
The combination of base and addition codes listed above include all the features and functions of the Socket-less Socket™. HCPCS code L5999 must not be used to bill for features or functions included in the socket. Use of L5999 in this manner will be rejected as incorrect coding (unbundling).
Suspension:
HCPCS add-on L-codes used to describe the type of suspension incorporated into the socket may be added to the claim. Use of more than one type of suspension is considered incorrect billing (same/similar item).
Other Additions:
HCPCS codes describing features that may not be necessary on all sockets may only be used when the feature is provided for the individual beneficiary. Some examples of features that are not automatically included in every socket or for all beneficiaries are (not all-inclusive):
L5651 – ADDITION TO LOWER EXTREMITY, ABOVE KNEE, FLEXIBLE INNER SOCKET, EXTERNAL FRAME
L5920 – ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNEE OR HIP DISARTICULATION, ALIGNABLE SYSTEM
NOTE: The Socket-less Socket™ includes an option to use a combination of "flower distal cup technology with special NASA-based mesh fabric" as a functional alternative to a flexible inner socket. This combination of materials is not considered to be a flexible inner socket and must not be coded using L5651. L5999 must not be used for these items as payment for these materials is considered included in the payment for the base code. Separate claims for these materials will be denied as incorrect coding (unbundling).
The prosthetic record must include specific, detailed information justifying the need for each additional feature.
Test sockets (L5624 – ADDITION TO LOWER EXTREMITY, TEST SOCKET, ABOVE KNEE) are not necessary for the production of this socket design. Claims for L5624 in conjunction with this socket design are considered incorrect billing.
Refer to the Lower Limb Prosthesis Local Coverage Determination and related Policy Article for additional information on coverage, coding and documentation for artificial limbs.
For questions about correct coding, contact the Pricing, Data Analysis, and Coding contractor (PDAC) at (877) 735-1326 during the hours of 8:30 a.m. to 4:00 p.m. CT, Monday through Friday, or e-mail the PDAC by completing the DME PDAC Contact Form.
Published by Noridian as the PDAC, June 2016. Republished by Palmetto GBA as the PDAC, February 2019. Please note that links in this document were accurate at the time of original publication and may change over time and are no longer active.