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December 19, 2019

Retired: Endoskeletal Prosthetic Knee-Shin Systems – Correct Coding

Joint DME MAC and PDAC Publication

The DME MACs want to remind DMEPOS suppliers which HCPCS L-Codes are available to fully describe the prosthetic knee-shin system incorporated into the prosthetic limb delivered to the beneficiary. This article addresses the range of L-codes appropriate for an endoskeletal lower limb claim submission.

Complete Endoskeletal Lower Extremity Prostheses

The endoskeletal prosthetic lower extremity codes (Group 1) include reimbursement for a molded prosthetic socket, an endoskeletal single axis knee-shin system and a SACH foot.

Group 1

L5312 KNEE DISARTICULATION (OR THROUGH KNEE), MOLDED SOCKET, SINGLE AXIS KNEE, PYLON, 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

Endoskeletal Knee-Shin Systems

The knee-shin systems found in Group 2 are considered an upgrade to the knee-shin system included in Group 1. The beneficiary may qualify for an upgraded knee-shin system found in Group 2. Qualification is dependent on medical documentation and assigned K-Level modifier (K0-K4). The Group 2 L-codes can fully describe a complete prosthetic knee-shin system commonly referred to as a "base knee code". The use of two L-codes from Group 2 to fully describe the knee-shin system would be considered incorrect coding (unbundling).

Group 2

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
L5616 ADDITION TO LOWER EXTREMITY, ENDOSKELETAL SYSTEM, ABOVE KNEE, UNIVERSAL MULTIPLEX SYSTEM, FRICTION SWING PHASE CONTROL
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

Additional Features and Functions

The Group 3 table includes a secondary list of L-codes which describe other features and functions not found in the Group 2 "base knee codes".  These addition codes describe additional features and/or functions that do not describe a complete knee-shin system and must be used in combination with an L-code with a base knee-shin system. The use of Group 3 L-codes may also depend on the medical documentation and the assigned K-Level modifier (K0-K4).

Group 3

L5925 ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNEE, KNEE DISARTICULATION OR HIP DISARTICULATION, MANUAL LOCK
L5930 ADDITION, ENDOSKELETAL SYSTEM, HIGH ACTIVITY KNEE CONTROL FRAME
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
L5856 ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE-SHIN SYSTEM, MICROPROCESSOR CONTROL FEATURE, SWING AND STANCE PHASE, INCLUDES ELECTRONIC SENSOR(S), ANY TYPE
L5857 ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE-SHIN SYSTEM, MICROPROCESSOR CONTROL FEATURE, SWING PHASE ONLY, INCLUDES ELECTRONIC SENSOR(S), ANY TYPE
L5858 ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE SHIN SYSTEM, MICROPROCESSOR CONTROL FEATURE, STANCE PHASE ONLY, INCLUDES ELECTRONIC SENSOR(S), ANY TYPE
L5859 ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE-SHIN SYSTEM, POWERED AND PROGRAMMABLE FLEXION/EXTENSION ASSIST CONTROL, INCLUDES ANY TYPE MOTOR(S))

HCPCS code L5999 must not be used to bill for features or functions of the knee-shin system included in Group 1, Group 2 or Group 3 code lists. Use of HCPCS code L5999 in this manner will be considered incorrect coding (unbundling).

Suppliers are reminded to refer to the Lower Limb Prostheses LCD (L33787External Website) for the appropriate K-Level modifier for each HCPCS code.

PDAC’s Product Classification List should be checked for the appropriate assigned L-codes for products billed to Medicare. Suppliers should also read the DME MAC publication, HCPCS CODING RECOMMENDATIONS FROM NON-MEDICARE SOURCES - CORRECT CODINGExternal Website, for guidance with coding products not found in the Product Classification List.

For questions about correct coding, contact the PDAC Contact Center at 877-735-1326 during the hours of 9:30 a.m. to 5:00 p.m. ET, Monday through Friday, or email the PDAC by completing the DME PDAC Contact FormExternal Website located on the PDAC websiteExternal Website.

Publication History

April 9, 2020 Retired due to content incorporation into the applicable Local Coverage Determination or related Policy Article
December 19, 2019 Originally Published
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