CMS Announces New Orthotic and Prosthetic Codes and Payment Amounts
CMS Announces New Orthotic and Prosthetic Codes and Payment Amounts
What You Need to Know
CMS's HCPCS Coding Workgroup recently published its final coding and payment determinations for the 2025 Second Biannual Coding Cycle. Along with establishing payment amounts for 12 partial hand prosthetic codes (as discussed in our previous R&R post), they also established payment for a lower extremity prosthetic volume management socket insert and created new HCPCS codes for a replacement prosthetic foot shell and a microprocessor orthotic ankle. These three updates are summarized below and will be effective April 1, 2026.
HCPCS Code -- Average Medicare Reimbursement -- Description
- L5657 -- $306.30 -- Addition to lower extremity prosthesis, manual/automated adjustable air, fluid, gel or equal socket insert for limb volume management, any materials
- L5992 -- $127.11 -- All lower extremity prosthesis, foot shell for modular foot/non-solid ankle cushion heel (SACH) replacement only
- L2221 -- $1,889.92 -- Addition to lower extremity orthosis, ankle system, microprocessor-controlled feature plantarflexion and/or dorsiflexion, includes power source
What This Means for You
Similar to the new upper extremity payment determinations, all the finalized payment rates discussed above present significant challenges for orthotic and prosthetic providers. While the HCPCS code set is now expanded to better represent O&P components/supplies, the payment determinations do not cover the cost of most devices available, let alone reflect the true clinical value and complexity of providing orthotic and prosthetic care. Medicare rates take effect April 1, and we anticipate other payers will be updating their fee schedules shortly after. As those updates roll out, be sure to review your contracts and verify that these codes are recognized and reimbursable by your payers.
For more information, review the complete 2025 Second Biannual HCPCPS Final Coding Determinations.