CMS Announces New Prosthetic and Bracing Codes

What You Need to Know

The Coding Workgroup created the following new L-codes:

1. L1007: Scoliosis orthosis, sagittal-coronal control provided by a rigid lateral frame, extends from axilla to trochanter, includes all accessory pads, straps, and interface, custom fabricated. Fee: to be presented at a future Coding Workgroup public meeting.
2. L5657: Addition to lower extremity prosthesis, manual/automated adjustable air, fluid, gel or equal socket insert for limb volume management, any materials. Fee: to be presented at a future Coding Workgroup public meeting.
3. L6034: Partial hand, finger, and thumb prosthesis without prosthetic digit(s)/thumb, amputation at distal to metacarpal joint, including flexible or non-flexible interface, molded to patient model, for use without external power and/ or passive prosthetic digit/thumb, not including inserts described by L6692. Fee: to be addressed in the 2025 second half coding cycle.
4. L6035: Single prosthetic digit, mechanical, can include metacarpophalangeal (mcp), proximal interphalangeal (pip), and/or distal interphalangeal (dip) joint(s), with or without locking mechanism, can include flexion or extension assist, any material, attachment, initial issue or replacement. Fee: to be addressed in the 2025 second half coding cycle.
5. L6036: Prosthetic thumb, mechanical, can include metacarpophalangeal (mcp), interphalangeal (ip) joint(s), with or without locking mechanism, can include flexion or extension assist, any material, attachment, initial issue or replacement. Fee: to be addressed in the 2025 second half coding cycle.
6. L6038: Addition to single prosthetic digit or thumb, mechanical, attachment, multiaxial and/or internal/external rotation/abduction/adduction mechanism, with or without locking feature, any material. Fee: to be addressed in the 2025 second half coding cycle.
7. L6039: Passive prosthetic digit or thumb prosthesis not including hand restoration partial hand, full or partial, custom made, any material, initial or replacement, per single passive prosthetic digit or thumb. Fee:  to be addressed in the 2025 second half coding cycle.

What This Means for You

The Coding Workgroup notes that "[a]ll new coding actions will be effective October 1, 2025, unless otherwise indicated. Based on that, we expect all of the above codes to get added to the HCPCS Level II code set on that date.

However, CMS has not yet established fees for any of these new codes. This means their inclusion in any claims require you, the supplier, to select the fee submitted for reimbursement. The DME MACs will then process the claim using the Individual Consideration process, which is akin to how they process claims involving Not Otherwise Classified codes where, similarly, you select a fee for a code that does not have a pre-defined amount attached to it. This process will take effect beginning on October 1st until Medicare sets fees itself. 

We will continue to monitor any CMS updates regarding these new codes and will provide you updates as soon as new information becomes available.