Medicare Announces New Code Preliminary Decisions
What You Need to Know
Earlier this week, Medicare's HCPCS Coding Workgroup released its preliminary decisions for the first half 2025 Coding Cycle. The Workgroup has proposed creating a total of 5 new prosthetic codes. Four describe upper extremity prosthetics and the fifth discontinues/replaces a previously created code.
1.The Four Upper Extremity Codes
a. Single digit, per articulation, mechanical, metacarpophalangeal (mcp), proximal interphalangeal (pip), and/or distal interphalangeal (dip) joint(s), with or without locking mechanism, any material, attachment, initial issue or replacement
b. Thumb, per articulation, mechanical, metacarpophalangeal (mcp) and interphalangeal (ip) joint, with or without locking mechanism, any material, attachment, initial issue or replacement
c. Addition to digit or thumb, per articulation, attachment, multiaxial and/or internal/external rotation/abduction/adduction mechanism, with or without locking feature, any material
d. Passive digit or thumb, full or partial, custom made, any material, initial or replacement, per single digit or thumb
2.The Elimination/Replacement of L5783/L7406
a. L5783 and L7406 describe a residual limb volume management system for lower and upper limb prostheses, respectively. They became effective in 2024.
b. In response to a request to create a new add-on code describing the lamination process for this kind of system when used in a custom-fabricated orthosis, the Coding Workgroup proposed eliminating L5783 and L7406 and replacing them with a new code that (i) applies to both prostheses and orthoses utilizing these volume management systems and (ii) includes lamination as part of that code. The new code will have the same fee schedule amount as L5783/L7406.
The HCPCS Coding Workgroup did not create any new codes describing bracing products in this coding cycle.
What This Means for You
The first three of the four new upper extremity codes listed above will likely require clarification from CMS before they get finalized. In particular, the meaning of "per articulation" in those codes is unclear and will require explanation to ensure appropriate billing.
CMS has stated that the fee schedule amounts for all four of these upper extremity codes will be determined at a future HCPCS public meeting. Based on the HCPCS Coding Workgroup's written policies, the earliest we would see defined fee schedule amounts taking effect for these codes would be October of this year, though it's possible this delay could extend to April 2026 as there's no requirement that fee schedules be set within a specific time frame after code creation. We do expect, however, that these four new codes will be added to the DMEPOS fee schedule in October of this year. Pending the establishment of a fee schedule amount, these claims will be reviewed on an "individual consideration" basis and suppliers would submit claims at a fee amount that they themselves set. The DME MACs will then process those claims and pay amounts that they deem appropriate. (Seven new upper extremity codes created in 2024 also currently lack a defined fee schedule amount and are subject to the same "individual consideration" process that the four codes from this coding cycle will be once they are finalized.)
L5783 still remains a valid code at this time as the HCPCS Coding Workgroup's decision is a preliminary one. However, if the Workgroup does finalize it then we would expect L5783 to be discontinued effective October 1st and replaced with the new code at the same fee schedule amount as L5783.
We will provide an update once the Coding Workgroup issues its final decisions for the first half 2025 coding cycle.