New Coding for Powered Knees

 What You Need to Know

During the second biannual 2024 HCPCS coding cycle, Palmetto GBA submitted a request to the HCPCS coding committee to create a new code that more accurately describes the Power Knee™. Their application pointed out that both L5828 and L5845 refer to prosthetic knees with a fluid control mechanism, however, the Power Knee™ has an electromechanical actuator. The committee approved the request and created code L5827 to replace L5828, L5845, and L5848 when billing for the Power Knee™. The long description of this code is: "Endoskeletal knee-shin system, single axis, electromechanical swing and stance phase control, with or without shock absorption and stance extension damping." CMS added this code to the April 2025 HCPCS file, and it should be used in conjunction with L5856 and L5859 when billing powered knees delivered on or after April 1, 2025. CMS also determined the fee schedule for the new code, which is equivalent to the sum of the fee schedule amounts for codes L5828, L5845, and L5848 (average value of $7,242.27). 

 What This Means for You

For any powered knee prosthetic claims billed with a date of service on or after April 1, 2025, use HCPCS codes L5827, L5856, and L5859. The PDAC verifications for Ossur's Power Knee™, WillowWood's Intuy® Knee, and Bionic M's Bio Leg® were all updated to reflect this change. Although you are now required to bill for these products with only three HCPCS codes, the total Medicare reimbursement amount has not changed because the fee schedule for L5827 is equivalent to the sum of the fee schedule amounts for the three replaced codes (L5828, L5845, and L5848). Medicare's Lower Limb Prostheses LCD was also updated to include this new code, and even though L5827 does not have any specific coverage restrictions, the coverage criteria for L5856 and L5859 remain unchanged. Furthermore, the Policy Article clarifies that L5827 is a new "base" knee code and that billing this code with addition codes L5845 and L5848 is considered unbundling.

For more information, review pages 155-157 of the HCPCS Application Summary for the 2024 second biannual coding cycle.