Academy Society Leads the Way in Prosthetic Coding Improvements
Responding to Confusing Guidance
Members of the American Academy of Orthotists and Prosthetists Upper Limb Prosthetics Society (ULPS) have been spearheading an effort to upgrade and expand Medicare’s Upper Limb Prosthetic Code Set. The Academy’s ULPS was approached by the O&P Alliance to assist in responding to a DME/MAC publication issued in March 2022 titled: Upper Limb Prostheses: Correct Coding. The intent of that article was to clarify correct coding usage for upper limb prostheses. Unfortunately, though well intended, the guidance created more confusion than clarity. It was clear that a response was required to that document and the Alliance reached out to the Academy’s Society to collaborate on a reply.
Forming a Strategic Response
As a result, a subgroup was formed, led by Chris Baschuk, MPO, CPO, FAAOP(D), Chair of the Academy’s ULPS, which includes a number of other upper limb specialists. Their contributions helped to formulate a response letter that expressed some specific concerns, as well as potential solutions to those concerns. Ultimately, that letter and other communications, resulted in the DME/MACs ‘retiring’ that guidance document in March of 2023.
Expanding Access through New Codes
Since that time, a concentrated effort by the subcommittee members has been undertaken to recommend improvements to the current upper limb code set, including the addition of new codes to more adequately address partial hand prostheses. Historically, the widely varied amputation levels associated with partial hands have lacked appropriate coverage language to accommodate the prosthetic variations required to treat them. The solution for this will require new codes to be added to the existing code set. Additionally, the upper limb prosthetic code set in general, will require future edits to some existing codes and the deletion of others.
The process to rectify such existing shortcomings is already underway, with 12 specific language modification suggestions having already been submitted by the subcommittee in July 2024. A public meeting presentation followed in November of that same year as a part of the process. The HCPCS Coding Committee’s final response to those suggested modifications was received in January of 2025. Its decision was to create 7 new codes for partial hand amputations and revise 2 others to allow for inclusion of partial hand coverage. Positive steps in the right direction, with many more anticipated in the future.
Looking Ahead
A parallel benefit from this process is an increased interaction with CMS and its representatives. The DME/MACs in particular, share an interest in updating and improving the code sets as necessary, to include new technologies that have yet to be recognized by the coding system.
The latest new code applications were submitted in January of this year, requesting a partial hand base code, a partial finger base code and a custom static post code. This focused effort to improve and expand the upper limb prostheses code set, has provided a blueprint for other code set improvements such as in lower limb prostheses and upper and lower limb orthoses as well.
The O&P Alliance and the ULPS subcommittee will continue to interact with CMS to the benefit of the Medicare beneficiaries we serve, to ensure that proper coverages exist, now and in the future, for all those who need them.