Individual prosthetic component selection can be tricky, especially when faced with reduced fee schedules, lengthy administrative requirements, and patients with widely varying sizes and shapes. In recent years we have seen an increase in patients who are exceeding the maximum weight for most typical prosthetic componentry and sockets.
We work hard to provide excellent, patient-centered prosthetic care, meeting every patient’s unique clinical needs—even when those needs demand more expensive materials. For heavier patients, durable titanium and other heavy-duty components are not a luxury; they are essential to long-term mobility, safety, and comfort. Yet reimbursement schedules have not kept pace with modern component costs, creating gaps that challenge providers who are committed to doing what’s right for patients.
Our clinic, like many others, has been grappling with this gap. For guidance, we turned to colleagues across the profession and were encouraged to hear that some providers had successfully billed heavy-duty components under L-5999 (lower extremity prosthesis, not otherwise specified) and later won redeterminations with cost comparisons. We asked our regional Medicare representative for clarification only to be advised that billing this way was inappropriate. The absence of a clear explanation, especially in light of peers’ successful appeals, highlights the inconsistency and confusion surrounding current reimbursement options.
We see this as an opportunity to advocate for clarity and fairness. The former L-5995 code once served this exact purpose, but it has been retired for years. Reinstating L-5995 (or creating two comparable codes: one for socket costs and one for alignable system costs) at fee levels reflecting current material costs would resolve ambiguity for providers and ensure that patients of all sizes receive prostheses designed for their real-world demands. On average, we are seeing a cost increase of 53.9 percent for socket fabrication, as well as a cost increase of 63.08 percent for alignable system componentry.
This is not simply a financial issue. When reimbursement falls short, clinics may be forced to absorb costs or risk compromising component choices—decisions that could affect a patient’s safety, gait, or long-term mobility. Ensuring equitable reimbursement protects patient outcomes, provider sustainability, and payer integrity.
We want to engage constructively with industry partners, payers, and regulators. This platform offers an opportunity to highlight the challenge and to solicit informed and different suggestions. We ask that you contact us with any helpful information. Specifically, we are seeking information on the following:
- Industry insight: Are there advocacy efforts already underway to modernize or reinstate heavy-duty component codes? What do your facility’s cost comparisons look like?
- Coding application guidance: How was the previous cost of L-5995 calculated, so that we may replicate the application format?
- Networking support: Are there key contacts within CMS, professional associations, or supplier networks you recommend we consult to build a credible coalition for change?
We believe the O&P profession takes a step forward when it shares knowledge and works collaboratively. By recognizing this reimbursement gap and by inviting comments into the conversation, we can help form a level playing field for the future for our patients.
On behalf of the Optimus team, thank you for considering this topic. We look forward to collaborating with the broader community to advance a solution that aligns clinical excellence with responsible reimbursement.
Doug Oaks is the COO of Optimus Prosthetics, Ohio. Tara Salamone is the revenue cycle team lead. She can be contacted at tsalamone@optimusprosthetics.com.
