Medicare Considers Improvements to Upper-limb Prosthetic Access

Over the past two years, several national organizations representing the O&P profession have worked collaboratively to try to improve access to upper-limb prosthetic care. Although this effort is clearly a work in progress, there are signs that this collective advocacy is beginning to yield progress. The O&P Alliance, comprised of five national organizations, NAAOP, AOPA, ABC, BOC, and the Academy, have worked in conjunction with the Academy’s Upper Limb Prosthetics Society to address deficiencies in the Healthcare Common Procedure Coding System (HCPCS) pertaining to upper-limb prosthetic care. As upper-limb clinical practice has advanced in recent years and available technologies to address upper-limb loss deficits have proliferated, the uniform code set that describes upper-limb clinical practice has become outdated, and the guidance interpreting this code set needs revision. Without changes to coding, patient access to upper-limb prosthetic care is compromised. The O&P stakeholders have embarked on a multipronged effort to improve access through coding, coverage, and payment changes to better reflect contemporary clinical practice. History of the Problem On April 4, 2022, the Durable Medical Equipment Medicare Administrative Contractor (DME MAC) Medical Directors jointly issued coding guidance along with the Pricing, Data and Analysis Contractor (PDAC) in Upper Limb Prostheses - Correct Coding about upper-limb prostheses that raised serious concerns with prosthetics practitioners. The guidance was viewed as restricting access to upper-limb prostheses for certain Medicare beneficiaries. The O&P Alliance, in conjunction with experts in upper-limb prosthetics, drafted a comprehensive letter on July 13, 2022, to the DME MAC and PDAC Medical Directors and the Centers for Medicare & Medicaid (CMS) Technology Coding and Pricing Group (TCPG) critiquing this coding guidance and seeking significant changes to the guidance. The letter stated: “We believe the Guidance constitutes a departure from the substantive legal standards governing the coding, coverage, and payment of certain upper-limb prostheses. We are concerned that this new interpretation of the upper-limb prostheses code set will impede the ability of some upper-limb amputees—particularly, the partial hand amputee population—to receive the most appropriate clinical level of prosthetic care. The Guidance also reveals significant flaws within the upper-limb prosthetic code set that we hope [CMS] will consider remedying as the DME MACs and the PDAC refine the Guidance.” The O&P organizations met in fall 2022 with CMS officials to discuss concerns with the guidance and sought another meeting with the DME MAC Medical Directors and the PDAC who were responsible for issuing the guidance document. In March 2023, the DME MAC Medical Directors, the PDAC, CMS, and the O&P organizations met to discuss the impact the guidance document was having on Medicare beneficiary access to upper-limb prosthetic care. To their credit, the following week the DME MACs retired this coding guidance, a major victory for patients and providers. But guidance that existed before the April 2022 guidance was put in place was still in effect, much of which was restated in the newly retired guidance document, creating confusion with respect to upper-limb coding. It quickly became clear that retirement of the coding guidance was only step one and that more advocacy would be necessary. In response, the O&P organizations developed an action plan to rewrite the retired coding guidance to comport with contemporary prosthetic practice and inquired with the DME MACs about the necessity for a comprehensive revision of the upper-limb prosthetic code set. The O&P organizations believe that some HCPCS codes are outdated and can be deleted, some codes require updated descriptors to more accurately reflect modern upper-limb prosthetic practices, and new codes need to be created to better capture new technologies and current standards of care. After months of development, the O&P organizations, led by the Upper Limb Prosthetics Society, sent a comprehensively revised coding guidance document to the DME MACs for their consideration and review. The goal was to prompt the DME MACs to reissue updated coding guidance that would improve access to care for Medicare beneficiaries. However, the DME MACs responded that before they would be willing to reissue guidance of this nature, they would expect to see a concerted effort by the profession to work with CMS’ HCPCS Workgroup to update the upper-limb prosthetic codes, a position the O&P organizations stated explicitly as being necessary during our discussions for the need to retire the March 2022 coding guidance. Upper-limb Prosthetic Coding Changes Led by the Upper Limb Prosthetics Society, the O&P organizations established a coding action plan that created a comprehensive list of necessary new codes, existing codes whose descriptors need to be updated, and proposed deletions of outdated codes that are no longer useful or accurately describe contemporary clinical practice. All these code revisions were designed to update and streamline the uniform code set to better enable access to patient care. One of the most egregious gaps in coding involves partial hand and finger prostheses, which are largely missing from the existing HCPCS code set. A decision was made to submit, as Phase I of this coding project, a series of requests for changes to the descriptors of 12 upper-limb codes to reflect their application to individuals with partial hand and finger loss. Future phases of this project will address base codes, interface codes, terminal devices and components, and deletion or modification of other outdated codes. This Phase I proposal was submitted to the HCPCS Workgroup on July 1 by the Upper Limb Prosthetics Society and endorsed by the O&P Alliance. Specifically, the proposal focused on a request to revise 12 existing HCPCS codes (L-6380, L-6400, L-6680, L-6687, L-6694, L-6695, L-6696, L-6697, L-6698, L-6883, L-7400, and L-7403) to include a description of “partial hand and finger” prostheses in each of these codes. The application stated: “Each of the codes listed describes a component of the prosthetic socket, whether the socket itself, a material subcomponent, or a test socket that allows the clinician to get to a well-fitting, clinically viable prosthesis that is functional for the user. The codes currently include descriptors for below-elbow and wrist disarticulation prosthetic sockets, but they do not specify partial hand and finger prosthetic sockets. The purpose of a prosthetic socket is to serve as the interface between the individual and the prosthetic components. It must be properly suspended from the limb for the individual to be able to hold and grasp objects. For partial hand, the socket often serves as the interface for operation of the prosthesis as well. The amount of clinical care, expertise, time, and materials required to address the unique functional needs of individuals with partial hand or finger loss are equivalent to what is required to provide the corresponding services to more proximal levels of upper limb difference such as wrist disarticulation and below elbow. CMS’ HCPCS Workgroup responded to this application on October 8 with a preliminary decision and set a date of November 8 for a hearing—an opportunity for the applicant and the public to comment—on this decision. This preliminary determination contained great news because CMS acknowledged that the current HCPCS code set for partial hand prostheses “does not adequately represent the evolving clinical practices in this field.” CMS also has determined that, due to advancements in technology and clinical practice, it is more appropriate to create new, distinct HCPCS Level II codes for partial hands and fingers. As such, CMS is proposing to create an additional seven HCPCS codes to address partial hand and finger prostheses. The codes proposed are as follows: L-XXX1 , “Immediate post-surgical or early fitting, application of initial rigid dressing, including fitting alignment and suspension of components, and one cast change, finger, partial hand” L-XXX2 , “Partial hand, flexible inner socket, endoskeletal system, molded to patient model, for use with or without external power” L-XXX3 , “Upper extremity addition, test socket, partial hand” L-XXX4 , “Upper extremity addition, frame type socket, partial hand” L-XXX5 , “Replacement socket, partial hand, molded to patient model, for use with or without external power” L-XXX6 , “Addition to upper extremity prosthesis, partial hand, ultralight material (titanium, carbon fiber, or equal)” L-XXX7 , “Addition to upper extremity prosthesis, partial hand, acrylic material” CMS also determined that these new codes qualify under the Medicare benefit category of artificial arms, or prosthetics. This was no surprise as they all pertain to upper-limb prosthetic care. CMS did not propose Medicare payments for these codes and requested additional information to aid in the establishment of payment rates. The agency also seeks comments on the date these new codes should go into effect. O&P Organizations’ Reaction to the Proposed Code Set As the first phase of this upper-limb prosthetic coding initiative, CMS’ reaction to the proposal is very encouraging and bodes well for the development of additional new codes and modified descriptors for existing codes in the future, as part of a comprehensive overhaul of the code set for this benefit category. However, there are some significant concerns with the approach CMS proposes, and the O&P organizations are in the process of trying to improve on the proposal before CMS issues a final decision in early 2025. There are four main areas of concern that will be addressed with CMS. Explicit Recognition of Prosthetic Fingers: First and most apparent is the fact that only the first proposed code, L-XXX1, mentions both “partial hand” and “finger” in the code descriptor. The other six new codes include the words “partial hand” but fail to clarify whether they also apply to prosthetic replacement of fingers. This is likely an oversight that the O&P organizations expect to be resolved in the final determination. Confusion With Base and Add-On Codes: More concerning is the confusion of base codes with new codes that are treated as add-on codes. For instance, L-XXX2 was cross-walked from an existing base code for upper-limb prostheses but appears to be treated as an add-on code for partial hand and finger prostheses. For this reason, the O&P organizations argue that CMS should not finalize this new code and accept a new proposal from the field to clarify this coding scenario in the future. Bundling Flexible Sockets and Liners: Even more concerning is the intention of the HCPCS Workgroup to “streamline” the coding for flexible sockets and liners under the mistaken belief that, as the HCPCS Workgroup states, “Partial hands and fingers do not require all of the same HCPCS Level II codes that are currently applied to the below-elbow and wrist disarticulation prostheses.” The preliminary decision continues with this explanation: “By updating the code language to specify ‘flexible inner socket,’ CMS aims to streamline the process and eliminate the need for separate liners. Currently, the interface for partial hand and finger prostheses serves a dual purpose, acting as both a socket and a socket insert (also known as a liner). The O&P organizations disagree with these statements and will argue to the HCPCS Workgroup that the final determination must be improved to more accurately reflect clinical practice. Determining Payment Levels for the New Codes: The O&P organizations never intended to open a pricing discussion about new HCPCS codes, opting instead to propose adding “partial hand and finger” to each of 12 existing codes in the upper-limb prosthetic code set. If CMS were to adopt this proposal as written, a pricing discussion of new codes would not have been triggered. With CMS’ preliminary determination of creating seven new HCPCS codes, the agency asks—not surprisingly—for public comment on the process it should use to assign a reimbursement value for each new code. The O&P organizations feel strongly that the same or greater level of clinical time, technical time, and fabrication cost necessary to perform the services described by the existing codes similarly applies to the newly proposed partial hand and finger prosthetic codes. Individuals with partial hand amputations experience a higher degree of disability than their transradial counterparts and exhibit a wider range of surgical presentations. Thus, partial hand prostheses are some of the most clinically challenging and technically intensive prostheses to deliver to beneficiaries. For these reasons, the CMS Workgroup should adopt equivalency between the reimbursement levels for partial hand/finger limb loss and transradial/wrist disarticulation limb loss. CMS has a claims history for these new codes and should simply cross-walk the current reimbursement amounts from the existing HCPCS codes to the newly created HCPCS codes. The O&P organizations will strongly resist any effort to use the gap-filling methodology to assign new prices to these new codes as this process will likely result in reimbursement levels that are not sufficient to permit appropriate access to patient care. Next Steps The O&P Alliance organizations will continue working closely with the Academy’s Upper Limb Prosthetics Society to obtain the best possible result for partial hand and finger prostheses and will embark on new phases of this coding initiative in the coming months and beyond. Once the code set is comprehensively reformed, the O&P organizations will seek publication of new coding guidance by the DME MAC Medical Directors and the PDAC that should significantly improve access to patient care and bring the code set in line with contemporary upper limb prosthetic practice. Peter W. Thomas, JD, is NAAOP General Counsel, O&P Alliance Counsel, and managing partner of Powers Law Firm.

Medicare Considers Improvements to Upper-limb Prosthetic Access

Lasting Impressions in Patient Care

Leading the Way for Bone-anchored Prostheses

Leading the Way for Bone-anchored Prostheses

O&P JOBS

HH Manager, Orthotics & Prosthetics

Orthotics and Prosthetics Assistant

Certified Orthotist — Full-Time or Part-Time, Pediatric Practice

Get unlimited access!

EDGE DIRECT

Welcome Back!

Retrieve your password

Not enough quota to unlock this post

Medicare Considers Improvements to Upper-limb Prosthetic Access

Support authors and subscribe to content.

Subscribe

Related posts:

Lasting Impressions in Patient Care

Leading the Way for Bone-anchored Prostheses

Leading the Way for Bone-anchored Prostheses

O&P JOBS

HH Manager, Orthotics & Prosthetics

Orthotics and Prosthetics Assistant

Certified Orthotist — Full-Time or Part-Time, Pediatric Practice

Get unlimited access!

EDGE DIRECT

Welcome Back!

Retrieve your password

Not enough quota to unlock this post