As advancements in upper limb clinical practice and the availability of technologies to address upper limb loss have increased in recent years, the standardized code set describing this practice has become outdated. One significant gap in the current Healthcare Common Procedure Coding System (“HCPCS”) coding system is the lack of codes for partial hand and finger prostheses. This gap in coding hinders patient access to upper limb prosthetic care. As a response, prosthetic stakeholders—in consultation with Powers Law Principals Peter Thomas and Leela Baggett—have developed a coding action plan that includes a comprehensive list of new codes that are needed, updates to existing codes whose descriptors require revision, and proposals to remove outdated codes that no longer reflect contemporary clinical practice.
As a result of this effort, the HCPCS Workgroup established 7 new partial hand and finger codes and revised 2 upper extremity add-on codes—effective April 1, 2025. CMS did not render a final payment determination, deciding that payment would be established in a subsequent cycle. In the meantime, local fee schedule amounts will be established by the Durable Medical Equipment Medicare Administrative Contractors (“DME MACs”) pending a payment determination.
Powers Law Principals Peter Thomas and Leela Baggett continue to provide counsel to prosthetic stakeholders in an effort to establish a nuanced upper limb prosthetic code set with an appropriate reimbursement amount to help ensure that Medicare beneficiaries receive the most appropriate upper limb prosthetic care from qualified practitioners and suppliers. Peter and Leela regularly assists healthcare innovators with complex coding/coverage/payment issues, including offering strategic advice on submitting HCPCS Level II coding and payment applications to CMS for healthcare products.
For additional information, please contact Peter Thomas (Peter.Thomas@powerlaw.com) and Leela Baggett (Leela.Baggett@powerslaw.com).