Summary & Overview
HCPCS Level II L5200: Above-Knee Prosthesis with Single-Axis Knee
HCPCS Level II code L5200 denotes an above-knee prosthetic assembly composed of a molded socket, a single-axis constant friction knee, a shin component, and a SACH foot. This code identifies a basic mechanical transfemoral prosthesis designed to restore limited ambulation and basic functional mobility for individuals with above-knee amputations. Nationally, L5200 is relevant for coverage determinations, device selection, and durable medical equipment (DME) billing workflows.
Key payers addressed in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of billing and coding context for L5200, typical care settings and service types, and the common clinical scenarios in which this prosthetic assembly is used. The publication summarizes payer coverage considerations and benchmarking context where available, highlights policy and documentation elements that affect claim adjudication, and outlines coding relationships for prosthetic service lines.
This summary provides clinicians, prosthetists, revenue cycle staff, and policy analysts with a concise reference to the clinical role of L5200, its placement within prosthetic service delivery, and the payer landscape that commonly governs reimbursement and utilization decisions.
Billing Code Overview
HCPCS Level II code L5200 describes an above knee prosthesis with a molded socket, single axis constant friction knee, shin, and sach foot. This item represents a lower-extremity prosthetic assembly intended to replace an above-knee amputation and provide basic ambulation function.
Service Type: Prosthetic device provision and fitting
Typical Site of Service: Outpatient prosthetics clinic or orthotics and prosthetics (O&P) facility, with fitting and adjustments commonly performed in clinical O&P settings.
Clinical & Coding Specifications
Clinical Context
A 58-year-old male with a transtibial amputation that has progressed to an above-knee limb loss following a high-energy motorcycle crash is fitted for a definitive prosthesis. The prosthetic prescription is for an above-knee prosthesis with a molded socket, single-axis constant friction knee joint, and a SACH foot to provide stable, durable ambulation for community mobility. The clinical workflow begins with the prosthetist’s initial evaluation and measurement, followed by socket casting or digital scan, fabrication of the molded socket, integration of the single-axis constant friction knee mechanism, attachment of the SACH foot, alignment and dynamic alignment trial, gait training with a physical therapist, and final adjustments before delivery. Typical follow-up visits include socket comfort checks, minor alignment changes, and documentation of fit and function. The typical site of service is an outpatient prosthetics clinic or specialized orthotics and prosthetics facility. Key caregivers in the episode include a certified prosthetist, a physical therapist, and the referring orthopedic or vascular surgeon.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
11 | Professional component | When billing the prosthetist’s professional services separately from technical fabrication (rare for prosthetics but used if allowed). |