Summary & Overview
HCPCS L5230: Above-Knee Prosthesis for Proximal Femoral Focal Deficiency
HCPCS Level II code L5230 identifies an above-knee prosthetic assembly for patients with proximal femoral focal deficiency that includes a constant friction knee, shin component, and a SACH foot. This code captures a clinically specialized prosthesis used for congenital or acquired proximal femoral deficiency where limb-sparing prosthetic solutions are indicated. Nationally, accurate coding for complex prosthetic components affects device coverage, prior authorization workflows, and durable medical equipment reimbursement pathways.
Key payers discussed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a clinical and billing overview of the prosthetic configuration represented by L5230, guidance on typical sites of service for provision and fitting, and a summary of common modifiers used with prosthetic billing (list provided separately). The publication outlines benchmarks and policy-relevant considerations such as coverage criteria, documentation expectations, and claim submission practices for complex above-knee prostheses.
The report is intended for billing professionals, prosthetists, clinical managers, and policy analysts seeking a concise reference on this HCPCS Level II prosthetic code, its clinical context, and implications for payers and facilities that supply and fit advanced lower-limb prostheses. Data not available in the input is noted where applicable.
Billing Code Overview
HCPCS Level II code L5230 describes a prosthetic component configuration for patients with significant proximal femoral deficiency. The code covers an above-knee prosthesis designed for proximal femoral focal deficiency, incorporating a constant friction knee mechanism and a shin component with a SACH foot (solid ankle cushion heel).
Service type: Prosthetic limb device — above-knee prosthesis with constant friction knee, shin, and SACH foot.
Typical site of service: Outpatient prosthetics/orthotics clinic or specialty prosthetics manufacturer/dispensing facility.
Clinical & Coding Specifications
Clinical Context
A 6-year-old child with unilateral proximal femoral focal deficiency (PFFD) presents for fitting of an above‑knee prosthesis. The patient has a shortened femur with an unstable hip and a functional residual limb that requires a prosthetic socket, a constant friction knee joint for swing and stance control, and a SACH (solid ankle cushioned heel) foot to provide stability and energy return for early ambulation. The multidisciplinary workflow includes: initial orthopedic and prosthetics evaluation, gait and functional assessment by a physical therapist, measurement and casting of the residual limb by a prosthetist, fabrication and fitting of the socket and components (including the constant friction knee and SACH foot), alignment and dynamic tuning in the prosthetics clinic, and follow‑up visits for adjustments and functional training. Coding and billing use the HCPCS Level II code L5230 for the complete above‑knee prosthesis assembly specified for PFFD with the indicated components. Typical site of service is an outpatient prosthetics clinic or orthotics and prosthetics fabrication center. The typical patient scenario includes staged visits: evaluation and measurements, delivery and fitting, and 1–3 follow‑ups for alignment and skin checks within the first 90 days.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
26 |