L6310 Shoulder Disarticulation | HCPCS Reimbursement | OpenPayer

Summary & Overview

HCPCS L6310: Shoulder Disarticulation, Passive Complete Prosthesis

HCPCS Level II code L6310 denotes a complete prosthesis for shoulder disarticulation with passive restoration. This code captures prosthetic provision intended to restore limb form and passive function after shoulder-level amputation, a specialized and resource-intensive service. Nationally, accurate coding for high-level upper-limb prostheses is important for durable medical equipment (DME) suppliers, prosthetists, hospital outpatient departments, and payers due to device complexity and varied coverage policies.

Key payers discussed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of what the code represents, the typical clinical and care settings, and the scope of payers relevant to national coverage discussions. The publication outlines benchmarks and policy considerations for prosthetic reimbursement, clarifies the clinical context of shoulder disarticulation prostheses, and summarizes common billing considerations such as service line placement and site of service implications.

This summary is intended for clinicians, billing specialists, prosthetic providers, and policy analysts seeking a clear, national-level briefing on HCPCS Level II code L6310 and its role in prosthetic services delivery and payer interactions.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareL6310HCPCS Level IIshoulder disarticulationprosthesisupper limb prostheticsprosthetic provisionDMEprosthetics clinic

Billing Code Overview

HCPCS Level II code L6310 describes shoulder disarticulation, passive restoration (complete prosthesis). This code represents provision of a complete prosthetic device designed to restore form and passive function following shoulder disarticulation (amputation at the shoulder level).

Service type: Prosthetic device provision and fitting for a complete prosthesis with passive restoration
Typical site of service: Prosthetics and orthotics clinic, hospital outpatient department, or specialized prosthetic fabrication facility

Data not available in the input for associated taxonomies, ICD-10 diagnoses, and related codes.

Clinical & Coding Specifications

Clinical Context

A 62-year-old male with a history of a high-grade sarcoma involving the proximal humerus and shoulder girdle undergoes an oncologic shoulder disarticulation with subsequent fitting for a passive, complete prosthesis coded as L6310. The clinical workflow begins with multidisciplinary tumor board planning, preoperative imaging (plain radiographs, CT or MRI of the shoulder and chest for staging), and preoperative clearance. The surgical team performs the shoulder disarticulation (amputation through the shoulder joint) with oncologic margins. Postoperative care includes wound management, pain control, and early physical and occupational therapy focusing on residual limb shaping and prosthetic training. Once healed and residual limb volume stabilized, the patient is seen by a prosthetist and orthotist for measurement, casting or digital scanning, fabrication, fitting, and alignment of the passive complete prosthesis. Follow-up visits assess socket fit, comfort, skin integrity, and function of passive components; adjustments, repairs, or replacement are provided as needed. Typical sites of service include inpatient acute care for the amputation and outpatient prosthetics clinic or specialized orthotics and prosthetics facility for prosthesis fabrication and fitting.

Coding Specifications

Modifier	Description	When to Use
`00`	No modifier	Use when no specific modifier applies to the billed service.

HCPCS Level II L8480: Prosthetic Sock, Single Ply, Above-Knee Fitting

HCPCS-L5976-LOWER-EXTREMITY-ENERGY-STORING-FOOT

HCPCS L5976: All Lower Extremity Energy-Storing Prosthetic Foot

HCPCS-L5535-PREPARATORY-BELOW-KNEE-PTB-SOCKET-PREFABRICATED

HCPCS L5535: Preparatory Below-Knee PTB Socket, Prefabricated

HCPCS-L8641-METATARSAL-JOINT-IMPLANT

HCPCS L8641: Metatarsal Joint Implant

HCPCS-L6620-UPPER-EXTREMITY-WRIST-FLEXION-EXTENSION-UNIT

HCPCS L6620: Upper Extremity Flexion/Extension Wrist Unit

HCPCS-L6900-PARTIAL-HAND-PROSTHESIS-THUMB-OR-ONE-FINGER

HCPCS L6900: Partial Hand Prosthesis, Glove/Thumb/Single Finger

HCPCS-L5613-ABOVE-KNEE-4-BAR-HYDRAULIC-SWING-KNEE-ADDITION

HCPCS L5613: Addition to Above-Knee Prosthetic, 4-Bar Hydraulic Swing Knee

HCPCS-L8515-GELATIN-CAPSULE-APPLICATION-DEVICE-TRACHEOESOPHAGEAL-PROSTHESIS

HCPCS L8515: Gelatin Capsule Application Device for Tracheoesophageal Voice Prosthesis

HCPCS-L5925-ENDOSKELETAL-ABOVE-KNEE-KNEE-HIP-DISARTICULATION-MANUAL-LOCK

HCPCS L5925: Endoskeletal Addition for Above-Knee or Hip Disarticulation, Manual Lock

HCPCS-L8470-PROSTHETIC-SOCK-BELOW-KNEE-SINGLE-PLY

HCPCS L8470: Prosthetic Sock, Single-Ply, Below-Knee Fitting

Showing 1–10 of 472

Taxonomy Code	Specialty	Notes
`231H00000X`	Physical Medicine & Rehabilitation Physician	Medical management of prosthetic prescription, functional assessment.
`332B00000X`	Prosthetist/Orthotist	Primary provider for prosthesis fabrication, fitting, and adjustments.
`2080P0200X`	Orthopedic Surgeon	Performs amputations such as shoulder disarticulation and coordinates surgical care.
`225100000X`	Occupational Therapist	Provides training in donning/doffing and functional use of passive prosthesis.
`363L00000X`	General Surgeon	May perform amputations in trauma or oncologic settings when orthopedic surgeon not available.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`C40.2`	Malignant neoplasm of scapula and long bones of the upper limb	Tumors of the proximal humerus/scapula may necessitate shoulder disarticulation and prosthetic reconstruction.
`C49.1`	Malignant neoplasm of connective and soft tissue of upper limb, including shoulder	Soft tissue sarcomas involving shoulder girdle are common indications for this amputation and subsequent prosthesis.
`S48.091A`	Traumatic amputation of right shoulder joint, initial encounter	Traumatic shoulder disarticulation is an indication for a complete passive prosthesis fitting.
`S48.092A`	Traumatic amputation of left shoulder joint, initial encounter	As above, for left-sided traumatic amputations requiring prosthetic rehabilitation.
`T79.A11A`	Traumatic compartment syndrome of right upper limb, initial encounter	Severe limb injury with ischemia/compartment syndrome can lead to shoulder disarticulation and need for prosthesis.
`G82.50`	Quadriplegia, unspecified	In patients with high-level neurologic injury where active control is limited, a passive prosthesis may be prescribed for cosmesis and positioning.
`Z43.1`	Fitting and adjustment of prosthetic limb	Used to indicate encounters specifically for prosthesis fitting and adjustment after shoulder disarticulation.
`Z89.111`	Acquired absence of right shoulder joint	Diagnostic code documenting the residual limb status after disarticulation; relevant for ongoing prosthetic management.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`11042`	Debridement, subcutaneous tissue, first 20 sq cm or less; for wounds, if required during postoperative management	May be used for wound debridement of the residual limb prior to or during prosthetic preparation.
`29580`	Application of prosthesis, shoulder disarticulation, initial fitting or subsequent adjustments (note: CPT 29580 is descriptive of prosthetic fitting procedures)	Used for initial fitting and adjustments of an upper-limb prosthesis following shoulder disarticulation in the clinical workflow.
`97760`	Orthotic(s)/prosthetic(s) management and training, initial encounter, each 15 minutes	Used by therapists for training the patient in use and care of the passive prosthesis.
`99070`	Supplies and materials provided by the physician over and above those usually included with the office visit	Used to bill for noncovered supplies or additional materials used during prosthetic fitting, if allowed by payer policy.
`99223`	Initial hospital care, typically 70 minutes or more, per day for the admitting physician	May be used for the admitting physician’s initial inpatient evaluation for the amputation surgery.

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