HCPCS L7402: Addition to Upper Extremity Prosthesis, Shoulder Disarticulation - OpenPayer

Summary & Overview

HCPCS L7402: Addition to Upper Extremity Prosthesis, Shoulder Disarticulation

HCPCS Level II code L7402 denotes an ultralight-material addition to an upper extremity prosthesis for shoulder disarticulation or interscapular thoracic amputations. This prosthetic component supports restoration of arm function for high-level amputations where lightweight, durable materials such as titanium or carbon fiber are preferred to improve wearability and mobility. Nationally, prosthetic components for shoulder-level fittings are a specialized segment of durable medical equipment with implications for device availability, clinician expertise, and payer coverage policies.

Key payers in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of the clinical application and setting for L7402, plus what to expect from payer coverage patterns and common billing practices. The publication outlines typical service lines and site-of-service considerations, summarizes benchmarks where available, and highlights recent policy considerations affecting prosthetic component authorization and documentation. This resource is intended to inform billing staff, prosthetists, and policy analysts about the role of L7402 in prosthetic care delivery and reimbursement workflow.

Data not available in the input: associated taxonomies, ICD-10 diagnoses, related codes, and specific payer coverage limits or rates.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareL7402HCPCS Level IIupper extremity prosthesisshoulder disarticulationprostheticsultralight materialsprosthetic fabricationoutpatient rehabilitation

Billing Code Overview

HCPCS Level II code L7402 describes an addition to an upper extremity prosthesis for shoulder disarticulation/interscapular thoracic fittings constructed from ultralight material (titanium, carbon fiber or equal). This component is intended to be integrated into a prosthetic system to restore upper-limb function for individuals with shoulder-level amputations.

Service type: Prosthetic component fabrication and fitting

Typical site of service: Prosthetics and orthotics clinics, specialty prosthetic fabrication labs, and outpatient rehabilitation settings

Clinical & Coding Specifications

Clinical Context

A 42-year-old male with a prior traumatic shoulder disarticulation presents to a prosthetics clinic for fitting of an upper extremity prosthetic system. The patient requires an ultralight structural addition to a shoulder disarticulation/interscapular thoracic prosthesis to reduce weight and improve function. The clinical workflow includes a consultation with a prosthetist and physician for medical necessity documentation, measurement and casting of the residual thoracic/shoulder anatomy, fabrication of the ultralight component (titanium or carbon fiber), fitting and alignment, and follow-up visits for adjustments and training in donning/doffing and functional use. Documentation includes the prosthetic prescription, description of the ultralight material used, justification for addition versus standard componentry, itemized device parts, and functional goals (e.g., improved prosthesis endurance and shoulder harness comfort). Typical sites of service are outpatient prosthetics clinics, hospital-based prosthetics departments, or specialized orthotics and prosthetics (O&P) facilities that handle upper extremity prosthetic fabrication and fittings.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services	Use when additional work or complexity beyond usual is documented (e.g., extensive modification, complex fitting).

HCPCS Level II L8605: Anal Canal Injectable Bulking Agent

HCPCS-L5811-ENDOSKELETAL-KNEE-SHIN-SINGLE-AXIS-MANUAL-LOCK

HCPCS L5811: Endoskeletal Knee-Shin Single-Axis Manual-Lock, Ultra-Light

HCPCS-L6965-SHOULDER-DISARTICULATION-MYOELECTRIC-PROSTHESIS

HCPCS L6965: Shoulder Disarticulation Myoelectric Prosthesis

HCPCS-L6706-MECHANICAL-HOOK-TERMINAL-DEVICE

HCPCS L6706: Mechanical Voluntary-Opening Hook Terminal Device

HCPCS-L7405-UPPER-EXTREMITY-PROSTHESIS-SHOULDER-DISARTICULATION-ACRYLIC

HCPCS L7405: Upper Extremity Prosthesis Addition for Shoulder Disarticulation, Acrylic

HCPCS-L5637-BELOW-KNEE-TOTAL-CONTACT-ADDITION-PROSTHESIS

HCPCS L5637: Addition to Below-Knee Prosthesis, Total Contact

HCPCS-L5960-ENDOSKELETAL-HIP-DISARTICULATION-ULTRA-LIGHT-ADDITION

HCPCS L5960: Endoskeletal Hip Disarticulation Addition, Ultra-Light Material

HCPCS-L6605-UPPER-EXTREMITY-SINGLE-PIVOT-HINGE-PAIR

HCPCS Level II L6605: Upper Extremity Additions, Single Pivot Hinge, Pair

HCPCS-L5634-LOWER-EXTREMITY-SYMES-POSTERIOR-CANADIAN-SOCKET

HCPCS L5634: Lower Extremity Symes-Type Posterior Opening (Canadian) Socket

HCPCS-L6386-POST-SURGICAL-CAST-CHANGE-REALIGNMENT

HCPCS Level II L6386: Immediate Post-Surgical Cast Change and Realignment

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Taxonomy Code	Specialty	Notes
`261QM0800X`	Prosthetics and Orthotics	Primary specialty performing device measurement, fabrication, and fitting.
`207L00000X`	Orthopedic Surgery	Surgeon involved in amputation care, residual limb preparation, and surgical revisions affecting prosthetic fit.
`106E00000X`	Physical Medicine & Rehabilitation	Physiatrist managing functional goals, mobility training, and coordination of prosthetic rehabilitation.
`208800000X`	Physical Therapy	Physical therapist providing training in prosthesis use, strengthening, and activities of daily living.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`Z89.011`	Acquired absence of right shoulder and upper arm	Indicates prior shoulder disarticulation amputation requiring an interscapular thoracic prosthetic solution.
`Z89.012`	Acquired absence of left shoulder and upper arm	Indicates prior shoulder disarticulation amputation on the left side necessitating prosthetic fitting.
`S48.191A`	Major amputation of right shoulder girdle, initial encounter	Traumatic indication leading to need for a shoulder disarticulation prosthesis and ultralight additions.
`S48.192A`	Major amputation of left shoulder girdle, initial encounter	Traumatic indication leading to need for a shoulder disarticulation prosthesis and ultralight additions.
`T90.2XXA`	Sequelae of amputation stump of shoulder and upper arm, initial encounter	Addresses complications of the residual limb that can affect prosthetic fitting and require specialized components.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`97760`	Orthotic(s) management and training; initial encounter, each 15 minutes	Used when providing patient training and education for donning, doffing, and use of an upper extremity prosthesis.
`97763`	Orthotic/prosthetic training, upper and lower extremities, first 15 minutes	Used for focused prosthetic training sessions specific to upper extremity prosthesis function and activities.
`99070`	Supplies and materials (noncovered items) provided by the physician over and above those usually included	Used to bill for additional nonstandard supplies or materials related to prosthetic fabrication when applicable and permitted by payer policy.
`20610`	Arthrocentesis, aspiration and/or injection; major joint or bursa (e.g., shoulder)	May be performed before prosthetic fitting for management of shoulder or residual limb pain that affects fitting; not routinely billed with the prosthetic addition but may appear in the workflow.
`99080`	Special reports or forms, completion requested by third parties	Used for completion of disability forms, letters of medical necessity, or detailed reports required by payers for prosthetic coverage decisions.

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