2025 HCPCS code L5696
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Prosthetic Procedures - Socket Insert, Suspensions, and Other Prosthetic Additions Orthotics and Prosthetics Feed
Addition to lower extremity, above-knee or knee disarticulation, pelvic joint; a prosthetic joint attached to the pelvic area for patients with above-knee or knee disarticulation amputations to improve mobility.
Modifiers may be applied depending on the specific circumstances; for example, modifiers indicating bilateral procedures or reduced services.Consult the CMS National Correct Coding Initiative (NCCI) edits for applicable modifiers.
Medical necessity for L5696 is established when a patient requires a prosthetic pelvic joint due to a loss of lower limb above the knee or at the knee joint, directly impacting their ability to ambulate, maintain balance, and perform activities of daily living. The prosthesis should be considered medically necessary to improve function and quality of life.
Prosthetists, orthopedic surgeons, and rehabilitation specialists may be involved in the fitting, fabrication, and post-operative care associated with this procedure.The precise clinical responsibilities will vary based on the specific needs of the patient and the provider’s role.
In simple words: This code covers adding a special joint to a prosthetic leg for people who've had their leg amputated above the knee or at the knee. This joint connects to a band around the hip, allowing the leg to move more naturally and helping them walk and balance better.
This HCPCS code, L5696, represents the addition of a prosthetic pelvic joint to a lower extremity prosthesis for individuals with above-knee amputations (AKA) or knee disarticulation amputations.The pelvic joint is a crucial component, connecting the prosthesis socket to a pelvic band, enabling hip movement and weight suspension. This procedure aims to improve ambulation, balance, and overall functionality for patients who have undergone these types of amputations. The prosthetic joint is meticulously fitted and adjusted to ensure optimal comfort and alignment.The procedure typically involves attachment to the residual limb, requiring precision and attention to detail for secure and stable fixation.Pre-operative assessment includes a thorough physical examination, imaging studies, and blood tests to determine candidacy. The surgery may be performed under regional or general anesthesia and typically lasts 2-4 hours, depending on individual patient factors and procedure complexity.
Example 1: A 60-year-old male patient with an above-knee amputation due to diabetic complications receives a custom-fitted prosthesis, including the L5696 pelvic joint, to improve ambulation and quality of life., A 25-year-old female patient sustains a traumatic knee disarticulation requiring a prosthesis.The L5696 pelvic joint is incorporated into the design to maximize mobility and facilitate participation in physical therapy., A 45-year-old patient with a congenital limb deficiency uses the L5696 pelvic joint as part of a complex prosthetic system to increase functional independence and reduce reliance on assistive devices.
Detailed medical history, including reason for amputation, type of amputation (above-knee or knee disarticulation), and assessment of functional capabilities.Pre-operative imaging studies (radiographs, CT scans if needed).Documentation of prosthesis fitting, adjustments, and patient training.Post-operative follow-up notes and progress in rehabilitation.Any complications encountered during or after the procedure.
** This code should only be reported when a pelvic joint is a necessary component of the prosthesis.Accurate documentation is crucial for proper reimbursement.
- Revenue Code: Refer to payer-specific guidelines for appropriate revenue codes.
- RVU: RVUs are not directly available for HCPCS codes. Reimbursement is determined by payer-specific fee schedules and may vary by location and provider type.Consult the relevant payer's fee schedule for current payment rates.
- Global Days : Global period information is not available for this HCPCS code.It's essential to consider the specific circumstances of each case and refer to the individual payer's guidelines for reimbursement.
- Payment Status: Active
- Modifier TC rule: A technical component (TC) modifier is not applicable to this code.
- Fee Schedule : Fee schedule information varies by payer and is not consistently available in a centralized database. It's crucial to consult individual payer fee schedules for the most up-to-date payment amounts.
- Specialties:Orthopedic Surgery, Prosthetics and Orthotics, Physical Medicine and Rehabilitation
- Place of Service:Office, Outpatient Hospital, Ambulatory Surgical Center