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Prosthetic Coding Playing Detective 


Confused about the explanation of benefits for a single prosthesis, where there may be fifteen different charges?

Each component of a prosthesis is listed separately on the bill to the insurance company… everything from the various parts of the socket to particular mechanisms inside the prosthetic foot.  These are called HCPCS procedure codes.  Procedure codes are defined by the Center for Medicare & Medicaid Services (CMS).  The charges are all published and can vary by region.  Not sure how to code a particular prosthetic foot?  Here are some ideas:


  • Call the manufacturer of the foot, or look up the foot on the manufacturer’s website. Manufacturers often recommend certain procedure codes for certain items.
  • Contact 1-800-Medicare

Amputees are put into one of four functional categories.  This is usually determined by theprosthetist and physician.  Here is the breakdown of functional level in easy-to-understand terms:


  • K0 :  This functional level is only used with an amputee has not ability or potential to use aprosthesis to walk or transfer safely with or without assistance.  In this case a prosthesiswould not enhance quality of life. 

  • K1 :  In this case, the amputee must have the ability or the potential to use a prosthesis for walking or transfer with or without assistance.  The patient would only have the ability or potential for walking on level surfaces at a single cadence, or speed.  This is typical of anamputee is able to accomplish limited walking inside the home. 

  • K2 :  Here, the amputee must have the ability or the potential to walk over low level barriers, such as curbs, stairs, or uneven surfaces.  This is typical of the limited community walker. 

  • K3 :  This functional level applies to an amputee who has the ability or the potential to walk of various speeds.  This person would be able to cross most environmental barriers and may have vocational, therapeutic, or exercise requirements that require a higher functioningprosthesis. 

  • K4 :  This functional level is typical of any athlete, children, or extremely active individuals.  This type of amputee exceeds basic abilities, experiences high stress when walking, and requires high energy levels.


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