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HCPCS L5859 · Level II · orthotic and prosthetic code

L5859: Addition to lower extremity prosthesis, endoskeletal knee-shin system, HCPCS Level II orthotic and prosthetic code

Compiled from CMS files by the QuickIntell RCM Editorial Team · Data effective · Method: reference methodology · Report a data correction

Data currency: HCPCS Level II file: October 2026 (effective October 1, 2026); DMEPOS fee schedule: DME26-D (October 2026) (effective October 1, 2026); NCCI MUE tables: 2026 Q4 (effective October 1, 2026); NCCI PTP edits: v323r0 (2026 Q4) (effective October 1, 2026); OPPS Addendum B: October 2026 (effective October 1, 2026); Medicare Coverage Database LCD export: MCD release October 8, 2026 (effective October 4, 2026). Next CMS release: January 1, 2027 (quarterly update) for the HCPCS Level II file and DMEPOS fee schedule and NCCI MUE tables and NCCI PTP edits and OPPS Addendum B; weekly, every Thursday for the Medicare Coverage Database LCD export.

Key facts for L5859

Medicare payment
$17,437.90 to $18,479.11
DMEPOS non-rural state fees
Coverage code
C
carrier judgment, so the Medicare contractor decides coverage
DME supplier MUE
2
MAI 3
OPPS status
SI A
Services not paid under OPPS; paid under fee schedule or other payment system
NCCI PTP pairs
0
practitioner file
LCDs and articles
1 / 0

TL;DR

HCPCS Level II L5859 reads "Addition to lower extremity prosthesis, endoskeletal knee-shin system, powered and programmable flexion/extension assist control, includes any type motor(s)" in the October 2026 file; it dates from 2013. DMEPOS fees for L5859, a PO (prosthetics and orthotics) item, run $17,437.90 in AZ, CA, CT and 14 more to $18,479.11 in ID, OR, WA (floor $16,017.70, ceiling $21,356.93) in the October 2026 file. Its 2026 Q4 MUEs per date of service: practitioner 0 (MAI 3, CMS Policy); hospital outpatient 2 (MAI 3, Nature of Equipment); DME supplier 2 (MAI 3, Nature of Equipment). 1 active LCD lists L5859: L33787 (Lower Limb Prostheses). OPPS status indicator A: Services not paid under OPPS; paid under fee schedule or other payment system. HCPCS record: BETOS D1F (prosthetic/orthotic devices); pricing indicator 38; type of service P (lump-sum purchase of DME, prosthetics or orthotics). 7 other active codes open with "Addition to lower extremity prosthesis"; related codes: L5856, L5990, L5685, L5657.

L5859 descriptor and code status

The October 2026 HCPCS Level II file describes L5859 as “Addition to lower extremity prosthesis, endoskeletal knee-shin system, powered and programmable flexion/extension assist control, includes any type motor(s)”. It sits in the L section (orthotic and prosthetic procedures and devices), listed with the other L codes.

HCPCS file attributes of L5859
FieldValue
Short descriptorKnee-shin pro flex/ext cont
Added to HCPCS2013-01-01
Last actionN (no maintenance), effective 2013-01-01
Coverage codeC: carrier judgment, so the Medicare contractor decides coverage
Pricing indicator38: DMEPOS orthotics, prosthetics, prosthetic devices and vision services (floors and ceilings)
BETOS categoryD1F: prosthetic/orthotic devices
Type of serviceP: lump-sum purchase of DME, prosthetics or orthotics

Medicare payment for L5859

DMEPOS fees for L5859, a PO (prosthetics and orthotics) item, run $17,437.90 in AZ, CA, CT and 14 more to $18,479.11 in ID, OR, WA (floor $16,017.70, ceiling $21,356.93) in the October 2026 file. The amounts below are national figures from the October 2026 CMS files; the contractor applies the locality, rural or state adjustment and the beneficiary's cost sharing.

DMEPOS fee schedule (DME26-D)

Jurisdiction D (DME MAC), payment category PO (prosthetics and orthotics). Fees are set per state; AK, HI, PR and VI are not subject to the national ceiling and floor and are listed separately. A rural fee applies only in ZIP codes on the CMS rural ZIP list.

DMEPOS fees for L5859 by modifier
ModifierFloor / ceilingNon-rural state rangeRural rangeAK / HI / PR / VI
none$16,017.70 / $21,356.93$17,437.90 (AZ, CA, CT…) to $18,479.11 (ID, OR, WA)—AK $17,437.90, HI $17,437.90, PR $19,181.69, VI $19,181.69

Hospital outpatient (OPPS Addendum B)

Status indicator A (Services not paid under OPPS; paid under fee schedule or other payment system), with no separate OPPS payment rate.

Medically Unlikely Edits for L5859

Its 2026 Q4 MUEs per date of service: practitioner 0 (MAI 3, CMS Policy); hospital outpatient 2 (MAI 3, Nature of Equipment); DME supplier 2 (MAI 3, Nature of Equipment). The DME supplier MUE is a date-of-service clinical edit: units above the limit deny but can be paid on appeal with documentation.

MUE values for L5859 by setting
SettingMUE (units/DOS)MAICMS rationale
Practitioner services03 Date of Service Edit: ClinicalCMS Policy
Facility outpatient hospital23 Date of Service Edit: ClinicalNature of Equipment
DME supplier23 Date of Service Edit: ClinicalNature of Equipment

The MUE lookup for L5859 shows every setting next to any other code on the same claim.

NCCI edits and add-on rules

No active practitioner PTP pair lists L5859 in v323r0.

L5859 is neither an add-on code nor a designated primary code in the 2026 Q4 NCCI add-on edit file.

Pair counts show exposure, not the answer for one claim. Check L5859 against a second code to see whether the pair bundles and whether a modifier can separate the services.

Medicare coverage policies for L5859

1 active Local Coverage Determination and 0 billing and coding articles list L5859. Each applies only in its contractor's jurisdiction, and the article carries the diagnosis codes that support the item or service.

Denials to expect on L5859

CARC 50 · N115

the diagnosis or documentation does not meet the LCD or billing article that lists L5859

CARC 151 · N362

units of L5859 exceed the DME supplier MUE of 2 per date of service

CARC 4

the modifier reported is inconsistent with the code

CARC 16

the claim lacks information needed to adjudicate the line, such as an order, NPI or required modifier

Where QuickIntell fits for L5859 claims

QuickAuth coordinates the requirement checks and documentation that DME claims for L5859 depend on, with human review of each case, and QuickRCM carries claim readiness and the CARC 50, 151 and modifier denials these items draw.

See QuickAuth for requirement checksSee QuickRCM for denial follow-upBook a meeting

Frequently asked questions: HCPCS L5859

What does HCPCS code L5859 describe?

"Addition to lower extremity prosthesis, endoskeletal knee-shin system, powered and programmable flexion/extension assist control, includes any type motor(s)" (short descriptor "Knee-shin pro flex/ext cont"), in the L section (orthotic and prosthetic procedures and devices). Added 2013-01-01.

Is L5859 a CPT code?

No. L5859 is a CMS HCPCS Level II code; CPT codes are the AMA's five-character set.

What does Medicare pay for L5859?

DMEPOS fees for L5859, a PO (prosthetics and orthotics) item, run $17,437.90 in AZ, CA, CT and 14 more to $18,479.11 in ID, OR, WA (floor $16,017.70, ceiling $21,356.93) in the October 2026 file.

How many units of L5859 can be billed per day?

Its 2026 Q4 MUEs per date of service: practitioner 0 (MAI 3, CMS Policy); hospital outpatient 2 (MAI 3, Nature of Equipment); DME supplier 2 (MAI 3, Nature of Equipment). For the DME supplier MUE (MAI 3), units above 2 deny for the day but can be paid on appeal with documentation; denials arrive as CARC 151.

Does Medicare cover L5859?

Coverage code C (carrier judgment, so the Medicare contractor decides coverage). 1 active LCD lists L5859: L33787 (Lower Limb Prostheses).

Sources

Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-10. Verify against the primary file before billing or contracting decisions. The reference methodology explains how each figure is computed from these files.

Disclaimer

This page is an operational reference compiled from CMS publications: the HCPCS Level II file, the physician, DMEPOS and clinical laboratory fee schedules, OPPS and ASC addenda, NCCI MUE, PTP and add-on edit tables and the Medicare Coverage Database. Amounts are Medicare national figures before locality and state adjustment; Medicaid and commercial payers set their own. CPT codes are shown as numbers only; CPT descriptors are copyright AMA. Nothing here is legal, clinical or billing advice.

Found a figure that does not match the CMS file? Report a data correction with the CMS file and the value you expected; the request reaches the editorial team through the contact form.