L5500 HCPCS code: Initial, below knee 'ptb' type socket, non-alignable system, pylon, no cover, sach foot, plaster socket, direct formed
L5500 is the HCPCS Level II code for initial, below knee 'ptb' type socket, non-alignable system, pylon, no cover, sach foot, plaster socket, direct formed. The 2026 Medicare DMEPOS fee schedule pays $1,572.33 to $2,284.23 depending on the state. Its Medicare coverage code is C (Carrier judgment): Coverage is decided by the Medicare contractor (MAC) case by case. The NCCI unit limit is 2 per day on DME suppliers. In 2022, 12 suppliers billed Medicare for L5500 (purchases), serving 12 beneficiaries. Its average fee ranks 1 of 13 L55 codes (family range $1,800.60–$5,634.97).
Code details
| Field | Value |
|---|---|
| Section | L codes — Orthotic and prosthetic procedures and devices |
| Coverage code | C — Carrier judgment |
| Pricing indicator | 38 — DMEPOS: orthotics, prosthetics, prosthetic devices and vision services |
| BETOS category | D1F — Prosthetic and orthotic devices |
| Added | 1986-01-01 |
| Last action effective | 1996-01-01 |
2026 Medicare DMEPOS fee schedule for L5500
| Modifier | Meaning | Lowest state fee | Highest state fee | Ceiling | Floor |
|---|---|---|---|---|---|
| — | base fee | $1,572.33 | $2,284.23 | $2,096.44 | $1,572.33 |
| State | Modifier | Fee | Rural fee |
|---|---|---|---|
| AK | — | $2,100.95 | — |
| AL | — | $1,572.33 | — |
| AR | — | $1,756.84 | — |
| AZ | — | $2,087.82 | — |
| CA | — | $2,087.82 | — |
| CO | — | $2,071.28 | — |
| CT | — | $1,790.73 | — |
| DC | — | $1,572.33 | — |
| DE | — | $1,572.33 | — |
| FL | — | $1,572.33 | — |
| GA | — | $1,572.33 | — |
| HI | — | $2,246.56 | — |
| IA | — | $2,059.70 | — |
| ID | — | $1,572.33 | — |
| IL | — | $1,815.83 | — |
| IN | — | $1,815.83 | — |
| KS | — | $2,059.70 | — |
| KY | — | $1,572.33 | — |
| LA | — | $1,756.84 | — |
| MA | — | $1,790.73 | — |
| MD | — | $1,572.33 | — |
| ME | — | $1,790.73 | — |
| MI | — | $1,815.83 | — |
| MN | — | $1,815.83 | — |
| MO | — | $2,059.70 | — |
| MS | — | $1,572.33 | — |
| MT | — | $2,071.28 | — |
| NC | — | $1,572.33 | — |
| ND | — | $2,071.28 | — |
| NE | — | $2,059.70 | — |
| NH | — | $1,790.73 | — |
| NJ | — | $1,572.33 | — |
| NM | — | $1,756.84 | — |
| NV | — | $2,087.82 | — |
| NY | — | $1,572.33 | — |
| OH | — | $1,815.83 | — |
| OK | — | $1,756.84 | — |
| OR | — | $1,572.33 | — |
| PA | — | $1,572.33 | — |
| PR | — | $2,284.23 | — |
| RI | — | $1,790.73 | — |
| SC | — | $1,572.33 | — |
| SD | — | $2,071.28 | — |
| TN | — | $1,572.33 | — |
| TX | — | $1,756.84 | — |
| UT | — | $2,071.28 | — |
| VA | — | $1,572.33 | — |
| VI | — | $1,572.33 | — |
| VT | — | $1,790.73 | — |
| WA | — | $1,572.33 | — |
| WI | — | $1,815.83 | — |
| WV | — | $1,572.33 | — |
| WY | — | $2,071.28 | — |
How the L5500 fee compares
| Measure | Value |
|---|---|
| Rank among 13 L55 codes (lowest = 1) | 1 |
| Family fee range (average of state fees) | $1,800.60–$5,634.97 |
| Rural fee uplift | — |
Who bills L5500 (2022)
| Measure | Value |
|---|---|
| Suppliers billing rentals | — |
| Suppliers billing purchases | 12 |
| Referring clinicians | 12 |
| Medicare beneficiaries | 12 |
| States with claims | 0 |
Counts only. Supplier and clinician names, contact lists and state-by-state detail are in Caduvo.
Medicare utilization for L5500, 2022–2022
| Year | Services | Beneficiaries | Avg. allowed | Avg. paid |
|---|---|---|---|---|
| 2022 | 15 | 12 | $821.75 | $648.77 |
NCCI unit limits (MUE)
| Claim type | Max units per day | Rationale |
|---|---|---|
| DME suppliers | 2 | Anatomic Consideration |
| outpatient hospital claims | 2 | Anatomic Consideration |
Medicare policy articles for this code
- A52481: Orthopedic Footwear - Policy Article (CGS Administrators, LLC (DME MAC) Noridian Healthcare Solutions, LLC (DME MAC)) — mentions this code in its coding guidance
- A52496: Lower Limb Prostheses - Policy Article (CGS Administrators, LLC (DME MAC) Noridian Healthcare Solutions, LLC (DME MAC)) — mentions this code in its coding guidance
Covered diagnoses (84 ICD-10-CM codes)
The diagnoses most often listed as covered in the policy articles above:
| ICD-10-CM | Diagnosis | Articles listing it |
|---|---|---|
| Q72.00 | Congenital complete absence of unspecified lower limb | 1 |
| Q72.01 | Congenital complete absence of right lower limb | 1 |
| Q72.02 | Congenital complete absence of left lower limb | 1 |
| Q72.03 | Congenital complete absence of lower limb, bilateral | 1 |
| Q72.30 | Congenital absence of unspecified foot and toe(s) | 1 |
| Q72.31 | Congenital absence of right foot and toe(s) | 1 |
| Q72.32 | Congenital absence of left foot and toe(s) | 1 |
| Q72.33 | Congenital absence of foot and toe(s), bilateral | 1 |
| Q72.70 | Split foot, unspecified lower limb | 1 |
| Q72.71 | Split foot, right lower limb | 1 |
Showing 10 of 84. The full list, non-covered diagnoses and CSV export are in Caduvo.
What changed for L5500
- 2026-01-01: Average state fee rose 2.0%: $1,765.30 to $1,800.60
- 1986-01-01: L5500 added to HCPCS Level II
- Next scheduled CMS quarterly update (HCPCS and DMEPOS fee schedule): 2027-01-01
Frequently asked questions
What is HCPCS code L5500?
L5500 is the HCPCS Level II code for initial, below knee 'ptb' type socket, non-alignable system, pylon, no cover, sach foot, plaster socket, direct formed. Short descriptor: "Init bk ptb plaster direct".
How much does Medicare pay for L5500?
Under the 2026 DMEPOS fee schedule, non-rural state fees are base (base fee): $1,572.33–$2,284.23. Rural fees can be higher.
Does Medicare cover L5500?
Coverage code C — Carrier judgment. Coverage is decided by the Medicare contractor (MAC) case by case.
Which diagnoses support coverage for L5500?
Medicare policy articles that cite L5500 list 84 covered ICD-10-CM diagnosis codes across 2 articles. The most cited include Q72.00 (Congenital complete absence of unspecified lower limb), Q72.01 (Congenital complete absence of right lower limb), Q72.02 (Congenital complete absence of left lower limb). A listed diagnosis is necessary but not sufficient; the policy's other criteria still apply.
Did the Medicare fee for L5500 change in 2026?
The average non-rural state fee moved from $1,765.30 in 2025 to $1,800.60 in 2026 (+2.0%). CMS's next quarterly HCPCS and DMEPOS update takes effect January 1, 2027.
How many units of L5500 can be billed per day?
2 on DME suppliers; 2 on outpatient hospital claims (NCCI medically unlikely edits).
Related L55 codes
- L5505 — Initial, above knee - knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, sach foot, plaster socket, direct formed ($2,129.35–$3,997.43)
- L5510 — Preparatory, below knee 'ptb' type socket, non-alignable system, pylon, no cover, sach foot, plaster socket, molded to model ($1,782.34–$3,045.67)
- L5520 — Preparatory, below knee 'ptb' type socket, non-alignable system, pylon, no cover, sach foot, thermoplastic or equal, direct formed ($1,760.53–$3,045.67)
- L5530 — Preparatory, below knee 'ptb' type socket, non-alignable system, pylon, no cover, sach foot, thermoplastic or equal, molded to model ($1,206.25–$3,245.65)
- L5535 — Preparatory, below knee 'ptb' type socket, non-alignable system, no cover, sach foot, prefabricated, adjustable open end socket ($2,076.09–$3,553.71)
- L5540 — Preparatory, below knee 'ptb' type socket, non-alignable system, pylon, no cover, sach foot, laminated socket, molded to model ($2,215.83–$3,140.85)
- L5560 — Preparatory, above knee- knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, sach foot, plaster socket, molded to model ($2,379.43–$4,568.53)
- L5570 — Preparatory, above knee - knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, sach foot, thermoplastic or equal, direct formed ($1,308.69–$3,428.66)
- L5580 — Preparatory, above knee - knee disarticulation ischial level socket, non-alignable system, pylon, no cover, sach foot, thermoplastic or equal, molded to model ($1,738.32–$4,142.56)
- L5585 — Preparatory, above knee - knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, sach foot, prefabricated adjustable open end socket ($3,132.31–$4,568.53)
- L5590 — Preparatory, above knee - knee disarticulation ischial level socket, non-alignable system, pylon no cover, sach foot, laminated socket, molded to model ($2,943.01–$4,568.53)
- L5595 — Preparatory, hip disarticulation-hemipelvectomy, pylon, no cover, sach foot, thermoplastic or equal, molded to patient model ($4,929.43–$11,195.96)
Building a device that would bill under a code like this? Caduvo matches a device description to HCPCS/CPT codes, Medicare coverage and payment, and the FDA pathway in one report.
Next steps
- Run a reimbursement report for a device billed under L5500
- Watch L5500 for fee, coverage and descriptor changes
- Build a full Medicare revenue model for L5500
Sources: CMS HCPCS Level II release October 2026; CMS DMEPOS fee schedule 2026; CMS NCCI MUE tables; CMS Medicare utilization (physician and DME supplier files); CMS Medicare Coverage Database articles. Fees are Medicare allowables, not commercial rates. Not billing or legal advice.