L8042 HCPCS code: Orbital prosthesis, provided by a non-physician
L8042 is the HCPCS Level II code for orbital prosthesis, provided by a non-physician. The 2026 Medicare DMEPOS fee schedule pays $3,809.10 to $4,844.80 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. Medicare volume fell 18% from 2022 to 2024 (56 to 46 services). In 2024, 19 suppliers billed Medicare for L8042 (purchases), serving 41 beneficiaries. Its average fee ranks 14 of 17 L80 codes (family range $48.09–$5,112.29).
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 | 2001-01-01 |
| Last action effective | 2001-01-01 |
2026 Medicare DMEPOS fee schedule for L8042
| Modifier | Meaning | Lowest state fee | Highest state fee | Ceiling | Floor |
|---|---|---|---|---|---|
| — | base fee | $3,809.10 | $4,844.80 | $4,919.66 | $3,689.75 |
| KM | prosthetics and orthotics | $3,618.60 | $4,602.58 | $4,673.66 | $3,505.25 |
| KN | prosthetics and orthotics | $1,523.65 | $1,937.90 | $1,967.87 | $1,475.90 |
| State | Modifier | Fee | Rural fee |
|---|---|---|---|
| AK | — | $4,569.01 | — |
| AL | — | $4,052.70 | — |
| AR | — | $3,996.01 | — |
| AZ | — | $4,263.82 | — |
| CA | — | $4,263.82 | — |
| CO | — | $3,894.33 | — |
| CT | — | $4,356.33 | — |
| DC | — | $4,148.60 | — |
| DE | — | $4,148.60 | — |
| FL | — | $4,052.70 | — |
| GA | — | $4,052.70 | — |
| HI | — | $4,374.53 | — |
| IA | — | $3,809.10 | — |
| ID | — | $4,069.63 | — |
| IL | — | $4,133.93 | — |
| IN | — | $4,133.93 | — |
| KS | — | $3,809.10 | — |
| KY | — | $4,052.70 | — |
| LA | — | $3,996.01 | — |
| MA | — | $4,356.33 | — |
| MD | — | $4,148.60 | — |
| ME | — | $4,356.33 | — |
| MI | — | $4,133.93 | — |
| MN | — | $4,133.93 | — |
| MO | — | $3,809.10 | — |
| MS | — | $4,052.70 | — |
| MT | — | $3,894.33 | — |
| NC | — | $4,052.70 | — |
| ND | — | $3,894.33 | — |
| NE | — | $3,809.10 | — |
| NH | — | $4,356.33 | — |
| NJ | — | $4,524.39 | — |
| NM | — | $3,996.01 | — |
| NV | — | $4,263.82 | — |
| NY | — | $4,524.39 | — |
| OH | — | $4,133.93 | — |
| OK | — | $3,996.01 | — |
| OR | — | $4,069.63 | — |
| PA | — | $4,148.60 | — |
| PR | — | $3,835.15 | — |
| RI | — | $4,356.33 | — |
| SC | — | $4,052.70 | — |
| SD | — | $3,894.33 | — |
| TN | — | $4,052.70 | — |
| TX | — | $3,996.01 | — |
| UT | — | $3,894.33 | — |
| VA | — | $4,148.60 | — |
| VI | — | $4,844.80 | — |
| VT | — | $4,356.33 | — |
| WA | — | $4,069.63 | — |
| WI | — | $4,133.93 | — |
| WV | — | $4,148.60 | — |
| WY | — | $3,894.33 | — |
| AK | KM | $4,340.59 | — |
| AL | KM | $3,850.07 | — |
| AR | KM | $3,796.17 | — |
| AZ | KM | $4,050.64 | — |
| CA | KM | $4,050.64 | — |
| CO | KM | $3,699.59 | — |
| CT | KM | $4,138.50 | — |
| DC | KM | $3,941.15 | — |
| DE | KM | $3,941.15 | — |
| FL | KM | $3,850.07 | — |
| GA | KM | $3,850.07 | — |
| HI | KM | $4,155.80 | — |
| IA | KM | $3,618.60 | — |
| ID | KM | $3,866.13 | — |
| IL | KM | $3,927.24 | — |
| IN | KM | $3,927.24 | — |
| KS | KM | $3,618.60 | — |
| KY | KM | $3,850.07 | — |
| LA | KM | $3,796.17 | — |
| MA | KM | $4,138.50 | — |
| MD | KM | $3,941.15 | — |
| ME | KM | $4,138.50 | — |
| MI | KM | $3,927.24 | — |
| MN | KM | $3,927.24 | — |
| MO | KM | $3,618.60 | — |
| MS | KM | $3,850.07 | — |
| MT | KM | $3,699.59 | — |
| NC | KM | $3,850.07 | — |
| ND | KM | $3,699.59 | — |
| NE | KM | $3,618.60 | — |
| NH | KM | $4,138.50 | — |
| NJ | KM | $4,298.14 | — |
| NM | KM | $3,796.17 | — |
| NV | KM | $4,050.64 | — |
| NY | KM | $4,298.14 | — |
| OH | KM | $3,927.24 | — |
| OK | KM | $3,796.17 | — |
| OR | KM | $3,866.13 | — |
| PA | KM | $3,941.15 | — |
| PR | KM | $3,643.45 | — |
| RI | KM | $4,138.50 | — |
| SC | KM | $3,850.07 | — |
| SD | KM | $3,699.59 | — |
| TN | KM | $3,850.07 | — |
| TX | KM | $3,796.17 | — |
| UT | KM | $3,699.59 | — |
| VA | KM | $3,941.15 | — |
| VI | KM | $4,602.58 | — |
| VT | KM | $4,138.50 | — |
| WA | KM | $3,866.13 | — |
| WI | KM | $3,927.24 | — |
| WV | KM | $3,941.15 | — |
| WY | KM | $3,699.59 | — |
| AK | KN | $1,827.59 | — |
| AL | KN | $1,621.08 | — |
| AR | KN | $1,598.41 | — |
| AZ | KN | $1,705.54 | — |
| CA | KN | $1,705.54 | — |
| CO | KN | $1,557.72 | — |
| CT | KN | $1,742.54 | — |
| DC | KN | $1,659.45 | — |
| DE | KN | $1,659.45 | — |
| FL | KN | $1,621.08 | — |
| GA | KN | $1,621.08 | — |
| HI | KN | $1,749.80 | — |
| IA | KN | $1,523.65 | — |
| ID | KN | $1,627.86 | — |
| IL | KN | $1,653.59 | — |
| IN | KN | $1,653.59 | — |
| KS | KN | $1,523.65 | — |
| KY | KN | $1,621.08 | — |
| LA | KN | $1,598.41 | — |
| MA | KN | $1,742.54 | — |
| MD | KN | $1,659.45 | — |
| ME | KN | $1,742.54 | — |
| MI | KN | $1,653.59 | — |
| MN | KN | $1,653.59 | — |
| MO | KN | $1,523.65 | — |
| MS | KN | $1,621.08 | — |
| MT | KN | $1,557.72 | — |
| NC | KN | $1,621.08 | — |
| ND | KN | $1,557.72 | — |
| NE | KN | $1,523.65 | — |
| NH | KN | $1,742.54 | — |
| NJ | KN | $1,809.75 | — |
| NM | KN | $1,598.41 | — |
| NV | KN | $1,705.54 | — |
| NY | KN | $1,809.75 | — |
| OH | KN | $1,653.59 | — |
| OK | KN | $1,598.41 | — |
| OR | KN | $1,627.86 | — |
| PA | KN | $1,659.45 | — |
| PR | KN | $1,534.04 | — |
| RI | KN | $1,742.54 | — |
| SC | KN | $1,621.08 | — |
| SD | KN | $1,557.72 | — |
| TN | KN | $1,621.08 | — |
| TX | KN | $1,598.41 | — |
| UT | KN | $1,557.72 | — |
| VA | KN | $1,659.45 | — |
| VI | KN | $1,937.90 | — |
| VT | KN | $1,742.54 | — |
| WA | KN | $1,627.86 | — |
| WI | KN | $1,653.59 | — |
| WV | KN | $1,659.45 | — |
| WY | KN | $1,557.72 | — |
How the L8042 fee compares
| Measure | Value |
|---|---|
| Rank among 17 L80 codes (lowest = 1) | 14 |
| Family fee range (average of state fees) | $48.09–$5,112.29 |
| Rural fee uplift | — |
Who bills L8042 (2024)
| Measure | Value |
|---|---|
| Suppliers billing rentals | — |
| Suppliers billing purchases | 19 |
| Referring clinicians | 40 |
| Medicare beneficiaries | 41 |
| States with claims | 0 |
| Year | Suppliers | Beneficiaries |
|---|---|---|
| 2022 | 24 | 53 |
| 2023 | 18 | 43 |
| 2024 | 19 | 41 |
Counts only. Supplier and clinician names, contact lists and state-by-state detail are in Caduvo.
Medicare utilization for L8042, 2022–2024
| Year | Services | Beneficiaries | Avg. allowed | Avg. paid |
|---|---|---|---|---|
| 2022 | 56 | 53 | $3,298.18 | $2,585.63 |
| 2023 | 46 | 43 | $3,593.78 | $2,814.43 |
| 2024 | 46 | 41 | $3,768.13 | $2,950.13 |
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
- A52463: Facial Prostheses - Policy Article (CGS Administrators, LLC (DME MAC) Noridian Healthcare Solutions, LLC (DME MAC)) — mentions this code in its coding guidance
What changed for L8042
- 2026-01-01: Average state fee rose 2.0%: $4,041.99 to $4,122.83
- 2026-01-01: Average state fee (KM) rose 2.0%: $3,839.88 to $3,916.67
- 2026-01-01: Average state fee (KN) rose 2.0%: $1,616.80 to $1,649.13
- 2001-01-01: L8042 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 L8042?
L8042 is the HCPCS Level II code for orbital prosthesis, provided by a non-physician. Short descriptor: "Orbital prosthesis".
How much does Medicare pay for L8042?
Under the 2026 DMEPOS fee schedule, non-rural state fees are base (base fee): $3,809.10–$4,844.80; KM (prosthetics and orthotics): $3,618.60–$4,602.58; KN (prosthetics and orthotics): $1,523.65–$1,937.90. Rural fees can be higher.
Does Medicare cover L8042?
Coverage code C — Carrier judgment. Coverage is decided by the Medicare contractor (MAC) case by case.
Did the Medicare fee for L8042 change in 2026?
The average non-rural state fee moved from $4,041.99 in 2025 to $4,122.83 in 2026 (+2.0%). CMS's next quarterly HCPCS and DMEPOS update takes effect January 1, 2027.
How many units of L8042 can be billed per day?
2 on DME suppliers; 2 on outpatient hospital claims (NCCI medically unlikely edits).
Related L80 codes
- L8000 — Breast prosthesis, mastectomy bra, without integrated breast prosthesis form, any size, any type ($44.70–$78.16)
- L8001 — Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, unilateral, any size, any type ($150.77–$165.83)
- L8002 — Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, bilateral, any size, any type ($198.27–$218.12)
- L8010 — Breast prosthesis, mastectomy sleeve
- L8015 — External breast prosthesis garment, with mastectomy form, post mastectomy ($72.05–$86.41)
- L8020 — Breast prosthesis, mastectomy form ($245.60–$366.25)
- L8030 — Breast prosthesis, silicone or equal, without integral adhesive, any type ($386.23–$514.97)
- L8031 — Breast prosthesis, silicone or equal, with integral adhesive, any type ($386.23–$514.97)
- L8032 — Nipple prosthesis, prefabricated, reusable, any type, each ($47.08–$51.79)
- L8033 — Nipple prosthesis, custom fabricated, reusable, any material, any type, each
- L8035 — Custom breast prosthesis, post mastectomy, molded to patient model, any type ($4,403.11–$5,283.69)
- L8039 — Breast prosthesis, not otherwise specified
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 L8042
- Watch L8042 for fee, coverage and descriptor changes
- Build a full Medicare revenue model for L8042
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.