Requirements for Medicare Coverage of Lymphedema Compression, Supplies & Accessories
The last post on the Lymphedema Treatment Act (LTA) passage was in December. (The LTA passed December, 2022, & became effective Jan 1, 2024, providing coverage to Medicare beneficiaries for lymphedema compression garments, supplies & accessories.) Since my last post on the topic, I’ve had questions about what’s needed for Medicare coverage. The following are required:
- DMEPOS Enrolled Supplier – a supplier can be a DME supplier or a medical professional providing items to their own patients after enrolling with Medicare to do so. (To learn about becoming a supplier or how a medical professional can become a supplier for their own patients, click here.)
Note: A therapist cannot be a provider & a DME supplier in the same space unless solely providing these items to their own patients. They must still become an enrolled supplier & meet certain requirements to bill for items provided to their own patients. (Such therapists cannot bill items for people who are not their own patients. They can fit patients, however. See below.) (CFR, Title 42)
Note: A trained, experienced fitter is recommended to measure lymphedema compression (particularly custom) & to recommend appropriate accessories. If measurements have been obtained from a therapist who is not enrolled as a DMEPOS supplier, a 3rd party supplier can be used for ordering & billing Medicare. However, payment for the fitting itself is included in the garment payment amount. So, therapists fitting patients & submitting an order to a 3rd party must get payment for their service from that supplier (if payment is desired). Fitting Medicare patients is not a separate, billable service under this law.
- Script – there are specific items that must be on the physician’s order (i.e. script).2
Note: A physician, nurse practitioner, or clinical nurse specialist is considered a “treating practitioner.”
Note: A supplier must have additional information such as supportive documentation. They will likely ask for medical records (such as progress notes, therapist notes, etc.) verifying medical necessity.
Items Needed on Order:
– Beneficiary’s name or Medicare beneficiary identifier (i.e. Medicare number)
– Order date
– A lymphedema diagnosis (acceptable ICD-10 diagnosis codes include: I89.0, Q82.0, I97.2, I97.89)
– Item description (the HCPCS billing code). For a list of lymphedema compression HCPCS codes, click here.
– Quantity of item to be dispensed (i.e. how many are being ordered)
– Treating practitioner’s name or NPI
– Treating practitioner’s signature (no signature stamp is allowed)
Next month, we’ll review what Medicare covers, the frequency & allowable amounts.
************UPDATE 02/19/24**********
The Lymphedema Treatment Act recently published an article summarizing the above. Here’s that pdf.
References
1 https://med.noridianmedicare.com/web/jddme/dmepos/lymphedema-compression-treatment
2 https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=55426
3 https://www.cgsmedicare.com/jc/pubs/news/2023/12/cope147943.html
4 https://lymphedematreatmentact.org/final-coverage-rules/
