Lymphedema Therapy Source

  

By

Cash Pay for Medicare Compression?

Medicare will now pay for lymphedema compression supplies, aids & garments. But there may be an occasion when a patient wants to pay cash for an item. Simple, right? Well (as noted in last month’s post), government complicates things. (Next month, we’ll resume our normal educational blog about lymphedema.)

Disclaimer: Information is not garanteed to be comprehensive or accurate. Consult a healthcare law attorney for guidance.

Image by Andrew Patrick / Pexels

In this post, “provider” will be used interchangeably with “supplier” except where noted.

Billing Medicare 1,2

Most patients will want to bill Medicare for anything Medicare will cover. In such cases, providers (i.e. therapists who add a DME supplier aspect to their provider therapy business for their own patients) must have a PTAN (provider transaction access number). This is obtained when enrolling with Medicare. There are three classifications: “participating,” “non participating,” & those who “opt out”.

Participating Providers 3, 4

A participating provider is an individual who contracts with Medicare. They have agreed to accept what Medicare will pay. They are required (by law) to submit a claim on behalf of a Medicare beneficiary for any service or item that’s a covered benefit. This now includes lymphedema compression (thanks to Heather Ferguson & team – see also the Lymphedema Treatment Act). Because they contract with Medicare, these providers cannot accept cash for an item sold to a Medicare beneficiary (other than the deductible, 20% coinsurance or upgrades). They also have other rules (such as issuing an ABN – advanced beneficiary notice – when certain services or items are not expected to be covered.) Some commercial insurance companies require therapists to be Medicare participants in order to become an in-network provider with them.

A Participating Provider can become a Non Participating Provider by notifying their regional national provider enrollment contractor during the enrollment period (mid-Nov to Dec 31 each year). There are currently two regional enrollment providers (NPE East & NPE West) that took the place of the prior National Supplier Clearing House (“NSC”).

Non Participating Providers 5-8

Non participating providers are individuals who accept Medicare payment but not necessarily in full. (They are still “contracted” providers & must have a PTAN in order to bill Medicare – whether they accept or do not accept Medicare’s payment amount in full.) If they choose not to accept Medicare’s payment in full, they can charge more than Medicare’s payment amount (similar to out-of-network providers), but they have a limit (by law) on what amount they can charge. However, this limit only applies to providers, not suppliers.

Non participating providers can require payment upfront but must still issue an ABN (like participating providers). They’re supposed to submit a claim to Medicare on behalf of a patient in order to collect any billed amount. (If a patient submits a claim, a “CMS 1490S” form can be used.) Can a “non participating provider” sell an item for cash to a Medicare beneficiary? Possibly – if a patient specifically states they don’t want Medicare to be billed. (see image below)

Opting Out 9,10

The Social Security Act Title 18 amendment (of the Balanced Budget Act of 1997, §4507) has a provision allowing a provider to opt out of Medicare. Opt-out providers have chosen not to work with Medicare at all. Instead, they privately contract with patients. This decision is valid for two years at a time. Opting out means a provider can legally bill a Medicare patient directly for services that would be covered. This is not an option for therapists or suppliers.

Non-Contracted Providers (Cash Practices or “retail”) 11,12

Can cash-only practices (without a PTAN) choose to sell compression to Medicare patients? According to CFR 42, section 1395m (j)(4)(A), no. One exception may be if the supplier informed the patient before any transaction took place that the supplier did not bill Medicare & the patient agreed to pay cash. And an ABN should be issued for signature as well.

What about internet sales? 12

Can a Medicare patient pay cash for an item now covered by Medicare? Not without the supplier having liability. According to one legal source, a supplier needs to ensure they have an obvious notice on their website (& at checkout) for all Medicare beneficiaries informing the buyer that the supplier does not have a PTAN & does not bill Medicare. They might even consider having an ABN form signed by each Medicare buyer.

Competitive Bidding

Items covered under the LTA are not currently subject to Competitive Bidding according to 42 U.S. Code § 1395m – Special payment rules for particular items and services.

References
1 Title 42 USC section 1395 m(j), https://www.cgsmedicare.com/jc/pubs/pdf/chpt2.pdf
2 https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/pim83c10.pdf
3 (Upgrades) CFR 1395m (19) Certain Upgraded Items https://www.law.cornell.edu/uscode/text/42/1395m
4 (Enrollment Providers) https://www.achc.org/blog/cms-replacing-nsc/)(https://www.cms.gov/medicare/provider-enrollment-and-certification/medicareprovidersupenroll/downloads/contact_list.pdf
5 (Limit not for Suppliers) https://www.medicareinteractive.org/get-answers/medicare-covered-services/outpatient-provider-services/participating-non-participating-and-opt-out-providers#:~:text=Non%2Dparticipating%20providers%20accept%20Medicare,care%20services%20as%20full%20payment
6 (CMS 1490S) https://www.cms.gov/medicare/cms-forms/cms-forms/cms-forms-items/cms012949
7 (paying cash) https://www.webpt.com/blog/times-a-medicare-patient-cant-pay-cash#:~:text=As%20a%20non%2Dparticipating%20provider,may%20reimburse%20the%20patient%20directly
8 https://www.medicareinteractive.org/get-answers/medicare-covered-services/outpatient-provider-services/participating-non-participating-and-opt-out-providers#:~:text=Non%2Dparticipating%20providers%20accept%20Medicare,care%20services%20as%20full%20payment
9 (opting out) https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00093112#P22_1451
10 (opting out) https://www.congress.gov/bill/105th-congress/house-bill/2015#:~:text=were%20not%20notified.-,(Sec.,shall%20receive%20no%20Medicare%20reimbursement
11 (CFR 42, subch 18, part B, section 1395m, (j)(4)(A)) https://www.law.cornell.edu/uscode/text/42/1395m
12 https://medtrade.com/news/billing-reimbursement/selling-dme-by-a-supplier-without-a-ptan/#:~:text=AMARILLO%2C%20TX%20%2D%20Certain%20disclaimers%20must%20be,does%20not%20have%20a%20Medicare%20supplier%20number%2C

By

Billing for Compression (part 3)

We’ve been talking about how a therapist can bill for compression in light of the passage of the Lymphedema Treatment Act. Last month, we noted there were (3) models. The third model involved:

  • a therapist billing Medicare for compression as a supplier & for service as a provider for their own patients, and
  • the same therapist also billing for compression for people who are not their patients.

This gets tricky because the model gives rise to unique ownership concerns related to Medicare & Medicaid payments. (Government complicates things.) These concerns revolve around federal statutes & criminal liability. That’s the focus of this month’s blog.

Disclaimer: Information is not guaranteed to be comprehensive or accurate. Consult a healthcare law attorney for guidance.

Model 3

You would think billing for other people’s patients could be done in your therapy business. But that’s not the case – unless the individual is your patient. And would another therapist want to refer their patients to you – a competitor? Of course, there are several people seeking compression that aren’t wanting treatment. They just need someone who can bill insurance. But does billing for a supply item constitute someone becoming a patient?  Besides that, the 42 CFR has special considerations for therapists billing for compression for their own patients that doesn’t apply to therapists billing for individuals who are not their patients. (See April’s blog update.) A seemingly easy solution is to have a second business.

If you have a second business for DME, why not simplify things? Keep your therapy services in the therapy business & the DME in a DME business. You could have both businesses in the same location & save on costs (like rent). Additional benefits could include having a different taxonomy code (for potential better reimbursement rates), less confusion among insurance payors, & legal protection from financial losses.  You could refer your therapy patients to the DME business. Right? Wrong. (Why not? Well, government complicates things.)

Medicare Supplier Standards2

Anyone who plans to bill federal healthcare programs for DME must be mindful of the 42 CFR Supplier Standards. One of those standards states a supplier is prohibited from sharing a practice location with another Medicare provider or supplier. But there are a few exceptions. Two of these include:

  • a therapist (i.e. provider) who is billing DME for their own patients only
  • a DME supplier can be co-located with & owned by a Medicare provider (e.g. therapist), but the businesses must operate separately (separate phone lines, separate computers, separate staff, etc.). You must also meet the definition of a Medicare provider.7,8

It would seem you actually could separate the therapy business & refer your patients to your DME company. But that’s not the case. (Did I mention government complicates things?)

The Anti-Kickback Statute

The Anti-Kickback Statute is one of the fraud & abuse laws mentioned last month. It was an amendment added to the Social Security Act & first passed by Congress in 1972 as an effort to prevent fraud & abuse of federal healthcare programs (i.e. Medicare & Medicaid).6 It can be found in Title 42 of the U.S. code which covers public health & welfare. (These laws are broken down into titles, chapters, subchapters, parts & sections.)3,4 Specifically, Section 1320a-7b talks about the Anti-Kickback Statute. This amendment prevents giving or receiving anything of value (e.g. money, free rent or other perks) for generating healthcare business paid for by federal programs.

In other words, if you had two businesses that billed Medicare or Medicaid, & you wanted to refer patients from one to the other, you can’t. (Unless, of course, you don’t mind jail time & hefty monetary penalties. Most therapists try to avoid these.) There are a few “safe harbor” exclusions that will allow such business transactions.5 But all elements of a safe harbor must be met. (And these have pros & cons.)

Two notes: First, this only applies to providers/suppliers billing federal healthcare programs (clarification is needed as to whether the non-direct plans like the exchange programs provided by commercial plans are included in this). Second, you can still have a therapy business providing therapy services & DME to your own patients. You can also have a separate DME business for other people’s patients in addition. But these must operate entirely separately & cannot refer business between them if you bill federal healthcare programs unless you fall within one of the safe harbor exclusions. You would also be wise to consider other mitigating factors to prevent implication of Anti-Kickback Statute violation.

There’s one more question that comes to mind regarding billing. What if a Medicare patient wants to pay cash for an item? We’ll look at that next month.

References
1 https://oig.hhs.gov/compliance/physician-education/fraud-abuse-laws/
2 (supplier standards) https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-424/subpart-D/section-424.57
3 https://www.govinfo.gov/app/details/USCODE-2010-title42/USCODE-2010-title42-chap7-subchapXI-partA-sec1320a-7b
4 https://uscode.house.gov/
5 (safe harbors) https://www.ecfr.gov/current/title-42/chapter-V/subchapter-B/part-1001/subpart-C/section-1001.952
6 https://www.whistleblowerllc.com/anti-kickback-statute/#:~:text=Congress%20first%20enacted%20the%20AKS,physicians%20corrupt%20medical%20decision%2Dmaking.
7 (clinic definition) https://www.govinfo.gov/content/pkg/USCODE-2011-title42/html/USCODE-2011-title42-chap7-subchapXVIII-partE-sec1395x.htm, https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R5BP.pdf & https://www.ssa.gov/OP_Home/ssact/title18/1861.htm
8 (OTPP definition) https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R5BP.pdf

Attribution
Photo by Olia Danilevich Pexels

By

Billing for Compression (part 2)

Last month, we highlighted how therapists can bill insurance for compression for their own patients. It’s not exactly straight-forward. There are several federal & state laws that must be considered (among others). And if you want to bill compression for other people’s patients, well – that throws a wrench into the mix! This post will discuss how therapists can do that & what needs to be considered.

Disclaimer: Information is not guaranteed to be comprehensive or accurate. Consult a healthcare law attorney for guidance.

Billing Medicare

Let’s recap your options for billing for compression as a therapist. There are (3) models.

  1. You only bill Medicare for compression as a supplier (not for service as a provider). You still have to know the laws relevant to DME & pay related fees. But the model is simple.
  2. You bill Medicare for compression as a supplier & for service as a provider within your business. It’s still fairly simple but it is a bit more complex than the first model.
  3. You bill Medicare for compression as a supplier & for service as a provider – but you also want to bill compression for other people’s patients. Hmmm….that’s tricky. This model has unique ownership precautions that not only gets into federal statutes (as do the above options) but also criminal liability.

First, in order to bill for compression, you must have a DME license in your state & follow your laws (therapist or not). You must also credential with insurance companies (if you want to be in-network) & decide whether you’re going to bill yourself (using a software) or whether you’re going to use a third-party. (Each of these has their own learning curve.)

Second, if you want to bill for compression in other states (obviously for people who are not your patients), you must follow the same procedures as above. You also need to be prepared to open a physical location in each of those states. Third, if you plan to bill for your own patient’s compression & also bill for other people’s compression, you need to be aware of federal statutes pertaining to fraud & abuse as well as to business ownership.

Federal Statutes: Fraud & Abuse Laws1

The Office of Inspector General outlines five of the most important laws pertaining to medical professionals. These include:

1. False Claims Act – don’t lie, overcharge or provide poor-quality goods
2. The Anti-Kickback Statute – don’t give or take rewards (money or otherwise) for referrals or business involving federal funds
3. Stark (or self-referral) Law – a physician (or their family) can’t have a financial interest in a business & refer Medicare or Medicaid patients to it
4. The Exclusion Authorities – people or business convicted of certain crimes are automatically excluded from federal health care plan participation
5. Civil Monetary Penalties Law – you may be fined fees (ranging from $10k-$50k per violation) based on certain laws breached

Some of these laws are for physicians only (such as Stark Law), but others pertain to everyone. The most relevant to our discussion is the Anti-Kickback Statute. We’ll pick that topic up next time.

References
https://oig.hhs.gov/compliance/physician-education/fraud-abuse-laws/

Attribution
Pexels calculation photo by Tom Miroshnichenko
Pexels gavel photo by Katrin Bolovtsova

By

Billing for Compression

It’s April Fools’ Day & do I have a hoax for therapists wanting to bill Medicare in light of the Lymphedema Treatment Act (LTA). Seems simple, right? Read on…

Applicable Laws

There are several federal & state laws you need to be aware of to bill for compression (which falls under DME or durable medical equipment). A non-comprehensive list of these laws includes the supplier standards in the Code of Federal Regulations (CFR), anti-kickback laws & state DME regulations. It’s also going to cost a fair amount of money to start. The good news is, if you’re a therapist who already bills insurance as a provider, you can also bill for DME as a supplier within the same business. (You do need to consider, however, how taxonomy codes may impact reimbursement for commercial payors in such case.) If you want to bill for your own patients, setting up is simpler. If you want to bill for other people’s patients, it’s tricky & potentially more expensive. Let’s look at the first scenario in this blog.

Billing Insurance for Your Own Patients

If you have a therapy practice which bills insurance as a provider for lymphedema treatment, you’ll need to establish a DME part to your business to be a supplier. You should already have an office space (hopefully, that’s no less than 200 sq feet as required by federal supplier standards). So, the next step is to familiarize yourself with the 42nd chapter of the Code of Federal Regulations. It says therapists in private practice can bill for their own patients & avoid some of the supplier standards that others must adhere to. Namely, you can avoid paying for a surety bond & having to keep the business open/staffed for a minimum of 30 hours/week. You still have to set up a separate land line that’s answered (no cell phones or call centers) & pay for accreditation, Medicare’s application fee & liability insurance (among other costs).

The second step is to contact your state’s DME licensing board to find out applicable laws. These laws may be under a different name such as “device distributors” for your purposes. Complete your state’s licensing paperwork & pay their fee.

Next, contact one of Medicare’s approved DME accreditation agencies. Medicare has a list of these agencies.1 After ensuring you’re in compliance with their rules, complete their application & pay that fee. (Many suggest you also retain a consultant to help with all the required policy & procedures that must be implemented & on-hand during site visits.)

Fourth, once all laws & fees are paid, you’re ready to credential with insurance (if you want to be in-network). Call the credentialing line for each insurance company you’d like to contract with & specify that you’re seeking to be a DME supplier in-network. They’ll send you the necessary paperwork & fee schedule once you’re approved. (Be prepared: There may be some confusion with insurance credentialing staff if you’re already credentialed as a provider. Again, you’ll need to specify you want to credential as a DME supplier. You can hire a 3rd party to assist with credentialing.) For Medicare, there’s an extra step. You’ll need to know your state’s local DMEPOS MAC (durable medical equipment, prosthetics, orthotics & supplies Medicare administrative contractor). These MACs have jurisdiction over specific regions in the United States. These jurisdictions are called A, B, C, & D. For example, Texas falls in jurisdiction C. The DMEPOS MAC for Texas is CGS Administrators (CGS Medicare).

Fifth, familiarize yourself with Medicare’s LTA billing requirements. If you’re already a provider billing insurance, you’ve got a leg up on understanding billing codes. For example, you know providers use CPT codes, but suppliers use HCPCS codes. You’ll also need to know about modifiers, when to use them & other billing requirements for the LTA.4  You can find out more about these requirements on your MACs site.

Conclusion

It’s important to note that just because you’re able to bill Medicare in your state doesn’t mean you can bill for DME for other states. We’ll cover that & billing DME for other people’s patients in the next post.

***UPDATE 06/11/24***

According to the National Provider Enrollment West (NPE West) division (granted to Palmetto GBA), therapists (billing for their own patients only) are no longer required to be accredited. But they must get a surety bond. (This is a change from the current rules.)2 In an email, the administrator said, “Per CMS, lymphedema items are a separate benefit under SSA 1861(s)(2)(JJ).  They are not orthotics, prosthetics, and supplies mentioned in 42 CFR 424.57(d)(15)(i)(D)(3), and any OT/PT wanting to update the enrollment to furnish lymphedema items would not be “only billing for orthotics, prosthetics, and supplies”, and would no longer qualify for the surety bond exemption. CMS also contacted the HHS Office of General Counsel, which confirmed CMS’ determination.“

References
1 (DME accreditation list) https://www.cms.gov/files/document/dmepos-accreditation-organizations.pdf
2 (CFR 42) https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-424/subpart-D/section-424.57
3 (DMEPOS MACs) https://www.cms.gov/medicare/coding-billing/medicare-administrative-contractors-macs/who-are-macs
4 (modifiers) https://www.cgsmedicare.com/jc/pubs/news/2023/12/cope147943.html

By

Compression Garments & Insurance (part 5/5)

Because of the Lymphedema Treatment Act, Medicare will now cover lymphedema compression, supplies & aids with the appropriate diagnosis code & medical necessity. What items are covered & how do you get them?

Diagnosis Codes

A diagnosis code must be written on a physician order. Appropriate diagnosis codes1 to qualify for the new lymphedema benefit category are

  • I89.0 Lymphedema, not elsewhere classified
  • I97.2 Post-mastectomy lymphedema
  • I97.89 Other postprocedural complications & disorders of the circulatory system, not elsewhere classified
  • Q82.0 Hereditary lymphedema

Medical Necessity

A patient must have a medical necessity for the ordered item(s). Medical necessity is proven by physician order & supportive documentation. A physician order can be signed by a “treating practitioner,” meaning, a medical doctor, doctor of osteopathy, podiatrist, physician’s assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS).2,3 The following must be on the “standard written order.”2

  • The name of the treating practitioner, their NPI (national provider identifier), their signature & the date
    • stamps can’t be used; signatures & dates can be electronic or handwritten1,4
  • The beneficiary’s name (the patient’s name) & Medicare number
  • Description of the item(s) (such as the HCPCS code1)
    • options or features constituting an upgrade above the basic item must be listed separately on the order (such as upgrading from an off-the-shelf hose to a custom hose or adding a lining, zipper or pocket to a custom garment, etc.)
    • supplies must be listed separately on the order (such as a donning frame, donning gloves, etc.)
  • The quantity to be dispensed.

Supportive documentation (if requested) would include medical or therapy notes. (Note: Some DME requires a face-to-face encounter with the treating practitioner within 6 months of an order.5 Lymphedema items are not currently on that list.)

Compression Supplies Covered

Phase 1 of lymphedema treatment (the reduction or decongestion phase) requires decongestion supplies. This typically includes a cotton liner, a padding layer & several short-stretch bandages. At times, a Velcro reduction garment or wound kit might be used instead.

For coverage, supportive documentation must include justification for the quantity & frequency of these items. In my experience, two sets of supplies are needed (one to use & one to wash). Each set can be laundered & reused each session. (Avoid bleach, fabric softener, Woolite, dryer use or placing items in the sun as these things can damage the elastic fibers.)

When it comes to billing, a supplier will need to line-item each compression bandaging supply, accessory, wrap or garment that doesn’t have a unique HCPCS code with one of the following best-matched HCPCS codes:

  • A6549 – Gradient compression garment, not otherwise specified
  • A6584 – Gradient compression wrap with adjustable straps, not otherwise specified
  • A6593 – Accessory for gradient compression garment or wrap with adjustable straps, not otherwise specified
  • A6609 – Gradient compression bandaging supply, not otherwise specified.

The supplier will also need to add:1

  • a description of the item (including the inch, foot or yard for supplies)
  • manufacturer name
  • product name & number
  • supplier price list
  • HCPCS of a related item.

Billing modifiers are needed as well (right, left, replacement – if an item is lost, stolen or damaged, etc.).

All therapists & patients should be good stewards & conservative in their utilization of this benefit. Abuse & waste will cause problems down the road (be it increased government debt, higher taxes or another outcome).

Compression Garments Covered

Phase 2 of lymphedema treatment is the maintenance phase. This is when compression garments are needed to maintain the volume loss attained in Phase 1. Medicare covers these garments which may include:

  • off-the-shelf or custom (for all body parts) (typically flat-knit, circular-knit or Velcro)
  • day &/or night garments (typically Velcro or foam garments).

Medicare allows for:

  • (3) daytime garments every 6 months
  • (2) nighttime garments every 24 months

    (Note: There are two situations in which additional compression may be covered. The first is if an item is lost, stolen or damaged. The second is if there is a change in the patient’s status or condition. Either situation will require a new order & the replacement clock will start over.1)

Garment Aids Covered

Many patients are not aware there are several donning & doffing aids available to help get compression on or to remove it. There are donning frames, slippery material, gloves & other tools your therapist may know about. Justification for the quantity of supplies & the frequency of dispensing must be supported by documentation.

YouTube
Check out the Lymphedema Savvy YouTube channel for an upcoming treatment vlog. Information about the Lymphedema Treatment Act & billing will be included in a future video.

*****UPDATE 07/22/24*****

The following educational handouts were provided by the Lymphedema Treatment Act:

Patients
Providers
Suppliers

*****UPDATE 02/19/25*****

The current list of HCPCS lymphedema compression billing codes can be found here. The US Medical Compression Alliance has noted Medicare approval of additional codes here (effective April 1, 2025). They are specifically listed in Medicare’s Final Rule here. Medicare Learning Network (MLN Matters publication) provides billing tips here.

References
1 (coverage) https://www.cgsmedicare.com/jc/pubs/news/2023/12/cope147943.html
2 (orders) https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=55426
3 (physician) https://www.ssa.gov/OP_Home/ssact/title18/1861.htm
4 (signatures) https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/pim83c03.pdf
5 (face to face) https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medical-review-and-education/dmepos-order-requirements or https://www.federalregister.gov/documents/2023/01/17/2023-00718/medicare-program-updates-to-face-to-face-encounter-and-written-order-prior-to-delivery-list#:~:text=For%20items%20on%20the%20F2F,of%20the%20written%20order%2Fprescription.

By

Compression Garments & Insurance (part 4)

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.

Coverage-for-Lymphedema-Compression-Supplies-copyDownload

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/

By

Lymphedema Savvy

Goals

January 1st, 2024. It’s a new year. And it’s 5:52 am. I’m sitting at my desk contemplating this month’s (& this year’s) blog theme. The new year is a time to begin fresh, to start anew, envisioning what you want to happen in your future & contemplating the past. I’m ever amazed at how quickly January 1st comes. And ever disappointed I didn’t accomplish all I wanted the past year. Why is that?

(Photo by cottonbro studio / Pexels)

No matter how hard we try, life seems to derail the best intentions. Intentions to lose weight, quit smoking, spend more time with family, get more sleep, exercise, save money, accomplish that long-term goal. Like any good travel plans, you have a destination (what you want to accomplish) & a map (or GPS…how you’re going to get there). But you have to check in once in a while to make sure you’re on the right track. The one goal I wanted to get done was the launch of the Lymphedema Savvy Treatment Vlog. It didn’t get done. Let’s “check in.”

A Year in Review

As I reflect on the past year, a lot has been accomplished.

The Clinic

The clinic re-opened in 2022 after settling in a new location. By early to mid-2023, decorating, storage & organization was complete. The business re-credentialed to be in-network with major insurance companies. Systems, processes & operations (intake, benefit verification, billing & documentation) were reviewed. Legal & financial aspects taken into consideration along with marketing ideas & vendor connections.

(before & after)

Durable Medical Equipment (DME) – i.e. compression garment billing

With the Lymphedema Treatment Act passage, the DME currently provided in the clinic is switching to a separate business for insurance billing. That requires accreditation, insurance credentialing, new vendor accounts, etc. It’s “complicated.” You can read more about the Lymphedema Treatment Act in the recent blog posts.

The YouTube Channel

The Lymphedema Savvy YouTube channel launched in 2021 with subsequent plans to create the treatment vlog. The vlog would feature video from patient treatment sessions (with patient approval) to raise awareness about lymphedema & conditions that cause it. But it has been quite a journey. From learning technology to losing data (more than 2 years of recording). From obtaining a trademark to setting up interviews. It’s been a challenge! Check out the revised (“after data loss”) intro below. It is coming!

Happy New Year! I hope you accomplish all you desire in 2024.

Lymphedema Treatment Vlog

By

Compression Garments & Insurance (part 3)

This post will wrap up (for now) Medicare’s recent passage of the Lymphedema Treatment Act (LTA) requiring coverage of lymphedema compression & supplies. (Included will be pictures of a few examples.) One concern I cited last month was the competency of the typical DME supplier to fit compression garments. I will expand on that in this post.

Bill Coverage summary

You can read last month’s post for a more comprehensive overview of what will be covered in the LTA. You can find the final Medicare rule here.

Swell spot (by JoViPak) – use to break up fibrosis or fluid pocketing on the chest wall & under the armpit typically related to breast cancer & mastectomy.

In short, compression garments (readymade or custom) & treatment supplies will be covered. Additionally, accessories like donning or doffing aids will be included in the coverage (items which help you put compression on or take it off).5 These will be covered at 80% (with 20% being your responsibility depending on what coinsurance you have). Garments are subject to the Medicare deductible.

Regarding frequency, as noted on p. 58 & 60 of the above final rule link:

  • Medicare has increased the frequency limitations to (3) sets of daytime compression garments every 6 months & (2) nighttime garments every two years.
  • Medicare doesn’t propose a specific frequency for bandaging systems & supplies (including accessories). The DME company will have to determine what is “medically necessary.”

Swell spot for the neck such as may be needed after head/neck cancer.

DME supplier requirements

Anyone providing DME-covered items must be a licensed DME supplier. That means a company must be enrolled with Medicare as a DME supplier & meet supplier standard requirements. There are several steps (& expense) to this process.

What is not highlighted is how important the knowledge & competency of a fitter is. A fitter should have a broad understanding of lymphedema & related pathology. Under this heading I would include an understanding & awareness of the following (non-comprehensive) list:

  • causes & complications of lymphedema
  • the disease process of the above lymphedema causes
    • for example, lipedema compression tolerance in stage 1 vs stage 3
    • for example, cancer precautions
  • complications of common comorbidities such as
    • weakness due to arthritis
    • restrictions due to arterial disease
    • restrictions due to fragile, thinning skin
    • limited mobility, back precautions & safety donning/doffing compression (or modification of tools)
    • edema-causes of swelling (like heart failure or venous reflux) which may not tolerate circular-knit hose
    • adaptive devices for assisting donning/doffing compression
  • recognizing & knowing how to address pressure spots caused by garments
  • textile properties & how they affect tissue containment
    • for example, gradient pressure or working pressure vs resting pressure

Farrow Velcro sleeve & readymade glove (readymade means it’s not custom).

DME supplier recommendations

While standard DME companies can address basic DME items like walkers, canes, wheelchairs, etc., fitting compression garments requires a more nuanced knowledge. Ideally, the fitter would also be an experienced lymphedema-certified therapist. An experienced therapist will have a working knowledge of lymphedema, comorbidities, problems with donning/doffing & creative solutions. They will have an idea of long-term outcomes associated with particular garments & lymphedema or related conditions. A therapist would also be an ideal person to educate patients on topics listed in the prior section.

But just because a therapist has experience treating lymphedema doesn’t mean they have experience fitting patients with compression. For example, fitting custom garments is a developed skill, & measuring technique can vary between manufacturers. In addition, an experienced lymphedema therapist may not have a good knowledge of billing practices. For example, they may not know how to verify copays, deductibles, prior authorization & pre-certifications or when to apply modifiers to HCPCS billing codes.

Thuasne chipped foam, Velcro lower leg garment. (Typically, a nighttime garment.)

DME fitters

Ideally, a DME fitter would be an experienced lymphedema therapist familiar with (& practiced in) fitting compression – including custom. They would also have a working knowledge of billing practices.

In cases where the DME fitter is not an experienced therapist, the next best scenario would be for the fitter to work closely with a lymphedema therapist. As noted above, unfortunately, many therapists don’t have a comprehensive knowledge of compression products. Their specialty is treating lymphedema. Hopefully, lymphedema training schools will add more compression training to their curriculum. But until then, most manufacturers offer free educational classes. A therapist only needs to contact them. Well-known manufacturers of lymphedema compression include:

  • Lohmann Rauscher (includes Solaris)
  • Essity (formerly BSN Medical – includes Jobst, Farrow, & JoViPak)
  • Juzo
  • Sigvaris (including Biacare)
  • Medi
  • Thuasne
  • LympheDIVAs

LympheDIVAs readymade sleeve & glove

For therapists who want to be fitters

From my experience, I’d recommend a therapist who wants to fit compression start by learning one manufacturer’s products well.  Lohman Rauscher, for example, offers both treatment supplies & compression garments. They would be a good manufacturer to start with. Once that manufacturer’s products are mastered, another manufacturer such as Essity (BSN Medical) could be learned. And so on.

Conclusion

The good news is compression garments & supplies will now be covered by Medicare. The bad news is lymphedema is a specialty field. Compression garments (& fitting them) are a niche within that specialty which many people do not have a good working knowledge of.

Jobst Readymade nighttime leg garment

P.S. If you don’t have traditional Medicare…

The Lymphedema Treatment Act team has requested you contact your insurance company (if it’s not traditional Medicare as your primary insurance) & request the company modify their coverage of lymphedema compression coverage (following Medicare’s new policy).  If you have private insurance plans (whether employer-based or purchased separately), supplemental and secondary plans, Medicare Advantage, Medicaid, TriCare, & VA health care, the LTA team provides a template you can print here.

Juzo readymade sleeve

By

Compression Garments & Insurance (part 2)

As you know from last month’s blog, the Lymphedema Treatment Act (LTA) was passed in December of 2022. Most of 2023 has been spent with Heather Ferguson & others communicating with legislators & Medicare on what should be included in the bill coverage.

Flat-knit hose & a toe cap

Bill Coverage

On page 45 of the “Medicare and You 2024” handbook,1 it states if you have a diagnosis of lymphedema, Medicare will cover your medically gradient compression garments (with a physician’s prescription) at 80%. Coverage is for standard, off-the-shelf garments or custom-fitted garments. You’ll pay your 20% (unless you have a supplemental plan). Your part B deductible applies.

The proposed final rule is a more specific.2 It states medically gradient compression garments (readymade or custom, Velcro or other) will be covered as well as bandaging supplies. Anyone providing these items must be enrolled with Medicare as a DME supplier & meet supplier standard requirements.

Where You Can Find a Supplier Who Can Bill For Compression Garments

You can use Medicare’s online search tool3 to search for a supplier capable of billing for the items. One concern I have is whether these will be competent fitters (vs standard DME suppliers whose knowledge is typically limited to basic sleeves & hose). Lymphedema Therapy Source plans to use a second business to bill for lymphedema supplies & compression (including pneumatic compression pumps). This will include a lengthy process of becoming an enrolled DMEPOS supplier, becoming accredited, meeting all DME supplier and quality standards, obtaining a surety bond & submitting claims to the appropriate Medicare contractor for DME. (No small task!)

circular-knit hose

Billing Codes4 (see updates at the end of page)

While therapy services are billed using CPT codes, products (or DME supplies) are billed with HCPCS Level II codes. Below is a list of expected codes & descriptions for lymphedema compression items covered by Medicare as a result of the Lymphedema Treatment Act.

HCPCS Codes for Compression Treatment Items:
Compression Hose
A6530 Gradient compression stocking, below knee, 18-30 mmHg each
A6531 Gradient compression stocking, below knee, 30-40 mmHg, each*
A6532 Gradient compression stocking, below knee, 40-50 mmHg, each*
A6533 Gradient compression stocking, thigh length, 18-30 mmHg, each
A6534 Gradient compression stocking, thigh length, 30-40 mmHg, each
A6535 Gradient compression stocking, thigh length, 40-50 mmHg, each
A6536 Gradient compression stocking, full length/chap style, 18-30 mmHg, each
A6537 Gradient compression stocking, full length/chap style, 30-40 mmHg, each
A6538 Gradient compression stocking, full length/chap style, 40-50 mmHg, each
A6539 Gradient compression stocking, waist length, 18-30 mmHg, each
A6540 Gradient compression stocking, waist length, 30-40 mmHg, each
A6541 Gradient compression stocking, waist length, 40-50 mmHg, each

Velcro (or other)
A6545 Gradient compression wrap, non-elastic, below knee, 30-50 mmHg, each*
A6549 Gradient compression stocking/sleeve, not otherwise specified

Compression Sleeves & Gloves
S8420 Gradient pressure aid (sleeve and glove combination), custom made
S8421 Gradient pressure aid (sleeve and glove combination), readymade
S8422 Gradient pressure aid (sleeve), custom made, medium -weight
S8423 Gradient pressure aid (sleeve), custom made, heavy -weight
S8424 Gradient pressure aid (sleeve), readymade
S8425 Gradient pressure aid (glove), custom made, medium -weight
S8426 Gradient pressure aid (glove), custom made, heavy -weight
S8427 Gradient pressure aid (glove), readymade
S8428 Gradient pressure aid (gauntlet), readymade

Other (including treatment supplies)
S8429 Gradient pressure exterior wrap
S8430 Padding for compression bandage, roll
S8431 Compression bandage, roll

There may be changes to some of these codes. For those with an asterisks (*), new HCPCS codes may be assigned when these items are used as surgical dressings (such as in the case of an open venous stasis ulcer).

Velcro leg & foot compression

***UPDATE 11/30/23***

Beginning in 2024, there will be 81 HCPSC codes specifically for lymphedema compression supplies (most will be new).

Where You Can Find More Information

Visit the Lymphedema Treatment Act for more information & an up-to-date status on the bill & its coverage: https://lymphedematreatmentact.org/faqs/.

A special thank-you to Heather Ferguson & her team for their ongoing fight to get the LTA passed.

***UPDATE 01/05/24***

Lymphedema HCPCS billing codes have been published & are listed here. A person must have one of the following diagnosis codes:

  • I89.0 (lymphedema, not elsehwere classified)
  • I97.2 (postmastectomy lymphedema)
  • I97.89 (Other postprocedural complications and disorders of the circulatory system, not elsewhere classified)
  • Q82.0 (hereditary/primary lymphedema)

References
1 https://www.medicare.gov/publications/10050-Medicare-and-You.pdf
2 https://lymphedematreatmentact.org/wp-content/uploads/2023/07/LTA-Section-Home-Health-Rule.pdf
3 https://www.medicare.gov/medical-equipment-suppliers/
4 LTA Home Health Rule, p. 13

By

Compression Garments & Insurance Coverage

Even though the legislation was submitted over 10 years ago to government delegates, the Lymphedema Treatment Act is still not widely recognized by most people who have lymphedema. Yet passage of the bill (which was accomplished Dec. 23, 2022) is so important to lymphedema care. It will become effective Jan. 1, 2024. Why is it important to lymphedema?

Lymphedema Care

Lymphedema treatment has two phases. Phase I is decongestion. This is the therapy phase when CDT is administered. (CDT is complete decongestive therapy & involves manual lymph drainage, bandaging, skin care & exercise.) Once maximum reduction is attained in therapy, the next step is fitting with a compression garment (usually for day & night). This is a part of Phase II (the maintenance phase).

Maintenance Phase

Compression garments are mandatory for lymphedema maintenance. Without them, swelling will promptly recur, & the reduction obtained during therapy will be lost. There are a few different types of compression.

  • Flat-knit (usually custom-made, but readymade is available) – daytime garment
  • Circular-knit (usually readymade, but custom is available) – daytime
  • Velcro (commonly used in wound care or as a night option) – day or night
  • Foam sleeves (nighttime use) – night
    (Note: Self-bandaging at night is the textbook recommendation for lymphedema maintenance.)

Recommended Compression

While circular-knit & Velcro can be used in some edema-related cases (such as venous edema) or combination edema-lymphedema cases (such as phlebolymphedema), the recommended compression for lymphedema is custom, flat-knit. One reason is the fact the many lymphedematous extremities don’t fit into the readymade dimensions. Another reason is the way flat-knit garments are made. While other garments provide compression, flat-knit provides the best containment. Flat-knit also aids in softening hardened, fibrotic tissue caused by lympedema. Finally, flat-knit is a thicker fabric less prone to bunching & causing pain in joints (such as ankles & behind knees).

Cost & Insurance

The downside to compression is cost. Compression should be replaced every 6 months (to a year) because it loses its effectiveness as fibers wear out.1 Many insurance carriers follow Medicare’s guidelines, & until 2024, Medicare won’t cover the cost of lymphedema compression. Here’s where you come in! (For more on cost, see the below video clip.)

Lymphedema Treatment Act (LTA)

The Lymphedema Treatment Act was passed in December of 2022. But the legislation details are still being worked out. Heather Ferguson is the founder of this legislation. She sends out a newsletter with updates. And she needs your help. Please read the below letter, & contact your insurance company. Heather makes it easy for you by providing templates & links.

LETTER: https://ltstherapy.com/wp-content/uploads/2023/09/LTA-1.pdf
Action Item #1: click here
Action Item #2: click here

References
1 Foldi, M, Foldi, E. (2006). Foldi’s Textbook of Lymphology (2nd ed.), p. 595. Germany: Urban and Fisher. Foldi, M., & Foldi, E. (2012). Foldi’s Textbook of Lymphology (3rd ed.). Urban and Fisher.

Contact Us

309 W. Eldorado Pkwy
Little Elm, Texas 75068-5196
214-422-8265 | 469-579-5034
214-614-9352 fax
info@LTStherapy.com

cropped-Cropped-beach-lts-header.png