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:
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.
