Lymphedema Therapy Source

  

By

Compression Billing Confusion

We’re resuming our educational blog about lymphedema. And we’re moving on from the last few posts about Medicare’s new coverage of lymphedema supplies & compression … almost. I had a recent incident worth mentioning.

Lymphedema Treatment Act Website

The Lymphedema Treatment Act (LTA) website has a list of durable medical equipment (DME) suppliers for lymphedema compression supplies & garments. It’s a good start, but it’s not entirely accurate. I’ve had a few inquiries from people who saw this business (Lymphedema Therapy Source) listed on the LTA website as a Medicare supplier. While this business just became an approved Medicare DME supplier this month, it can’t provide supplies or compression garments for people in states outside of Texas (not yet, anyway). That’s because most states (if not all) require a business to have a (DME) license in their state. And that usually requires a physical presence in that state.

The LTA advocacy team sent an email in Aug informing readers that Medicare has updated their online supplier search tool to include compression supplies. Unfortunately, Medicare (nor the Lymphedema Treatment Act website) contain an accurate list of businesses that can bill Medicare for lymphedema supplies.

August LTA newsletter. While both Medicare & the LTA lists include DME suppliers, Medicare’s list may not specialize in lymphedema products. And the LTA list may not include DME suppliers that can bill Medicare in your state (or at all).

How to Find a Billing Supplier

If you have insurance other than Medicare, your carrier may provide a list of suppliers for DME that are in-network. But like the Medicare list, they may not specialize in lymphedema products. The takeaway is: You should call before making a trip to visit a supplier to make sure they sell (on site) the item you’re seeking.

Here’s an example. A few weeks ago, a man came to my office building looking for an orthotic (with a doctor’s script in hand). His doctor had sent him to the building because another company (Accentus) is a local DME supplier who showed as in-network with his insurance. What the man didn’t know is the company specializes in diabetic supplies & that particular office is solely composed of backend office staff (i.e. it’s not a storefront). The girls in the office came looking for me assuming I could help him.

While this business can now bill insurance for DME, the specialty is lymphedema. Not orthopedic products like an ankle brace. I was able to read the script, explain the situation, & advise the man he needed to contact his insurance company again for a list of in-network suppliers. He then needed to call those companies to ensure they sold the ankle support he needed.

Conclusion

While it’s terrific that Medicare will now pay for lymphedema compression, treatment supplies & aids thanks to the efforts of the Lymphedema Treatment Act team, the downside is there’s a lot of confusion among beneficiaries as to how to find a supplier who can bill for their DME needs.

(First posted 09/16/24 for Aug.)

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

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

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