Over the past couple of months, we’ve discussed staying up to date with Medicare coverage of compression following the passage of the Lymphedema Treatment Act, as well as how to determine coverage from other payers, like commercial or Medicare Advantage plans. Once you know what your plan covers, the next step is understanding what’s needed to submit a valid claim. Fortunately, these requirements are fairly consistent across Medicare and other insurance providers.
The Script: Your Doctor’s Order2
A script is simply a doctor’s order for your compression garments or therapy services. Usually, either your DME (durable medical equipment) supplier or your therapist will send this to your doctor for signature.
A valid script must include:
- Your name (as the patient) and date of birth
- Your insurance member ID
- Diagnosis code
- Ordering doctor’s name, signature, and date
- Doctor’s NPI (National Provider Identifier) used for billing
- The specific item needed, including strength if applicable, and any non-standard accessories
- Quantity of items
- Laterality (which side—left or right)
How often the item(s) should be dispensed.
The Item Needed – Billing Codes
Insurance pays for your therapy services or compression garment based on codes.
For services, CPT codes (current procedural terminology codes) are used. For example, in lymphedema, when your therapist does an evaluation (i.e. a service), a code like 97165 may be used (for occupational therapists) or 97161 (for a physical therapist). If education is provided, 97535 may be used.
For compression garments (supplies or products), HCPCS codes1 (Healthcare Common Procedure Coding System codes) are used. For example. A knee-high hose (not custom) with a strength level of 30-40 mmHg & a silicone band to prevent slipping is known as:
- A6552 – GRADIENT COMPRESSION STOCKING, BELOW KNEE, 30-40 MMHG, EACH
- A6593 – ACCESSORY FOR GRADIENT COMPRESSION GARMENT OR WRAP WITH ADJUSTABLE STRAPS, NOT-OTHERWISE SPECIFIED.
Supporting Evidence
Insurance typically requires documentation to support your claim. Examples include:
- Therapy notes: Usually an evaluation and at least one daily visit note
Having the proper script, correct billing codes, and supporting documentation makes it much more likely your claim will be approved.
References
1 Lymphedema Compression Treatment Items – Correct Coding and Billing – Revised
2 Supplier Manual – Chapter 3 Supplier Documentation
3 SWOs – Article Detail – JA DME – Noridian
