Lymphedema Compression Treatment - JA DME

Accessories (e.g., zippers, linings, padding or fillers, etc.) necessary for the effective use of a lymphedema compression treatment item fall under this benefit. For example, a liner that is used with a garment could be covered under this benefit if it is determined that it is needed to prevent skin breakdown associated with wearing the garment.

When an order for a customized item is canceled, the beneficiary passes away before the scheduled delivery, or the beneficiary's condition changed and the item is no longer reasonable and necessary or appropriate, suppliers are eligible for reimbursement for the labor and parts invested in the customization process.

Miscellaneous HCPCS Codes Requiring Narrative

CMS established four not otherwise specified HCPCS codes to identify compression bandaging supplies, accessories, wraps, and compression garments that are not identified by a unique HCPCS code:

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

Each of the codes above must be billed on a separate claim line with the appropriate units of service with a narrative. The claim line must include the following information in the narrative field of an electronic claim (NTE 2300 or NTE 2400) or Item 19 of a paper claim:

Required Narrative

To process the claim correctly, the claim must Indicate what it is, what is it for, what is Supplier Price List (PL) amount.

• Description of the item (including the quantity represented by each unit of service (e.g., per inch, foot, or yard for supplies))
• Manufacturer name
• Product name, model name and number
• Supplier Price List (PL) amount
• HCPCS of related item (where applicable)
• Example
  • Titanium Hooks 3010865 Manufacture, for XXXXX (HCPCS Code), Supplier Price List (PL) amount $XXX.XX

Note: If the narrative information is not added to the claim, the claim will deny as missing/incomplete/invalid description of service for a Not Otherwise Classified (NOC) code and must be corrected and rebilled as the denial will indicate there are no appeal rights because the claim is unprocessable.

The right (RT) and left (LT) modifiers must be used with gradient compression garments, related supplies and accessories when laterality is indicated. Please utilize the Modifier Lookup Tool for questions on which modifiers are applicable to each HCPCS code.

When the same code for bilateral items (left and right) is billed on the same date of service, bill each item on two separate claim lines using the RT and LT modifiers and one unit of service (UOS) on each claim line. Do not use the RTLT modifier on the same claim line and bill with two UOS. Claims billed without modifiers RT and/or LT, or with RTLT on the same claim line and two UOS, will be rejected as incorrect coding.

Daytime: If one daytime garment or wrap is lost, stolen, or irreparably damaged, the DME MACs shall allow payment for three replacements. The frequency limitation clock of six months restarts based on the date of service for the replacement claim.

Nighttime: If a nighttime garment is lost, stolen, or irreparably damaged, the DME MACs shall allow two replacements. If only one nighttime garment or wrap is lost, stolen, or irreparably damaged, the frequency limitation clock of two years (24 months) restarts based on the date of service for the replacement claim.

Note: The RA modifier is required when replacing an item due to loss, irreparable damage, or when item has been stolen, a narrative explaining the reason for replacement is also required, if prior to end of RUL of the item.

Lymphedema compression treatments are a DMEPOS benefit category established for items furnished on or after January 1, 2024. Items include:

• Standard daytime gradient compression garments
• Custom daytime gradient compression garments
• Nighttime gradient compression garments
• Gradient compression wraps
• Accessories (e.g., zippers, linings, padding or fillers, etc.) necessary for the effective use of gradient compression garment or wrap; and
• Compression bandaging systems/supplies

• CMS Medicare Learning Network (MLN) Matters (MM) 13286 - Lymphedema Compression Treatment Items: Implementation

Coverage of lymphedema compression treatment items is available under the new benefit for use in treating beneficiaries with any diagnosis of lymphedema. Claims billed with a diagnosis not listed below will be denied as noncovered. An Advance Beneficiary Notice of Noncoverage (ABN) is not required in these situations; however, one may be issued to notify the beneficiary of financial responsibility.

• Lymphedema, not elsewhere classified (I89.0)
• Hereditary Lymphedema (Q82.0)
• Postmastectomy Lymphedema Syndrome (I97.2)
• Other postprocedural complications and disorders of the circulatory system, not elsewhere classified (I97.89)

• Standard Documentation Requirements for All Claims Submitted to DME MACs
• Documentation Checklist [PDF] - Checklist to ensure suppliers gather all required documentation

• Payment for three gradient compression garments or wraps with adjustable straps per each affected extremity or part of the body can be made once every six months.
• Payment for two nighttime garments per each affected extremity or part of the body once every two years.

Suppliers can bill for lymphedema compression treatment items for more than one body part or area per beneficiary. Also, both a daytime (gives a higher level of compression) and nighttime (offer milder compression and less snug against skin) garment for the same body part or area can be billed per beneficiary.