Lymphedema Compression Treatment Items Frequently Asked Questions (FAQs) - JD DME

To help our suppliers, Noridian and CGS Provider Outreach and Education worked together to answer the most frequently asked questions on lymphedema compression treatment items.

Reimbursement

1. Who can bill for the fitting (i.e., physicians, physical/occupational therapists, compression treatment specialists, or suppliers) and are the services separately billable?
   A: The national payment amounts made to the supplier includes all necessary services associated with supplying gradient compression garments and wraps, including fitting and measurements.
2. Are the items/garments in this category separately payable in a skilled nursing facility, home health, or hospice episode?
   A: Once the Part A stay benefits have ended, lymphedema compression treatment items are considered separately payable. These items are separately payable during a home health or hospice episode (if the diagnosis for the garment does not relate to the terminal diagnosis or related condition during the hospice episode).
   
   For more information, refer to the Noridian Consolidated Billing SNF, Home Health, Hospice Lookup Tool.
3. We are already accredited with Medicare; do we need to update the accreditation, or can we start billing lymphedema items?
   A: Send any questions about accreditation to your National Provider Enrollment Contractor:
   • NPE East: Novitas Solutions
   • NPE West: Palmetto GBA
4. Are upgrades allowable in this benefit category? For instance, a beneficiary chooses a garment with a HCPCS code considered for coverage, but it costs more than the allowable.
   A: CMS publishes the fee schedule for the HCPCS code payments. A price difference is not justification for an upgrade.
   
   For coding assistance, please contact Pricing Data Analysis, and Coding (PDAC).
5. If a beneficiary does not meet the benefit category coverage guidelines for lymphedema compression treatment items, is an Advance Beneficiary Notice of Noncoverage (ABN) needed?
   A: If a beneficiary does not meet benefit category requirements (i.e., no valid diagnosis), the claim will deny noncovered. In this situation, an ABN would be voluntary and not needed.
   
   Suppliers must issue an ABN when expecting Medicare to deny an item or service based on lack of medical necessity (including overutilization).
6. Are kits covered?
   A: Kits are typically made up of several components such as the compression garment/item, liner, etc. Suppliers should bill each component of the kit on a separate claim line.
7. Can qualified individuals virtually measure and fit standard and custom-fitted lymphedema garments?
   A: While there is nothing prohibiting virtual measurement and fitting of standard and custom-fitted garments, suppliers must replace garments at no charge if they do not fit properly. Per 42 CFR 424.57, Supplier Standard 15: "Must accept returns from beneficiaries of substandard (less than full quality for the particular item or unsuitable items, inappropriate for the beneficiary at the time it was fitted and rented or sold)."
8. Are there any updates on the rates for miscellaneous codes? Is it based on the Manufacturer’s Suggested Retail Price (MSRP/Cost or percentage of billed charges?
   A: Please refer to the Pricing page on the Noridian website.
9. Can we bill Medicare for a denial to cross over to secondary insurance if the patient has venous insufficiency? How will the claim deny?
   A:This benefit is specific to lymphedema; therefore, the claim would deny, "no benefit".
10. If a physical therapist is applying the lymphedema wraps and billing for the application of the wraps, can we as a DME company bill separately for the wraps being applied by the therapist?
    A: No, the DME company may not bill separately for supplies used by the lymphedema physical therapist. Per CMS-1780-F (page 361/531):
    
    "With regards to payment, we note that currently a therapist who applies compression bandaging supplies during Phase 1 of treatment can bill for the service of applying the bandages using CPT codes 29581 and 29584. It is important to note, however, that if the CPT codes are billed and paid for a particular date of service, then billing for the bandaging supplies used during that date of service using the HCPCS A codes is not allowed and would be denied as it would result in duplicate payment of the supplies since the Medicare payment amounts for codes 29581 and 29584 include payment for the compression bandaging supplies."
    
    Suppliers of lymphedema garments and accessories are responsible for all aspects of furnishing the item, including fitting and measuring services. A supplier receiving payment for supplying a lymphedema compression treatment item to a beneficiary is responsible for ensuring that any necessary fitting, training (how to apply/remove and maintain). The supplier receiving payment for the garment may work out an arrangement with the therapist for the fitting part that is an integral part of supplying the item.

Dispensing

11. Do we have to dispense daytime compression and nighttime compression items/garments at the same time?
    A: Medicare will consider payment for up to three daytime items/garments per body part/extremity every six months and up to two nighttime items/garments per body part/extremity every two years. They do not need to be dispensed on the same date of service. This also applies to custom garments.
12. Are the number of allowed items per body part/extremity or per HCPCS code?
    A: The number of allowed items are based on the specific body part. If the practitioner orders multiple types of items/garments to treat a specific body part, and they exceed allowed amounts, we will deny them for overutilization.
13. Can Medicare allow different types of garments if they don't go over three per body part?
    A: Regardless of the types of garments provided, the frequency limit for daytime garments is three per body area per six months and two nighttime garments per body area per 24 months.
14. Will Medicare cover donning and doffing accessories lymphedema treatment under HCPCS A6593? Many patients can’t put the garment on without a donning aid.
    A: Yes, Medicare will consider payment for donning and doffing aids, coded as A6593. Refer to question 18 for billing instructions.
15. When billing for two custom items (A6555 and A6556) that will both have accessories (A6593), would we bill all the accessories on one claim line for each of those associated items, or two separate claim line items? If two separate claim line items, will they deny as a duplicate because we will bill with the same date of service (DOS), same HCPCS, and no modifiers?
    A: You must bill each compression bandaging supply, accessory, wrap, or compression garment without a unique HCPCS on a separate claim line with A6549, A6584, A6593, or A6609 and the proper units of service. Claims for these HCPCS codes 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:
    
    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 and number
    • Supplier price list
    • HCPCS of related item (where applicable)

    Please refer to Noridian Common Abbreviations to Use as Narratives.

16. Do donning accessories, such as the butler donning aid, have a reasonable useful lifetime (RUL)?
    A: CMS has not given guidance to the DME MACs on the RUL for accessories. As noted in the joint DME MAC article: "Accessories (e.g., zippers, linings, padding or fillers, etc.) necessary for the effective use of a lymphedema compression treatment item are covered when medically necessary for the treatment of lymphedema. The justification for the quantity of supplies needed and the frequency of replacement must be documented in the beneficiary’s medical record and made available to the DME MAC upon request."
17. If the manufacturer only supplies garments/stockings in pairs and only one limb has lymphedema, do suppliers remove one stocking/garment from package?
    A: Medicare is only going to pay for the medically necessary item, regardless of how the manufacturer packages the items.

Coverage

18. When will Medicare publish the Local Coverage Determination (LCD) and Policy Article (PA)?
    A: At this time, the DME MACs are considering options for an LCD or PA.
19. Do the A6545 (gradient compression wrap) or A6531 (gradient compression stocking) still needed to have a venous stasis ulcer with open wound or has this changed?
    A: The lymphedema benefit does not cover the A6545 and A6531. These are covered under Surgical Dressing Policy.
20. Are these items/garments in the same/similar category?
    A: The DME MACS are considering this benefit for a same/similar category evaluation.
21. Will Medicare consider coverage for compression garments at the same time as a Pneumatic Compression Device (PCD)?
    A: Yes, Medicare will consider coverage for compression garments at the same time as a PCD.

Coding

22. Will CMS add other levels of compression strength to the list of HCPCS items such as 8 mmhg and 15 mmhg?
    A: Refer to the CMS HCPCS process: HCPCS - General Information
23. Why are there only HCPCS for nighttime bras, not daytime?
    A: The A6589 (GRADIENT PRESSURE WRAP WITH ADJUSTABLE STRAPS, BRA, EACH) is the HCPCS code for daytime use.
24. How will Medicare differentiate between daytime and nighttime wraps since there is not specific daytime and nighttime HCPCS codes?
    A: The HCPCS code describes nighttime garments and wraps. If "nighttime" is not in the descriptor, the garment or wrap is for daytime use.
25. If a patient has lymphedema and has a leg ulcer and we are providing gradient compression wraps, which code do we use: A6583 or A6545, or would we bill both HCPCS codes?
    A: The supplier must choose which benefit to bill the item(s) under, either Surgical Dressings or Lymphedema Treatment Items. If providing for the surgical dressings benefit, bill HCPCS code A6545; if providing for the lymphedema garments benefit, bill HCPCS code A6583. Under no circumstances should the supplier bill both HCPCS codes to represent one product.

Modifiers

26. Compression stockings often come as a pair, for example A6530 (Gradient compression stocking, below knee, 18-30 mmhg, each). In this case would we use the LT and RT modifiers to signify bilateral?
    A: Suppliers must use the right (RT) and left (LT) modifiers when billing gradient compression garments, related supplies and accessories when the description is indicated laterality.
    
    When billing the same HCPCS code for bilateral items (left and right) on the same date of service, bill each item on two separate claim lines using the RT and LT modifiers and appropriate number of units of service (UOS) on each claim line.
    
    The DME MACs will reject claim lines for HCPCS codes requiring use of the RT and LT modifiers, billed without the RT and/or LT modifiers or billed with RTLT modifiers on a single claim line.
27. What modifier should we use for waist high or panty hose type items/garments?
    A: Because laterality is not indicated for these items, you don’t need to use the LT or RT modifier

Documentation Requirements

28. Does Medicare require a face-to-face encounter for this benefit category?
    A: There is no face-to-face requirement for these items. Suppliers must replace garments at no charge if they do not fit properly. Per 42 CFR 424.57, Supplier Standard 15: "Must accept returns from beneficiaries of substandard (less than full quality for the particular item or unsuitable items, inappropriate for the beneficiary at the time it was fitted and rented or sold)."
29. If a patient needs a new size or type of garment or wrap due to a change in medical condition, we understand Medicare will pay for new garments or wraps. What guidance can be offered for a patient’s medical condition change?
    A: Medicare will consider payment for a new set of garments or wraps if determined to be reasonable and necessary due to a change in the beneficiary’s medical or physical condition that calls for a new size or type of garment or wrap.
30. Can suppliers ship compression garments to beneficiaries?
    A: Suppliers can ship compression garments to beneficiaries. However, suppliers are still responsible for:
    • Taking measurements of the patient’s affected body area
    • Performing necessary fitting services
    • Training the patient on how to take the item on and off
    • Showing the patient how to take care of the item
    • Adjusting the item, if needed
    Suppliers must replace garments at no charge if they do not fit properly.
31. A beneficiary receives garments and six months later they want to re-order. Does the therapist need to re-fit the patient to get the garments, even if they’re the same ones previously documented in the notes?
    A: No, however, suppliers must replace garments at no charge if they do not fit properly.
32. Can the fitters rather than the practitioner justify lymphedema compression custom fitted vs off-the shelf garments?
    A: The fitter may justify the need for custom fitted; however, the treating practitioner must acknowledge the medical necessity for custom fitted by completion of a new SWO.
33. When does Medicare require a new Standard Written Order (SWO) for lymphedema compression treatment items?
    A: Per the Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) Article, Medicare requires a new order/prescription:
    • "For all claims for purchases or initial rentals;
    • If there is a change in the DMEPOS order/prescription (e.g., quantity).
    • On a regular basis (even if there is no change in the order/prescription) only if it is so specified in the documentation section of a particular medical policy;
    • When an item is replaced;
    • When there is a change in the supplier, and the new supplier is unable to obtain a copy of a valid order/prescription for the DMEPOS item from the transferring supplier."
    Medicare does not require an annual SWO renewal; however, there may be state laws that require an order to be periodically renewed. The DME MACs suggest consulting with an attorney knowledgeable in healthcare matters.