Correct Coding for Items Used to Treat Edema - Revised

Joint DME MAC Publication

This article was originally published by the former Statistical Analysis Durable Medical Equipment Regional Carrier (SADMERC) in 2006 and republished by the Pricing, Data Analysis and Coding (PDAC) contractor in 2008. This article does not appear to have been published by the DME MACs.

Edema is swelling caused by the accumulation of excessive fluid in subcutaneous tissues.  Many products are used to provide treatment for this condition; however, Medicare reimbursement for edema treatments is limited to pneumatic compression devices and certain types of multi-component compression bandage systems. Coverage is available when the beneficiary meets the specified criteria in the Local Coverage Determinations (LCDs) - Pneumatic Compression Devices and Surgical Dressings, respectively.

Other items are non-covered by Medicare when used for the treatment of edema because they do not fall into a statutory benefit category. Some common examples of these non-covered items are (not all-inclusive):

  • A4465 NON-ELASTIC BINDER FOR EXTREMITY
    • Includes non-elastic binders for upper and lower extremity.
  • A4467 BELT, STRAP, SLEEVE, GARMENT, OR COVERING, ANY TYPE
    • Includes compression bras, elastic binders, compression gloves, elastic knee and ankle supports or other types of elastic and non-elastic devices.
  • A6530 GRADIENT COMPRESSION STOCKING, BELOW KNEE, 18-30 MMHG, EACH
  • A6531 GRADIENT COMPRESSION STOCKING, BELOW KNEE, 30-40 MMHG, EACH
  • A6532 GRADIENT COMPRESSION STOCKING, BELOW KNEE, 40-50 MMHG, EACH
  • A6533 GRADIENT COMPRESSION STOCKING, THIGH LENGTH, 18-30 MMHG, EACH
  • A6534 GRADIENT COMPRESSION STOCKING, THIGH LENGTH, 30-40 MMHG, EACH
  • A6535 GRADIENT COMPRESSION STOCKING, THIGH LENGTH, 40-50 MMHG, EACH
  • A6536 GRADIENT COMPRESSION STOCKING, FULL LENGTH/CHAP STYLE, 18-30 MMHG, EACH
  • A6537 GRADIENT COMPRESSION STOCKING, FULL LENGTH/CHAP STYLE, 30-40 MMHG, EACH
  • A6538 GRADIENT COMPRESSION STOCKING, FULL LENGTH/CHAP STYLE, 40-50 MMHG, EACH
  • A6539 GRADIENT COMPRESSION STOCKING, WAIST LENGTH, 18-30 MMHG, EACH
  • A6540 GRADIENT COMPRESSION STOCKING, WAIST LENGTH, 30-40 MMHG, EACH
  • A6541 GRADIENT COMPRESSION STOCKING, WAIST LENGTH, 40-50 MMHG, EACH
  • A6544 GRADIENT COMPRESSION STOCKING, GARTER BELT
  • A6545 GRADIENT COMPRESSION WRAP, NON-ELASTIC, BELOW KNEE, 30-50 MM HG, EACH
  • A6549 GRADIENT COMPRESSION STOCKING/SLEEVE, NOT OTHERWISE SPECIFIED
    • Includes custom fabricated items.
  • L8010 BREAST PROSTHESIS, MASTECTOMY SLEEVE
  • A9283 FOOT PRESSURE OFF LOADING/ SUPPORTIVE DEVICE, ANY TYPE, EACH.
    • See also article HCPCS Code A9283 – Devices Used for Edema or Ulcer Healing

For other non-covered items that do not fall within a specific code, A9270 (NON-COVERED ITEM OR SERVICE) is the appropriate code to bill to Medicare. Use of a miscellaneous or NOC code for billing of a non-covered item when a specific code exists is incorrect coding.

Correct coding is an essential element for correct claim payment. The PDAC contractor maintains a variety of resources to assist suppliers in determining the appropriate code for Medicare billing. For questions about correct coding, contact the PDAC Contact Center at (877) 735-1326 during the hours of 8:30 a.m. to 4:00 p.m. CT, Monday through Friday, or email the PDAC by completing the DME PDAC Contact Form. See the Contact Us webpage for details.

Publication history:

Originally published by the SADMERC in 2006

Republished by the PDAC in August 2008

 

Last Updated Nov 21 , 2023