Lymphedema Compression Treatment - JD DME

• Coverage
• Documentation
• Benefit Category
• Quantities
• What are my responsibilities?
• Modifiers
• Accessories
• Replacement When Lost, Stolen, or Irreparably Damaged
• Canceled Orders for Customized Items
• HCPCS for Lymphedema Benefit
• Resources

Coverage

• 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)

Documentation

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

Benefit Category

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

Quantities

• 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.

What Are My Responsibilities?

When you furnish a lymphedema compression treatment item, you're responsible for all aspects of providing the item, unless you work out an arrangement with an external fitter to perform the services. This includes:

• Taking measurements of the patient's affected body area
• Performing necessary fitting services
• Training the patient how to take the treatment item on and off
• Showing the patient how to take care of the treatment item
• Adjusting the treatment item, if needed

You must be an enrolled DMEPOS Supplier to get Medicare payment for furnishing these treatment items. Please follow the CMS Medicare Enrollment Guide to enroll.

Payment for all necessary services associated with providing gradient compression garments and wraps, including fitting and measurements, is included in the national payment amounts made to the supplier of the item.

Modifiers

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.

Accessories

Accessories (e.g., zippers, linings, padding or fillers, etc.) necessary for the effective use of a lymphedema compression treatment item also 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.

Replacement When Lost, Stolen, or Irreparably Damaged

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.

Canceled Orders for Customized Items

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.

Healthcare Common Procedure Coding System (HCPCS) for Lymphedema Benefit

Items being provided and billed must meet the description of HCPCS codes listed below:

Resources

• CMS MM 13286
• DME Medical Director Publication: Lymphedema Compression Treatment Items - Correct Coding - Revised
• Lymphedema Compression Treatment Items | CMS
• Enroll as a DMEPOS Supplier | CMS
• Pricing, Data Analysis and Coding (PDAC) Contractor