RETIRED - Lymphedema Compression Treatment Items - Correct Coding and Billing - JD DME

Joint DME MAC Publication

This Correct Coding and Billing publication is effective for claims with dates of service on or after January 1, 2024.

This publication provides billing and coding guidance pertinent to lymphedema compression treatment items, based on the Centers for Medicare & Medicaid Services’ (CMS’) Final Rule CMS-1780-F.

Information on initial and replacement coverage per the Final Rule:

Gradient compression garments, related supplies and accessories are covered only for the treatment of lymphedema (see ICD-10-CM Codes that Support Medical Necessity below). Claims for gradient compression garments, related supplies and accessories for non-lymphedema diagnoses will be denied as not reasonable and necessary.

A quantity of three (3) daytime garments or wraps per body area are allowed once every six (6) months.

A quantity of two (2) nighttime garments per body area are allowed once every two (2) years (24 months).

Replacement of the garments can only be made in accordance with the frequency limitations of once every six (6) months for daytime garments or wraps and once every two (2) years for nighttime garments.

Claims for gradient compression garments or wraps billed in excess of the frequency limitations outlined above will be denied as not reasonable and necessary unless replacements are needed in cases of loss, theft, or irreparable damage. In addition, payment can be made 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 warrants a new size or type of garment or wrap. Payment is made for replacement of an entire new set of three daytime garments or wraps and/or two nighttime garments in cases of loss, theft, irreparable damage, or change in medical or physical condition and the six month and/or two year replacement frequency begins anew at the time the replacement items are furnished.

Medicare covers custom fitted (custom or non-standard) gradient compression garments. Custom fitted gradient compression garments are uniquely sized and shaped to fit the exact dimensions of the affected extremity of an individual to provide accurate gradient compression to treat lymphedema. Examples of scenarios where a custom fitted gradient compression garment might be used (not all-inclusive) are:

• If the circumference of the proximal portion of the limb is significantly greater than the distal limb;
• If the skin/tissue has folds or contours requiring a specific type of knitting pattern;
• Beneficiary is unable to tolerate the fabric composition of a standard garment.

There must be documentation in the beneficiary’s medical record necessitating the use of a custom fitted gradient compression garment versus an off-the-shelf standard gradient compression garment. The patient’s medical record is not limited to the physician’s office records. It may include hospital, nursing home, or HHA records and records from other health care professionals, such as lymphedema treatment professionals. This documentation must be made available to the DME MAC upon request.

Compression bandaging supplies furnished during Phase 1 (acute or decongestive therapy) and Phase 2 (maintenance phase of therapy) are covered when medically necessary for the treatment of lymphedema. The therapists and other suppliers furnishing bandaging systems must be enrolled DMEPOS suppliers in order to be paid for furnishing these items. 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.

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.

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

HCPCS Codes

Group 1 Codes:

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 compression bandaging supply, accessory, wrap, or compression garment without a unique HCPCS must be billed on a separate claim line with A6549, A6584, A6593, or A6609 and the appropriate units of service. Claims for A6549, A6584, A6593, and A6609 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)

Modifiers

LT, RT, RA

The right (RT) and left (LT) modifiers must be used with gradient compression garments, related supplies and accessories when laterality is indicated (HCPCS codes A6520, A6521, A6522, A6523, A6524, A6525, A6526, A6527, A6530, A6533, A6534, A6535, A6552, A6553, A6554, A6555, A6556, A6557, A6558, A6565, A6572, A6573, A6574, A6575, A6576, A6577, A6578, A6579, A6580, A6581, A6582, A6583, A6584, A6585, A6586, A6587, A6588, A6594, A6595 and A6610). 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 1 unit of service (UOS) on each claim line. Do not use the RTLT modifier on the same claim line and bill with 2 UOS. Claims billed without modifiers RT and/or LT, or with RTLT on the same claim line and 2 UOS, will be rejected as incorrect coding.

The RA modifier (REPLACEMENT OF A DME, ORTHOTIC OR PROSTHETIC ITEM) may only be used if the gradient compression garment or wrap is lost, stolen, or irreparably damaged. Replacement of the garments can only be made in accordance with the frequency limitations of once every six (6) months for daytime garments or wraps and once every two (2) years for nighttime garments.

For replacement claims, if only one (1) daytime garment or wrap is lost, stolen, or irreparably damaged, payment is allowed for three (3) replacements, but the frequency limitation clock of six (6) months would restart based on the date of service for the replacement claim. For replacement claims for a nighttime garment, two (2) replacements are allowed if only one nighttime garment or wrap is lost, stolen, or irreparably damaged and the frequency limitation clock of two years (24 months) would restart based on the date of service for the replacement claim.

ICD-10-CM Codes That Support Medical Necessity

Payment for lymphedema compression treatment items is limited to the ICD-10-CM codes of lymphedema listed below. The presence of an ICD-10-CM code listed in this section is not sufficient by itself to assure coverage.

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