The Centers for Medicare & Medicaid Services (CMS) has released details of upcoming lymphedema compression treatment coverage, which goes into effect Jan. 1, 2024. Implementation will begin Jan. 2, 2024.
In a Nov. 9 edition of MLN Matters, CMS said the new benefit category would cover “standard and custom-fitted compression garments and additional lymphedema compression treatment items to service a medical purpose.
“Starting Jan. 1, 2024, authorized practitioners may prescribe these items to treat lymphedema. Medicare didn’t cover compression garments for treating lymphedema before the CAA [Consolidated Appropriations Act] legislation as there was no benefit category.”
What Will Now Be Covered
CMS said the “general scope” of the new benefit would include the following products:
— Standard daytime gradient compression garments.
— Custom daytime gradient compression garments.
— Nighttime gradient compression garments.
— Gradient compression wraps.
— Accessories, including zippers, linings, paddings, and fillers that are needed to effectively use a gradient compression garment or wrap.
— Compression bandaging systems and supplies.
The agency defined custom or non-standard garments as “uniquely sized and shaped to fit the exact dimensions of the affected extremity of a person to give accurate gradient compression.” CMS described gradient compression garments as designed differently for daytime or nighttime use, with daytime garments providing higher levels of compression and nighttime garments providing less compression.
Compression Product Coding & Definitions
CMS said it would add “a new Common Working File (CWF) category for lymphedema compression treatment items. Some codes that describe lymphedema compression treatment items, A6530- A6549, are currently in CWF category 21 for surgical dressings, with codes A6531, A6532, and A6545 describing garments currently covered as secondary surgical dressings. We’re keeping codes A6531, A6532, and A6545, with a modification to the descriptor to add ‘used as a surgical dressing,’ for use in billing surgical dressings.”
Beginning Jan. 1, CMS said, durable medical equipment suppliers as well as physicians and therapists should use the new codes for lymphedema compression treatment items:
— A6552: Gradient compression stocking, below knee, 30-40 mmhg, each.
— A6554: Gradient compression stocking, below knee, 40 mmhg or greater, each.
— A6583: Gradient compression wrap with adjustable straps, below knee, 30-50 mmhg, each.
Suppliers who want to provide lymphedema compression treatment items to Medicare beneficiaries must be enrolled as DMEPOS suppliers and are subject to supplier standards, accreditation requirements, quality standards, and all other requirements that apply to enrolled DMEPOS suppliers.
Compression Treatment Products & Competitive Bidding
The MLN Matters article said lymphedema compression treatment items “are subject to the DMEPOS Competitive Bidding Program.”
Regarding coverage amounts, the MLN Matters article said, “We’ll add lymphedema compression treatment item codes and national Medicare payment amounts to the DMEPOS fee schedule file for processing claims with dates of service on or after Jan. 1, 2024. Co-insurance and the Medicare Part B deductible apply. Payment is equal to 80 percent of the lesser of the supplier’s actual charge or the national payment amount on the DMEPOS fee schedule file. We’ll update the national payment amounts annually. Also, the field on the DMEPOS fee schedule file for the payment category indicator for lymphedema compression treatment items codes will include indicator LC for lymphedema compression treatment items.”
The article also included billing tips, including that claims will be denied “if you submit a claim for lymphedema treatment items that don’t have an appropriate diagnosis for lymphedema.”
CMS will allow suppliers to bill for lymphedema compression items “for more than one body part or area per patient,” and added, “You can bill for both a daytime and nighttime garment for the same body part or area per patient.”
Information on the scope of the benefit and payments for lymphedema compression treatment items were published in the Nov. 13 edition of the Federal Register.
Roger Herr, PT, MPA, President of the American Physical Therapy Association (APTA), said after the upcoming lymphedema coverage was announced, “I am thrilled that APTA has been able to advocate on both the legislative and regulatory fronts in development of this landmark new benefit category for lymphedema compression garments. This benefit is a critical first step for patients with lymphedema, but there’s more work to be done to ensure that physical therapists are appropriately recognized and compensated for the work they perform during compression therapy.”