Updates To Lymphedema Benefit

Published in Women's Health on August 07, 2024

A recent article by Medtrade Monday outlined the latest news regarding the lymphedema benefit. As of early 2024, Medicare Part B covers compression treatment for lymphedema, including standard and custom-fitted compression garments. Lymphedema is a condition that causes swelling due to lymph fluid accumulation and can lead to severe infections if untreated. Compression garments help manage lymphedema by reducing swelling and preventing infections. Medicare covers both daytime and nighttime garments. Medicare allows replacement of compression garments every six months, with specific guidelines for billing and diagnosis requirements.

Starting January 1, 2025, CMS will deny payments for lymphedema compression treatment bandaging if a duplicate payment is made for the same date of service for claims containing CPT codes 29581 or 29584. Separate billing for lymphedema compression treatment bandaging systems will not be allowed when using Level II HCPCS A codes in conjunction with CPT codes 29581 and 29584. Only specific providers are permitted to bill for the service of applying the bandages using CPT codes 29581 and 29584.

Read below for the full article:

Over 5 million people in the United States are affected by lymphedema, and about half of these individuals are Medicare beneficiaries.

Words by: Jeffrey Baird, Esq., and Jacque Steelman, Esq.

Over 5 million people in the United States are affected by lymphedema, and about half of these individuals are Medicare beneficiaries. As of early 2024, the Centers for Medicare and Medicaid Services (CMS) started covering compression treatment for lymphedema under Medicare Part B. This development comes after including a new benefit category in the Consolidated Appropriations Act, which covers standard and custom-fitted compression garments and additional items for medical purposes under the Medicare Durable Medical Equipment Prosthetic Orthotic Supplier (DMEPOS) benefit.

Lymphedema, which affects the lymphatic system—a part of the human circulatory system—results from an accumulation of lymph fluid in the body, leading to swelling. This condition occurs when lymphatic vessels and nodes are insufficient, causing fluid overload in a body region. Without treatment, lymphedema can lead to severe infections like cellulitis and sepsis.

Compression garments help reduce and prevent the progression of lymphedema in arms and legs, thus minimizing the risk of infection. Before this policy change, Medicare did not cover compression garments due to the absence of a benefit category. With the recent expansion, CMS introduced two new indicators to the HCPCS file for lymphedema compression treatment items. Only Medicare-enrolled DMEPOS suppliers may provide lymphedema compression treatment items.

Medicare’s coverage includes payment for standard and custom-fitted compression treatment items for each affected body part. The scope of the benefit encompasses:

Standard daytime gradient compression garments
Custom daytime gradient compression garments
Nighttime gradient compression garments
Gradient compression wraps
Accessories necessary for the effective use of compression garments or wraps, such as zippers, linings, paddings, or fillers
Compression bandaging systems and supplies

Custom-fitted garments are tailored to match the precise dimensions of the affected area, ensuring accurate gradient compression to manage lymphedema. Payments differ between daytime and nighttime use; daytime garments require higher gradient compression, while nighttime garments offer milder compression and a looser fit.

Medicare will deny payment for lymphedema treatment items if the claims lack an appropriate diagnosis. However, suppliers can bill for compression treatment items for multiple body parts or areas per patient and for both daytime and nighttime garments for the same area.

Replacement for compression treatment items is allowed every six months for three gradient compression garments or wraps with adjustable straps per affected body part. Nighttime garments can be replaced every two years. If the frequency limitations are exceeded, the claim will be denied unless a replacement is needed due to a change in medical need or if a garment or wrap is lost, stolen, or irreparably damaged. When a replacement is being billed for, the RA modifier must be used.

For Medicare to cover these treatment items, the patient must have Medicare Part B coverage, a diagnosis of lymphedema, and a prescription from an authorized practitioner, and the item must be used primarily and customarily to treat the condition.

Beginning January 1, 2025, CMS will deny lymphedema compression treatment bandaging HPCS Level II A codes when a duplicate payment is made for the same date of service for a claim that contains CPT codes 29581 or 29584 for a patient with a diagnosis of lymphedema.

These CPT codes include payment for the bandaging systems, so CMS does not allow separate billing for the lymphedema compression treatment bandaging systems. Level II HCPCS A codes are used in conjunction with them.

The providers who are permitted to bill for the service of applying the bandages using CPT codes 29581 and 29584 are:

Private practice physical and occupational therapists
Physicians and nonphysician practitioners, where physical therapists and outpatient therapists provide the services incident to a physician’s service
Physicians and nonphysician practitioners in the outpatient hospital setting
Outpatient hospitals
Skilled nursing facilities
Home health agencies
Rehabilitation agencies
Comprehensive outpatient rehabilitation facilities
Critical access hospitals

CMS is utilizing new codes for billing and retaining existing codes. CMS has also recognized that additional refinements may be necessary to the HCPCS codes, so it has directed interested parties to consider participating in the public HCPCS process.

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