This guide, provided by carcodescanner.store, serves as an expert resource for healthcare providers and suppliers on the correct coding and billing of lymphedema compression treatment items. Accurate Care Item Coding is crucial for ensuring proper reimbursement and compliance, particularly within the Medicare system. This revised information is based on the Centers for Medicare & Medicaid Services’ (CMS’) Final Rule CMS-1780-F and is effective for claims with dates of service on or after January 1, 2024.
Understanding Medicare Coverage for Compression Garments
Medicare coverage for gradient compression garments, along with related supplies and accessories, is specifically limited to the treatment of lymphedema. It’s vital to understand that claims submitted for these items for conditions other than lymphedema will be denied as non-covered. This underscores the importance of accurate diagnosis coding alongside correct care item coding.
Initial Coverage Rules
For initial coverage, Medicare allows a quantity of three daytime garments or wraps per affected body area every six months. Nighttime garments, which are often different and designed for lower compression, are covered at a quantity of two per body area every two years (24 months). These frequency limitations are integral to Medicare’s guidelines for care item coding and billing.
Replacement Guidelines
Replacement garments are only covered within these established frequency limits: every six months for daytime items and every two years for nighttime items. Claims exceeding these limits will be rejected as not reasonable and necessary unless there are documented exceptions such as loss, theft, or irreparable damage.
Furthermore, a new set of garments can be considered medically necessary and eligible for coverage if a significant change in the beneficiary’s medical or physical condition necessitates a different size or type of garment. In such cases of loss, theft, irreparable damage, or a change in medical condition, a complete new set of three daytime or two nighttime garments can be furnished, and importantly, the six-month or two-year replacement frequency period restarts from the date of service for these replacement items. This nuance is critical for correct care item coding in replacement scenarios.
Custom Fitted vs. Standard Garments: Coding Considerations
Medicare recognizes the necessity of custom fitted gradient compression garments in certain situations. These garments are uniquely designed to fit the specific measurements of a patient’s affected limb, ensuring accurate gradient compression essential for effective lymphedema treatment. Appropriate care item coding must reflect whether a garment is standard or custom fitted as this impacts the specific HCPCS code used.
When Custom Fitted Garments are Necessary
Custom fitted garments may be required in several instances, including:
- Significant disproportion between the proximal and distal limb circumference.
- Presence of skin/tissue folds or contours requiring specialized knitting patterns for proper fit and compression.
- Intolerance to standard garment fabric composition due to allergies or sensitivities.
Documentation Requirements for Custom Coding
To justify the use of custom fitted garments and ensure accurate care item coding, thorough documentation within the beneficiary’s medical record is mandatory. This documentation must clearly explain why a custom garment is medically necessary over an off-the-shelf standard option. Acceptable documentation sources extend beyond physician’s office records and can include records from hospitals, nursing homes, Home Health Agencies (HHAs), and other healthcare professionals involved in lymphedema treatment, such as certified lymphedema therapists. This documentation must be readily available to the Durable Medical Equipment Medicare Administrative Contractor (DME MAC) upon request for audit purposes.
Coding for Compression Bandaging Supplies & Accessories
Medicare coverage extends to compression bandaging supplies when medically necessary for lymphedema treatment, spanning both Phase 1 (acute decongestive therapy) and Phase 2 (maintenance therapy). Suppliers of these bandaging systems, including therapists, must be enrolled DMEPOS suppliers to be eligible for Medicare reimbursement. Justification for the quantity and frequency of replacement for these supplies must be meticulously documented in the patient’s medical record and be available to the DME MAC upon request. Accurate care item coding for these supplies is as important as it is for the garments themselves.
Similarly, accessories that are essential for the effective use of lymphedema compression treatment items are also covered when medically necessary. Examples include zippers, linings, padding, and fillers. The same documentation requirements regarding medical necessity, quantity, and replacement frequency apply to these accessories to support appropriate care item coding and billing.
It’s important to note that payment for all services associated with furnishing gradient compression garments and wraps, including fitting and measurements, is bundled into the national payment amount for the item itself. There are no separate billable codes for these services, emphasizing the need for correct care item coding of the primary item to encompass the entire service.
HCPCS Codes for Lymphedema Compression Items
Correct care item coding relies heavily on the use of appropriate Healthcare Common Procedure Coding System (HCPCS) codes. Below is a table outlining Group 1 HCPCS codes for lymphedema compression garments and related items, which are essential for accurate claim submission.
Group 1 Codes:
| HCPCS Code | Long Descriptor |
|---|---|
| A6520 | GRADIENT COMPRESSION GARMENT, GLOVE, PADDED, FOR NIGHTTIME USE, EACH |
| A6521 | GRADIENT COMPRESSION GARMENT, GLOVE, PADDED, FOR NIGHTTIME USE, CUSTOM, EACH |
| A6522 | GRADIENT COMPRESSION GARMENT, ARM, PADDED, FOR NIGHTTIME USE, EACH |
| A6523 | GRADIENT COMPRESSION GARMENT, ARM, PADDED, FOR NIGHTTIME USE, CUSTOM, EACH |
| A6524 | GRADIENT COMPRESSION GARMENT, LOWER LEG AND FOOT, PADDED, FOR NIGHTTIME USE, EACH |
| A6525 | GRADIENT COMPRESSION GARMENT, LOWER LEG AND FOOT, PADDED, FOR NIGHTTIME USE, CUSTOM, EACH |
| A6526 | GRADIENT COMPRESSION GARMENT, FULL LEG AND FOOT, PADDED, FOR NIGHTTIME USE, EACH |
| A6527 | GRADIENT COMPRESSION GARMENT, FULL LEG AND FOOT, PADDED, FOR NIGHTTIME USE, CUSTOM, EACH |
| A6528 | GRADIENT COMPRESSION GARMENT, BRA, FOR NIGHTTIME USE, EACH |
| A6529 | GRADIENT COMPRESSION GARMENT, BRA, FOR NIGHTTIME USE, CUSTOM, EACH |
| A6530 | GRADIENT COMPRESSION STOCKING, BELOW KNEE, 18-30 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 MMHG OR GREATER, 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 MMHG OR GREATER, 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 MMHG OR GREATER, EACH |
| A6549 | GRADIENT COMPRESSION GARMENT, NOT OTHERWISE SPECIFIED |
| A6552 | GRADIENT COMPRESSION STOCKING, BELOW KNEE, 30-40 MMHG, EACH |
| A6553 | GRADIENT COMPRESSION STOCKING, BELOW KNEE, 30-40 MMHG, CUSTOM, EACH |
| A6554 | GRADIENT COMPRESSION STOCKING, BELOW KNEE, 40 MMHG OR GREATER, EACH |
| A6555 | GRADIENT COMPRESSION STOCKING, BELOW KNEE, 40 MMHG OR GREATER, CUSTOM, EACH |
| A6556 | GRADIENT COMPRESSION STOCKING, THIGH LENGTH, 18-30 MMHG, CUSTOM, EACH |
| A6557 | GRADIENT COMPRESSION STOCKING, THIGH LENGTH, 30-40 MMHG, CUSTOM, EACH |
| A6558 | GRADIENT COMPRESSION STOCKING, THIGH LENGTH, 40 MMHG OR GREATER, CUSTOM, EACH |
| A6559 | GRADIENT COMPRESSION STOCKING, FULL LENGTH/CHAP STYLE, 18-30 MMHG, CUSTOM, EACH |
| A6560 | GRADIENT COMPRESSION STOCKING, FULL LENGTH/CHAP STYLE, 30-40 MMHG, CUSTOM, EACH |
| A6561 | GRADIENT COMPRESSION STOCKING, FULL LENGTH/CHAP STYLE, 40 MMHG OR GREATER, CUSTOM, EACH |
| A6562 | GRADIENT COMPRESSION STOCKING, WAIST LENGTH, 18-30 MMHG, CUSTOM, EACH |
| A6563 | GRADIENT COMPRESSION STOCKING, WAIST LENGTH, 30-40 MMHG, CUSTOM, EACH |
| A6564 | GRADIENT COMPRESSION STOCKING, WAIST LENGTH, 40 MMHG OR GREATER, CUSTOM, EACH |
| A6565 | GRADIENT COMPRESSION GAUNTLET, CUSTOM, EACH |
| A6566 | GRADIENT COMPRESSION GARMENT, NECK/HEAD, EACH |
| A6567 | GRADIENT COMPRESSION GARMENT, NECK/HEAD, CUSTOM, EACH |
| A6568 | GRADIENT COMPRESSION GARMENT, TORSO AND SHOULDER, EACH |
| A6569 | GRADIENT COMPRESSION GARMENT, TORSO/SHOULDER, CUSTOM, EACH |
| A6570 | GRADIENT COMPRESSION GARMENT, GENITAL REGION, EACH |
| A6571 | GRADIENT COMPRESSION GARMENT, GENITAL REGION, CUSTOM, EACH |
| A6572 | GRADIENT COMPRESSION GARMENT, TOE CAPS, EACH |
| A6573 | GRADIENT COMPRESSION GARMENT, TOE CAPS, CUSTOM, EACH |
| A6574 | GRADIENT COMPRESSION ARM SLEEVE AND GLOVE COMBINATION, CUSTOM, EACH |
| A6575 | GRADIENT COMPRESSION ARM SLEEVE AND GLOVE COMBINATION, EACH |
| A6576 | GRADIENT COMPRESSION ARM SLEEVE, CUSTOM, MEDIUM WEIGHT, EACH |
| A6577 | GRADIENT COMPRESSION ARM SLEEVE, CUSTOM, HEAVY WEIGHT, EACH |
| A6578 | GRADIENT COMPRESSION ARM SLEEVE, EACH |
| A6579 | GRADIENT COMPRESSION GLOVE, CUSTOM, MEDIUM WEIGHT, EACH |
| A6580 | GRADIENT COMPRESSION GLOVE, CUSTOM, HEAVY WEIGHT, EACH |
| A6581 | GRADIENT COMPRESSION GLOVE, EACH |
| A6582 | GRADIENT COMPRESSION GAUNTLET, EACH |
| A6583 | GRADIENT COMPRESSION WRAP WITH ADJUSTABLE STRAPS, BELOW KNEE, 30-50 MMHG, EACH |
| A6584 | GRADIENT COMPRESSION WRAP WITH ADJUSTABLE STRAPS, NOT OTHERWISE SPECIFIED |
| A6585 | GRADIENT PRESSURE WRAP WITH ADJUSTABLE STRAPS, ABOVE KNEE, EACH |
| A6586 | GRADIENT PRESSURE WRAP WITH ADJUSTABLE STRAPS, FULL LEG, EACH |
| A6587 | GRADIENT PRESSURE WRAP WITH ADJUSTABLE STRAPS, FOOT, EACH |
| A6588 | GRADIENT PRESSURE WRAP WITH ADJUSTABLE STRAPS, ARM, EACH |
| A6589 | GRADIENT PRESSURE WRAP WITH ADJUSTABLE STRAPS, BRA, EACH |
| A6593 | ACCESSORY FOR GRADIENT COMPRESSION GARMENT OR WRAP WITH ADJUSTABLE STRAPS, NOT-OTHERWISE SPECIFIED |
| A6594 | GRADIENT COMPRESSION BANDAGING SUPPLY, BANDAGE LINER, LOWER EXTREMITY, ANY SIZE OR LENGTH, EACH |
| A6595 | GRADIENT COMPRESSION BANDAGING SUPPLY, BANDAGE LINER, UPPER EXTREMITY, ANY SIZE OR LENGTH, EACH |
| A6596 | GRADIENT COMPRESSION BANDAGING SUPPLY, CONFORMING GAUZE, PER LINEAR YARD, ANY WIDTH, EACH |
| A6597 | GRADIENT COMPRESSION BANDAGE ROLL, ELASTIC LONG STRETCH, PER LINEAR YARD, ANY WIDTH, EACH |
| A6598 | GRADIENT COMPRESSION BANDAGE ROLL, ELASTIC MEDIUM STRETCH, PER LINEAR YARD, ANY WIDTH, EACH |
| A6599 | GRADIENT COMPRESSION BANDAGE ROLL, INELASTIC SHORT STRETCH, PER LINEAR YARD, ANY WIDTH, EACH |
| A6600 | GRADIENT COMPRESSION BANDAGING SUPPLY, HIGH DENSITY FOAM SHEET, PER 250 SQUARE CENTIMETERS, EACH |
| A6601 | GRADIENT COMPRESSION BANDAGING SUPPLY, HIGH DENSITY FOAM PAD, ANY SIZE OR SHAPE, EACH |
| A6602 | GRADIENT COMPRESSION BANDAGING SUPPLY, HIGH DENSITY FOAM ROLL FOR BANDAGE, PER LINEAR YARD, ANY WIDTH, EACH |
| A6603 | GRADIENT COMPRESSION BANDAGING SUPPLY, LOW DENSITY CHANNEL FOAM SHEET, PER 250 SQUARE CENTIMETERS, EACH |
| A6604 | GRADIENT COMPRESSION BANDAGING SUPPLY, LOW DENSITY FLAT FOAM SHEET, PER 250 SQUARE CENTIMETERS, EACH |
| A6605 | GRADIENT COMPRESSION BANDAGING SUPPLY, PADDED FOAM, PER LINEAR YARD, ANY WIDTH, EACH |
| A6606 | GRADIENT COMPRESSION BANDAGING SUPPLY, PADDED TEXTILE, PER LINEAR YARD, ANY WIDTH, EACH |
| A6607 | GRADIENT COMPRESSION BANDAGING SUPPLY, TUBULAR PROTECTIVE ABSORPTION LAYER, PER LINEAR YARD, ANY WIDTH, EACH |
| A6608 | GRADIENT COMPRESSION BANDAGING SUPPLY, TUBULAR PROTECTIVE ABSORPTION PADDED LAYER, PER LINEAR YARD, ANY WIDTH, EACH |
| A6609 | GRADIENT COMPRESSION BANDAGING SUPPLY, NOT OTHERWISE SPECIFIED |
| A6610 | GRADIENT COMPRESSION STOCKING, BELOW KNEE, 18-30 MMHG, CUSTOM, EACH |
Using “Not Otherwise Specified” Codes
CMS has established four “not otherwise specified” HCPCS codes for compression bandaging supplies, accessories, wraps, and garments that lack a unique specific HCPCS code. These are:
- 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
When using these codes for care item coding, each item must be billed on a separate claim line, along with the appropriate units of service. Crucially, claims using these codes must include detailed information in the narrative field of an electronic claim (NTE 2300 or NTE 2400) or Item 19 of a paper claim. This information should include:
- A comprehensive description of the item, specifying the quantity represented by each unit of service (e.g., per inch, foot, or yard for supplies).
- The manufacturer’s name.
- The product name and number.
- The supplier’s price list.
- The HCPCS code of the related primary item, where applicable.
Providing this level of detail is paramount for ensuring claim accuracy when using these less specific care item coding options.
Modifiers: LT, RT, and RA for Accurate Coding
Modifiers play a critical role in precise care item coding, particularly for indicating laterality and replacements.
Laterality Modifiers (LT, RT)
The right (RT) and left (LT) modifiers are mandatory when billing for gradient compression garments, supplies, and accessories where laterality is relevant. This applies to a wide range of HCPCS codes including A6520, A6521, A6522, and many others listed in the original document. When bilateral items (both left and right) using the same HCPCS code are furnished on the same date of service, each item must be billed on separate claim lines. Use the RT modifier on one line and the LT modifier on the other, each with 1 unit of service (UOS). Avoid using the RTLT modifier on a single claim line with 2 UOS, as claims billed incorrectly without RT/LT modifiers or with the RTLT modifier will be rejected due to incorrect care item coding.
Replacement Modifier (RA)
The RA modifier (REPLACEMENT OF A DME, ORTHOTIC OR PROSTHETIC ITEM) is specifically used when a gradient compression garment or wrap is being replaced due to loss, theft, or irreparable damage. It is essential to remember that replacements are still subject to the original frequency limitations: every six months for daytime garments and every two years for nighttime garments.
For replacement claims, if a single daytime garment is lost, stolen, or irreparably damaged, payment for a set of three replacements is allowed. However, the six-month frequency limitation period restarts from the date of service of the replacement claim. Similarly, for nighttime garment replacements, if one is lost, stolen, or irreparably damaged, two replacements are allowed, and the two-year frequency limitation restarts from the replacement claim’s date of service. Using the RA modifier correctly is vital for appropriate care item coding in these replacement scenarios.
ICD-10-CM Codes for Medical Necessity
Payment for lymphedema compression treatment items is strictly linked to specific ICD-10-CM codes that establish medical necessity. Care item coding is not complete without the inclusion of a relevant and payable ICD-10-CM code. The following ICD-10-CM codes are the only ones currently recognized by Medicare to support the medical necessity of lymphedema compression treatment items:
| Code | Description |
|---|---|
| I89.0 | Lymphedema, not elsewhere classified |
| I97.2 | Postmastectomy lymphedema syndrome |
| I97.89 | Other postprocedural complications and disorders of the circulatory system, not elsewhere classified |
| Q82.0 | Hereditary lymphedema |
It is crucial to understand that while the presence of one of these ICD-10-CM codes is necessary for coverage, it does not automatically guarantee payment. All other coverage criteria and care item coding guidelines must also be met.
Conclusion
Accurate care item coding for lymphedema compression garments and related supplies is paramount for healthcare providers and DME suppliers. Adhering to CMS guidelines, utilizing correct HCPCS codes, applying appropriate modifiers, and ensuring medical necessity through ICD-10-CM coding are all essential components of successful claim submission and reimbursement. This guide from carcodescanner.store aims to provide expert clarity on these complex guidelines, helping you navigate the intricacies of care item coding and ensure patients receive the necessary lymphedema care.
Publication History
| Date | Update |
|---|---|
| February 29, 2024 | Clarified that claims will be denied as noncovered if submitted without a qualifying lymphedema diagnosis, reinforcing the necessity of accurate care item coding and diagnosis alignment. |
| December 8, 2023 | Original Publication |
