New lymphedema benefit increases access for Medicare beneficiaries

The Lymphedema Treatment Act, passed by Congress at the end of 2022, mandated the creation of a new Medicare benefit category to cover reimbursement of compression garments and supplies used for the treatment of lymphedema. Prior to the development of this new benefit category, many compression garments and other treatment items were not guaranteed reimbursement, forcing patients to purchase garments and other treatment items based on what they could afford, instead of receiving the items that would be most beneficial to address their treatment needs. This new coverage policy, implemented by the Centers for Medicare and Medicaid (CMS), becomes effective January 1, 2024, and will standardize Medicare payment for lymphedema compression items for improved patient access to these garments and supplies. AOTA continues to have concerns about the ability of OT practitioners to provide fitting and measurement services under arrangements with DMEPOS suppliers, as discussed below. A summary of key provisions are highlighted below.

Coverage criteria

Medicare will reimburse for lymphedema garments and supplies when:

• a patient has Medicare Part B and a diagnosis of lymphedema
• the garment or wrap is ordered by a physician
• the garment or wrap is being utilized expressly to treat lymphedema symptoms.

Items covered

Medicare will cover standard and custom-fitted lymphedema compression treatment items for each affected body part, including:

• Standard and custom-fitted compression garments used for daytime or nighttime management of lymphedema
• Compression bandaging systems and supplies
• Gradient compression wraps with adjustable straps
• Accessories such as fillers, lining, padding, and zippers
• Aids necessary to facilitate patient and/or caregiver independence with donning/doffing garments such as foot slippers, butlers, etc.

Frequency

Medicare will pay for compression garments at the following frequencies:

• 3 daytime garments every 6 months
• 2 nighttime garments every 2 years

If a patient’s medical condition changes, requiring a new size or type of garment or wrap, or the garment is lost, stolen, or irreparably damaged, payment can also be made for new garments or wraps outside of the established replacement frequency with supporting documentation.

Medicare will pay for compression bandaging system replacement based on individual payer review of medical necessity.

Coding

With the implementation of this new benefit, CMS has added several new Healthcare Common Procedure Codes (HCPCS) for billing of treatment items to reflect more specific garment types and items including body parts treated, daytime versus nighttime use, and accessories. A complete list of the 81 HCPCS codes for lymphedema treatment items is available from CMS.

Payment

Medicare has established payment for lymphedema treatment items at the average Medicaid rate for the item plus 20%. Where a Medicaid rate is not established for an item or accessory, Medicare will utilize additional data from the Veterans Administration and internet pricing to make a determination on fee schedule rates.

The Medicare Administrative Contractors (MACs) responsible for processing DMEPOS claims will process claims for lymphedema compression treatment items. Medicare will cover 80% of the item’s established rate and patients will be responsible for a 20% copay. Pricing of compression treatment items will be available on the DME MAC fee schedule beginning January 1, 2024.

Covered providers

Because compression treatment items are considered durable medical equipment (DME), they fall under the DMEPOS policies for Medicare. Under the DMEPOS policies, providers supplying DME items must be enrolled as a DMEPOS supplier to bill Medicare. This means that in order to receive payment for lymphedema compression treatment items directly, an OTP would need to be a DMEPOS-credentialed supplier.

When billing for a lymphedema compression treatment item, DMEPOS suppliers receive a bundled payment for the item itself and all aspects of providing the item to the patient including:

• taking measurements of the patient’s affected body area
• performing necessary fitting services
• training the patient on 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.

Because Medicare is reimbursing the DMEPOS supplier for the measuring and fitting services as part of the bundled payment they receive, OT practitioners should not separately bill OT CPT codes for measuring and fitting services related to obtaining a compression garment that is ordered by the DMEPOS supplier as this would represent duplicative billing. OTPs who are not DMEPOS suppliers but participate in measuring and fitting services related to lymphedema compression garments would need to develop arrangements with the DMEPOS suppliers who are providing the garment to receive reimbursement for measuring and fitting services they may provide.

Concerns remain regarding DMEPOS suppliers' willingness to enter into arrangements with OT practitioners for measuring and fitting services, whether such arrangements could violate anti-kickback laws, and whether OT practitioners will be fairly reimbursed for their services under these arrangements. Before entering into such an arrangement, OTPs may wish to consider consulting a healthcare lawyer familiar with the laws in their state.

Advocacy for the future

While we are thankful for the improved access this benefit offers to Medicare beneficiaries who need lymphedema compression items, AOTA is disappointed by the lack of payment assurance offered within the final rule for OT practitioners who often perform these measuring and fitting services, especially in rural areas. We believe that these policies dis-incentivize DMEPOS suppliers from utilizing OT practitioners to perform measuring and fitting services, even though the OTP may be the most appropriate provider to determine the patient’s individual needs. AOTA will continue to advocate on OT practitioners’ behalf to fight for fair reimbursement for measuring and fitting services provided by OT practitioners. AOTA, in collaboration with the American Physical Therapy Association (APTA), has requested a meeting with CMS to discuss the potential impact these reimbursement policies will have on both the profession and the clients served by lymphedema therapy practitioners.

AOTA will also closely monitor the implementation of the replacement policies with the individual DME MACs to ensure that new garments and wraps are reimbursed based on OT practitioner recommendations as necessary to meet the medical needs of the patient.

Finally, this new benefit will be reviewed each year with an opportunity for public comment. Watch AOTA’s social media and website for a call to action next summer when the proposed rule for 2025 is released and consider commenting to CMS about how lymphedema practice has changed because of these new policies. As we continue our advocacy efforts, we also ask that if you are an OT practitioner encountering barriers to the provision of lymphedema treatment or with obtaining appropriate compression garments for your patients because of these new policies, please email regulatory@aota.org to share your story.

For additional compression item coverage and coding details, the lymphedema benefit coverage information begins on page 350 of the CY 2024 home health final rule.