We are providing clarification of coverage and documentation requirements for lymphedema decongestive treatment based on Noridian medical review findings. The two basic types of decongestive treatment are:
• Manual Lymphatic Drainage (MLD) which stimulates the movement of fluids in the tissues using gentle massage and;
• Comprehensive Decongestive Therapy (CDT) which is a combination of MLD, bandaging, skin care and exercises.
Coverage Requirements
Medicare will reimburse for necessary components of decongestive treatment when the medical record supports
- A diagnosis of lymphedema (not tissue edema due to other etiologies e.g., chronic venous insufficiency, congestive heart failure, acute infection).
- Recent changes in the patient’s condition
- Prior unsuccessful therapies (e.g., elevation, bandaging, diuresis) reported to justify the need for skilled services.
- Services were provided by a qualified clinician (i.e., physician, non-physician practitioner (NPP), qualified therapist, or appropriately supervised therapist assistant).
- Services must be under accepted standards of medical practice and considered to be specific and effective treatment for the patient’s condition.
Limitations
The goal of therapy is not to achieve maximum volume reduction but to ultimately transfer the responsibility for the care from the provider to the patient and/or caregiver, generally within a 1-3 week time period. There is only temporary benefit from the treatment unless the patient and/or caregiver are able to complete treatments at home on an ongoing basis. The end of treatment is not when the edema resolves or stabilizes but when the patient and/or caregiver are able to continue the treatments at home.
Skilled Level of Care
The key issue is whether the skills of a therapist are needed, or whether the services can be carried out by the patient and/or caregiver after sufficient training. The medical record must clearly indicate the patient’s condition before, during, and after the therapy episode to support that the patient significantly benefitted from ongoing therapy services and that the progress was sustainable and of practical value when measured against the patient’s condition at the start of treatment. Documentation should indicate clear objective evidence of improvement generally within the first week or 10 days of therapy (e.g., changes in weight, extremity circumference).
Maintenance Level of Care
When it is reasonable to assume that ongoing services could reasonably be carried out by the patient and/or appropriately trained caregiver(s), then the services are considered to be at a maintenance level of care and no longer require the skills of a qualified clinician. It is the patient's responsibility to acquire caregiver assistance for carrying out the of the home maintenance program when necessary. Generally, it is anticipated that an efficient home maintenance program will be effective for a lifetime. However, in the rare instance, when additional treatment for the same condition is necessary, then the documentation must support reasonableness and medical necessity for the additional services. For additional information, see the Noridian article titled "Medical Necessity of Therapy Services".
Coding Considerations
- Medically necessary hands-on MLD is a covered Medicare service and is coded using CPT® 97140 for manual therapy.
- There is no Medicare coverage for lymphedema compression bandage application as this is considered to be an unskilled service. This non-coverage extends to the application of high compression, multi-layered, sustained bandage systems (e.g., Profore®, Dynaflex®, Supress®, coded with CPT® 29581 or 29584.
- Minutes spent applying compression bandaging without patient/caregiver education should not be billed as skilled therapy services.
- However, Medicare will cover a brief period (e.g. three or fewer sessions if no new specific issues are identified), of patient/caregiver instruction in compression bandaging home management. Medical necessity for this education must be clearly documented and meet the code descriptor requirements for CPT® 97535.
- Note that high compression bandage application used for treatment of wounds may be appropriately coded with CPT® 29581 or 29584. However, these codes should not be billed for unskilled lymphedema compression bandage application. For additional information, see the Noridian article titled "High Compression Bandage System Clarification."
Sources:
- Federal Register (FR), Volume 76, Number 228, Part III, Section C-5
- Internet Only Manual (IOM) Medicare National Coverage Determinations Manual, Publication 100-03, Chapter 1, Part 4, Sections 270.5, 280.1, 280.6
- IOM Medicare Benefit Policy Manual, Publication 100-02, Chapter 15, Sections 220-230
- IOM Medicare Claims Processing Manual, Publication 100-04, Chapter 5, Section 20(B)
- Current Procedural Terminology Coding Manual
- Social Security Act (SSA), Title 18, Section 1862(a)(1)(A)
