SUPERSEDED LCD Reference Article Article

Lymphedema Decongestive Treatment

A55710

Expand All | Collapse All
Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.
Superseded
To see the currently-in-effect version of this document, go to the section.

Document Note

Note History

Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A55710
Original ICD-9 Article ID
Not Applicable
Article Title
Lymphedema Decongestive Treatment
Article Type
Article
Original Effective Date
08/31/2017
Revision Effective Date
01/01/2018
Revision Ending Date
N/A
Retirement Date
N/A

CPT codes, descriptions, and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

Copyright © 2024, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the AHA copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution, or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

N/A

Article Guidance

Article Text

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. Medicare will reimburse for
         necessary components of decongestive treatment when the medical
         record supports that the following requirements are met.

Documentation should support a diagnosis of lymphedema and not tissue edema due to other etiologies (chronic venous insufficiency, congestive heart failure, acute infection(s), etc.). Recent changes in the patient’s condition as well as prior unsuccessful therapies (elevation, bandaging, diuresis, etc.) should be reported to justify the need for skilled services. Therapy services must be provided by a qualified clinician (physician, non-physician practitioner (NPP) or qualified therapist). Treatment services may also be provided by an appropriately qualified and 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.

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. 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 (changes in weight, extremity circumference, etc.).

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. Medicare will however 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. Minutes spent applying compression bandaging without patient/caregiver education should not be billed as skilled therapy services.

Note: Compression application CPT codes 29581-29584 may be appropriately billed for the treatment of wounds when indicated; 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."

Maintenance Level
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 are no longer reimbursable by Medicare. It is the patient’s responsibility to acquire caregiver assistance for carrying out 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."


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
  • Current Procedural Terminology Coding Manual
  • Social Security Act (SSA), Title 18, Section 1862(a)(1)(A)

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description

Please accept the License to see the codes.

N/A

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Code Description

Please accept the License to see the codes.

N/A

CPT/HCPCS Codes

Please accept the License to see the codes.

N/A

CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that are Covered

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that are Not Covered

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-PCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Additional ICD-10 Information

Bill Type Codes

Code Description

Please accept the License to see the codes.

N/A

Revenue Codes

Code Description

Please accept the License to see the codes.

N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A N/A
N/A
Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation
01/01/2018 R1

Article is revised to delete 29582 and 29583 per the 2018 Annual HCPCS Code update.

N/A

Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related National Coverage Documents
N/A
SAD Process URL 1
N/A
SAD Process URL 2
N/A
Statutory Requirements URLs
N/A
Rules and Regulations URLs
N/A
CMS Manual Explanations URLs
N/A
Other URLs
N/A
Public Versions
Updated On Effective Dates Status
11/14/2023 01/01/2018 - N/A Currently in Effect View
10/28/2020 01/01/2018 - N/A Superseded View
12/08/2017 01/01/2018 - N/A Superseded You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • 97140
  • lymphatic
  • lymphedema
  • Comprehensive
  • Decongestive
  • Therapy
  • CDT
  • MDT
  • manual
  • 97535
  • 29581
  • 29584
  • compression