The 2024 Medicare Final Payment Rules Have Been Released: Part 3

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In the November and December Business Briefs columns, we reviewed the following:

• How hospital owned outpatient wound/ulcer management provider-based departments (PBDs) and physicians and other qualified healthcare professionals (QHPs) will be paid for the application of cellular and/or tissue-based products (CTPs) for skin wounds in 2024
• The new add-on code (G2211) to office and other outpatient services codes (99202–99215)
• Clarification of Medicare payment regulations for remote physiologic monitoring (RPM), remote therapeutic monitoring (RTM), and telehealth
• Outpatient Prospective Payment System (OPPS) 2024 coding and payment changes for diagnostic imaging used to assess wounds/ulcers
• Simplification of coding for disposable negative pressure wound therapy provided by home health agencies

The 2024 Home Health Prospective Payment System Final Rule also announced how the Centers for Medicare & Medicaid Services (CMS) will implement the long-awaited new benefit category for lymphedema compression treatment items. Prior to January 1, 2024, Medicare could not cover compression treatment items for lymphedema because an appropriate benefit category did not exist. Ever since the Consolidated Appropriations Act (CAA) of 2023 established an appropriate lymphedema benefit category, this author has received many questions about this topic. Therefore, this Part 3 article will address the most frequently asked questions and answers that pertain to the new lymphedema compression treatment items benefit category.

Q: What type of lymphedema compression treatment items are included in the new Medicare Part B benefit?

A: The following types of items are included in the new benefit:

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

Q: Who can bill Medicare Part B for lymphedema compression treatment items?

A: Lymphedema compression treatment items can only be billed to Medicare Part B by enrolled durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) suppliers. These suppliers must follow the DMEPOS supplier standards, accreditation requirements, quality standards, and all other requirements that apply to enrolled DMEPOS suppliers. The DME Medicare Administrative Contractors (MACs) will process the claims for the covered lymphedema compression items, which are submitted by the DMEPOS suppliers.

Q: Who can bill Medicare Part B for measuring, fitting, adjusting, and patient training for the gradient compression garments and wraps?

A: Because Medicare payment for this work is included in the DMEPOS allowable payment rates, no one can submit a separate bill to Medicare Part B. The DMEPOS supplier is responsible for measuring the affected body area(s), fitting the item and adjusting it when needed, and training the patient to put on/take off the item and how to care for the item.

NOTE: If the DMEPOS supplier requests a professional, such as a therapist to measure and fit the gradient compression garments and wraps, the DMEPOS supplier should pay the professional for their work.

Q: Who can order lymphedema compression treatment items?

A: A written order/prescription signed by the treating physician or other qualified healthcare professional (QHP)—i.e., physician assistant, nurse practitioner, or clinical nurse specialist—is required for all lymphedema compression treatment items covered by Medicare Part B. In addition to the beneficiary’s name or Medicare Beneficiary Identifier and order date, the order for the lymphedema compression treatment items must include:

• A description of the item which can be either a general description (e.g., gradient compression stocking, below knee, 30–40 mmHg), a HCPCS code (e.g., A6552), a HCPCS code narrative, or a brand name/model number
• All concurrently ordered supplies that are separately billed (list each separately)
• Quantity to be dispensed, if applicable
• Treating practitioner name or National Provider Identifier (NPI)
• Treating practitioner's signature 

The ordering physician or QHP must support the medical necessity for the lymphedema compression treatment items by documenting a specific lymphedema diagnosis in each patient’s medical record.

NOTE: If lymphedema compression treatment items are needed for more than one body part or area, a specific order should be written for each body part or area.

NOTE: If the patient requires daytime and nighttime garments for the same body part or area, a specific order should be written for each body part or area.

Q: I know some gradient compression stocking and wrap HCPCS codes are included in the Surgical Dressing Local Coverage Determination (LCD) and Local Coverage Article (LCA). Will these same HCPCS codes be used to order and supply compression stockings and wraps when the products are used for lymphedema?

A: No, the same HCPCS codes will not be used. In fact, CMS revised the definitions of those compression HCPCS codes:
A6531 Gradient compression stocking, below knee, 30–40 mmHg, used as a surgical dressing, each
A6532 Gradient compression stocking, below knee, 40–50 mmHg, used as a surgical dressing, each
A6545 Gradient compression wrap, non-elastic, below knee, 30–50 mmHg, used as a surgical dressing, each
 
Effective January 1, 2024, CMS created three new HCPCS codes that should only be used to report similar gradient compression stockings and wraps for lymphedema treatment:
 
A6552 Gradient compression stocking, below knee, 30–40 mmHg, each
A6554 Gradient compression stocking, below knee, 40 mmHg or greater, each
A6583 Gradient compression wrap, with adjustable strap, below knee, 30–50 mmHg, each

NOTE: Also, effective January 1, 2024, CMS revised the definitions of four other gradient compression HCPCS codes:
A6535 Gradient compression stocking, thigh length, 40 mmHg or greater, each
A6538 Gradient compression stocking, full length/chap style, 40 mmHg or greater, each
A6541 Gradient compression stocking, waist length, 40 mmHg or greater, each
A6549 Gradient compression garment, not otherwise specified
 
Q: Because there are many types of lymphedema compression treatment items, did CMS create any other HCPCS codes for any of those items?
 
A: Yes, CMS created more than 60 new HCPCS codes, which are displayed in Table 1. If additional HCPCS codes are needed for items missing from the list, applications for new HCPCS codes may be submitted to CMS twice a year.
           
Q: Is it true that Medicare Part B will cover accessories necessary for the effective use of lymphedema compression treatment items?
 
A: Yes, Medicare Part B will cover accessories such as zippers, linings, padding, fillers, etc., if documentation in the medical record supports their medical necessity. For example: a liner is needed to prevent skin breakdown when wearing a gradient compression garment.
 
Q: Has CMS published the 2024 Medicare allowable rates for the new lymphedema compression treatment items?
 
A: Yes, the 2024 Medicare allowable rates can be found on the DMEPOS fee schedule file¹ and they are also displayed on Table 1.
 
Q: Will the Medicare Part B deductible apply, and will Medicare beneficiaries be required to pay coinsurance for lymphedema compression treatment items?
 
A: Yes, just like all other Medicare Part B covered medical devices, coinsurance and the Medicare Part B deductible apply to the lymphedema compression treatment items. However, this is a huge win for patients with lymphedema! In the past, Medicare patients incurred the full cost for lymphedema compression treatment items. Now, original Medicare Part B will pay 80% of the DMEPOS fee schedule allowable rates if the items are provided by a Medicare-enrolled DMEPOS supplier.
 
NOTE: In the future, lymphedema compression treatment items may be included in the DMEPOS Competitive Bidding Program.
 
Q: When compression bandaging supplies are furnished during Phase 1 (acute or decongestive therapy) and Phase 2 (maintenance phase of therapy), of lymphedema therapy, will Medicare cover and pay for these supplies? If so, are there any frequency limitations?
 
A: If the therapist is a DMEPOS supplier, she/he should be paid to provide the compression bandaging supplies furnished during Phase 1 and Phase 2 of lymphedema therapy.
 
CMS does not have any frequency limitations for compression bandaging supplies. Because the quantity of compression bandaging supplies needed and the frequency of replacement is at the discretion of the DME MACs, the documentation in each patient’s medical record should clearly state the medical necessity for the quantity and change frequency of the compression bandaging supplies.
 
Q: Does Medicare have any frequency limitations for replacement of any lymphedema compression garments?

A: Yes. Medicare has replacement limitations for:

• Gradient compression garments or wraps with adjustable straps: 3 per each affected extremity or part of the body every 6 months
• Nighttime garments: 2 per each affected extremity or part of the body every 2 years.

NOTE: Medicare will allow replacement of these items more frequently if 1) the patient has a change in medical need, or 2) if the item is lost, stolen, or irreparably damaged. In those cases, the DME supplier should append the RA modifier (Replacement of a DME, Orthotic or Prosthetic Item due to loss, stolen, or irreparable damage) to the codes for replacement items. Claims with the RA modifier must include a narrative that explains the reason for prior replacement to the Reasonable Useful Lifetime (RUL) of the item. The reason for replacement should be documented in the supplier's records and may include a beneficiary statement, police report, fire or insurance report, etc.
 
Kathleen D. Schaum oversees her own consulting business and is a founding member of the Today’s Wound Clinic editorial advisory board. She can be reached for consultation and questions at kathleendschaum@gmail.com.   

Reference
 
1. Centers for Medicare and Medicaid Services. DMEPOS Fee Schedule File. Last accessed December 27, 2023.