Lymphedema Treatment and Coverage Updates
Restoring Shape and Function
Local Medicare Administrative Contractor (MAC) coverage updates during the last month included a new Article from Noridian Jurisdiction E and a combining of existing Parts A and B articles for Noridian JF concerning the topic of Lymphedema Decongestive Treatment. Noridian is the only MAC with a separate Article or Local Coverage Determination (LCD) that specifically addresses this topic. However, almost all the other MACs do address lymphedema treatment as part of their Physical/Occupational Therapy policies. Lymphedema treatment is important to restore normal shape, reduce the likelihood of complications, and to restore function (such as self-care and other activities of daily living [ADLs]). Here is a table of the Articles and LCDs that provide guidance on lymphedema treatment.
|MAC Coverage Determinations Addressing Lymphedema Decongestive Treatment|
|Policy ID Number||Policy Title||MAC|
|A55710||Lymphedema Decongestive Treatment||Noridian JE|
|A52959||Lymphedema Decongestive Treatment||Noridian JF|
|L35036||Therapy and Rehabilitation Services (PT, OT)||Novitas JH/JL|
|L33413||Therapy and Rehabilitation Services||First Coast JN|
|L34428||Outpatient Physical Therapy||Palmetto JM|
|L34427||Outpatient Occupational Therapy||Palmetto JM|
|L33631||Outpatient Physical and Occupational Therapy Services||NGS J6/JK|
|L34049||Outpatient Physical and Occupational Therapy Services||CGS J15|
|L34310||Medicine: Physical Therapy - Outpatient||Cahaba JJ|
|L34308||Medicine: Occupational Therapy - Outpatient||Cahaba JJ|
There are similarities and differences between the coverage policies from the various MACs, so be sure to refer to the policy for your jurisdiction to understand the requirements that apply to your hospital. In general, complex or comprehensive decongestive therapy (CDT) consists of skin care, manual lymphatic drainage (MLD), compression wrapping, and therapeutic exercises. Other key points related to the treatment are listed below.
- There must be a physician-documented diagnosis of primary or secondary lymphedema. Treatment is not for tissue edema from other causes (e.g. congestive heart failure).
- The patient should have documented signs and symptoms and functional limitations due to the lymphedema.
- The ultimate goal of treatment is to reduce and maintain reduction of lymphedema by establishing a management program that can be carried out by the patient, patient’s family, or patient’s caregiver. This means a major component of treatment is education of the patient and/or caregiver.
- Skilled therapy should not be continued once the patient/caregiver has been sufficiently trained.
- It is necessary for the patient or their caregiver to have the ability to understand and comply with continuation of the treatment regimen after skilled therapy is complete.
- Treatment should be provided by a skilled professional (physician, non-physician practitioner, or therapist) who has received specialized training in this form of treatment.
- Almost all the coverage policies place limits on the amount and duration of treatment. Common limits are 3-5 treatments weekly for up to 12-18 visits but vary by MAC.
- Most MACs support the use of CPT code 97140 (manual therapy) for manual lymphatic drainage and CPT 97110 (therapeutic exercise) for the exercise portion of CDT. Some MACs state they do not accept the compression application codes (29581-29584) for compression wrapping for lymphedema.
- Documentation requirements, when addressed, require supportive documentation of patient history and etiology, prior treatments, ability of patient and/or caregiver to continue home treatment, functional limitations and pain levels, limb measurements and any other skin conditions in that area.
Secondary lymphedema may be the result of surgical removal of lymph nodes (such as in association with surgery for breast cancer or other cancers), fibrosis secondary to radiation, and traumatic injury to the lymphatic system. Decongestive therapy for lymphedema is a valuable treatment for those patients who need it. Providers should be familiar with and follow the guidance of their area Medicare contractors for this beneficial service.
Other local coverage updates over the past month are listed below:
Article by Debbie Rubio
This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.