Lymphedema Treatment and Coverage Updates

on Monday, 11 September 2017. All News Items | Outpatient Services | Medicare Coverage

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:

 

Cahaba JJ

No updates this month

 

CGS J15

IDTitleEffective DateRevision Effective DateEnd DateLast UpdatedStatus
A55716  MolDX: Abbott RealTime IDH2 testing for Acute Myeloid Leukemia (AML) Coding and Billing Guidelines  8/31/2017 N/A N/A 8/23/2017 New
A55715  Coenzyme Q10 (Q10) Coding and Billing Guideline  8/31/2017 N/A N/A 8/23/2017 New

 

First Coast JN

IDTitleEffective DateRevision Effective DateEnd DateLast UpdatedStatus
L33379   Intraoperative Neurophysiology Monitoring  10/1/2015 N/A  8/11/2017 8/11/2017 Retired 
L33381  Low Density Lipoprotein (LDL) Apheresis  10/1/2015 10/1/2016 8/11/2017 8/11/2017 Retired 

 

NGS J6 and JK

No updates this month

   

Noridian JE

IDTitleEffective DateRevision Effective DateEnd DateLast UpdatedStatus
A55710  Lymphedema Decongestive Treatment  8/31/2017 N/A N/A 8/23/2017 New

   

Noridian JF

No updates this month

   

Novitas JH and JL

No updates this month

 

Palmetto JM

IDTitleEffective DateRevision Effective DateEnd DateLast UpdatedStatus
L35627  Non-Coverage of Extracorporeal Shock Wave Lithotripsy for Musculoskeletal Conditions  10/1/2015 1/1/2017 8/8/2017 8/8/2017 Retired
A55695  MolDX: Abbott RealTime IDH2 testing for Acute Myeloid Leukemia (AML) Coding and Billing Guidelines  8/17/2017 N/A N/A 8/11/2017 New
A55709  Coenzyme Q10 (Q10) Coding and Billing Guideline  8/31/2017 N/A N/A 8/21/2017 New
A55717  Flow Cytometry Coverage Clarification  8/31/2017 N/A N/A 8/24/2017 New

 

WPS J5 and J8

IDTitleEffective DateRevision Effective DateEnd DateLast UpdatedStatus
A55640  Not Otherwise Classified Chemotherapy Agents (NOC)  9/16/2017 9/16/2017 N/A 8/22/2017 New
A55639  Chemotherapy Agents for Non-Oncologic Conditions  9/16/2017 N/A N/A 7/18/2017 New
IDTitleComment Start DateComment End DateFinal Status
DL37537  Frequency of Hemodialysis  10/5/2017 11/19/2017 No  Draft
DL37539  MolDX: Prometheus IBD sgi Diagnostic Policy  10/5/2017 11/19/2017 No  Draft

 

Article by Debbie Rubio

Debbie Rubio, BS, MT (ASCP), is the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc.  Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system.  In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers.  You may contact Debbie at This email address is being protected from spambots. You need JavaScript enabled to view it..

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.

 

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