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License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2009 American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.

You, your employees and agents are authorized to use CPT only as contained in the following authorized materials including but not limited to CGS fee schedules, general communications, Medicare Bulletin, and related materials internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

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This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a)June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements.

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CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CGS or the CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

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This license will terminate upon notice to you if you violate the terms of this license. The AMA is a third party beneficiary to this license.

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

End User License Agreement

These materials contain Current Dental Terminology, Fourth Edition (CDT), copyright © 2002, 2004 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.

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Fact Sheet

Lymphedema Compression Treatment Items Fact Sheet

Use this fact sheet to quickly understand the new Lymphedema Compressions Treatment Items benefit. We have also listed helpful resources at the bottom of this page.

Coverage:

Section 4133 of the Consolidated Appropriations ActExternal PDF (CAA), 2023, established a new Medicare DMEPOS benefit category for standard and custom-fitted compression garments and additional lymphedema compression treatment items to service a medical purpose.

The new benefit started January 1, 2024, and includes standard and custom-fitted lymphedema compression treatment items for each affected body part:

  • Standard and custom daytime and nighttime compression garments
  • Gradient Compression wraps
  • Compression bandaging systems and supplies provided during Phase 1 (initial) and Phase 2 (maintenance)
  • Accessories needed for effective use of lymphedema compression treatment (not all-inclusive):
  • Donning and Doffing aids (Aids for putting on and taking off compression stockings)
  • Fillers
  • Lining
  • Padding
  • Zippers

Custom or Non-Standard Garments:

Custom fitted gradient compression garments are uniquely sized and shaped to fit the exact dimensions of the individual’s affected body to give accurate gradient compression for lymphedema treatment. Examples of when a beneficiary might use a custom fitted gradient compression garment:

  • If the circumference of the proximal part of the limb is significantly greater than the distal limb.
  • If the skin/tissue has folds or contours requiring a specific type of knitting pattern.
  • Beneficiary can’t tolerate the fabric composition of a standard garment.

The beneficiary’s medical record must have documentation explaining why the beneficiary needs a custom fitted gradient compression garment versus an off-the-shelf standard gradient compression garment.

Coding:

See Lymphedema Compression Treatment Items – Correct Coding and Billing.

If you have questions about coding, please contact the Pricing, Data Analysis and Coding (PDAC) at (877) 735-1326 during the hours of 9:30 a.m. to 5:00 p.m. ET, Monday through Friday. You may also visit the PDAC websiteExternal Website to chat with a representative, or select the Contact UsExternal Website button at the top of the PDAC website for email, FAX or postal mail information.

Diagnosis codes:

For Medicare to consider coverage, the beneficiary must have one of these ICD-10-CM codes:

  • I89.0 Lymphedema, not elsewise classified
  • 197.2 Postmastectomy lymphedema syndrome
  • I97.89 Other postprocedural complications and disorders of the circulatory system, not elsewhere classified
  • Q82.0: Hereditary lymphedema

If the beneficiary does not have one of the above diagnosis codes, your claim will deny as not covered.

Documentation:

See Standard Documentation Requirements for All Claims Submitted to the DME MACs Policy Article A55426.External Website

Quantity/Frequency/Replacement

Medicare will allow and replace:

  • 3 daytime garments or wraps per body area once every 6 months.
  • 2 nighttime garments per body area once every 2 years.
  • Compression bandaging supplies and accessories: When medically necessary for the treatment of lymphedema.

If you bill for over the quantity allowed, your claim will deny as not covered.

  • Whether you deliver all 3 items per body part on the same date or individually at different dates within the appropriate period, the 6-month or 2-year period begins when the first item ships.
  • Examples:
    • If you deliver all 3 daytime garments for the same body part on same date of April 2, you can’t ship again until after the 6-month period ends on October 2.
    • If you deliver only the first daytime garment for a specific body part on April 2, you can deliver the remaining 2 allowable garments for that body part at any time before October 2.
    • In either case, a new 6-month period doesn’t begin until you deliver the next new item “set” for that same body part.
    • The delivery of the next new item for that body part can be delivered as soon as the day after the previous 6-month period ends, or weeks or months later, depending on the needs of the beneficiary.

Garments or wraps may also be replaced when:

  • The beneficiary needs a new garment or wrap due to a change in medical or physical condition.
  • Garments or wraps are lost, stolen, or irreparably damaged in a specific incident.

When billing a claim for lost, stolen, or irreparably damaged item:

  • Use the RA modifier (Replacement of a DME, orthotic, or prosthetic item)
  • Add a claim narrative explaining reason for replacement

Resources:

Revised: November 5, 2024

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