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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.

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:

Published: August 16, 2024

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