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December 8, 2023

Lymphedema Compression Treatment Items – Correct Coding and Billing

Joint DME MAC Publication

This Correct Coding and Billing publication is effective for claims with dates of service on or after January 1, 2024.

This publication provides billing and coding guidance pertinent to lymphedema compression treatment items, based on the Centers for Medicare & Medicaid Services’ (CMS’) Final Rule CMS-1780-F.

Information on initial and replacement coverage per the Final Rule:

Gradient compression garments, related supplies and accessories are covered only for the treatment of lymphedema (see ICD-10-CM Codes that Support Medical Necessity below). Claims for gradient compression garments, related supplies and accessories for non-lymphedema diagnoses will be denied as not reasonable and necessary.

A quantity of three (3) daytime garments or wraps per body area are allowed once every six (6) months.

A quantity of two (2) nighttime garments per body area are allowed once every two (2) years (24 months).

Replacement of the garments can only be made in accordance with the frequency limitations of once every six (6) months for daytime garments or wraps and once every two (2) years for nighttime garments.

Claims for gradient compression garments or wraps billed in excess of the frequency limitations outlined above will be denied as not reasonable and necessary unless replacements are needed in cases of loss, theft, or irreparable damage. In addition, payment can be made for a new set of garments or wraps if determined to be reasonable and necessary due to a change in the beneficiary’s medical or physical condition that warrants a new size or type of garment or wrap. Payment is made for replacement of an entire new set of three daytime garments or wraps and/or two nighttime garments in cases of loss, theft, irreparable damage, or change in medical or physical condition and the six month and/or two year replacement frequency begins anew at the time the replacement items are furnished.

Medicare covers custom fitted (custom or non-standard) gradient compression garments. Custom fitted gradient compression garments are uniquely sized and shaped to fit the exact dimensions of the affected extremity of an individual to provide accurate gradient compression to treat lymphedema. Examples of scenarios where a custom fitted gradient compression garment might be used (not all-inclusive) are:

  • If the circumference of the proximal portion 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 is unable to tolerate the fabric composition of a standard garment.

There must be documentation in the beneficiary’s medical record necessitating the use of a custom fitted gradient compression garment versus an off-the-shelf standard gradient compression garment. The patient’s medical record is not limited to the physician’s office records. It may include hospital, nursing home, or HHA records and records from other health care professionals, such as lymphedema treatment professionals. This documentation must be made available to the DME MAC upon request.

Compression bandaging supplies furnished during Phase 1 (acute or decongestive therapy) and Phase 2 (maintenance phase of therapy) are covered when medically necessary for the treatment of lymphedema. The therapists and other suppliers furnishing bandaging systems must be enrolled DMEPOS suppliers in order to be paid for furnishing these items. The justification for the quantity of supplies needed and the frequency of replacement must be documented in the beneficiary’s medical record and made available to the DME MAC upon request.

Accessories (e.g., zippers, linings, padding or fillers, etc.) necessary for the effective use of a lymphedema compression treatment item are covered when medically necessary for the treatment of lymphedema. The justification for the quantity of supplies needed and the frequency of replacement must be documented in the beneficiary’s medical record and made available to the DME MAC upon request.

Payment for all necessary services associated with furnishing gradient compression garments and wraps, including fitting and measurements, is included in the national payment amounts made to the supplier of the item.

HCPCS CODES

Group 1 Codes:

HCPCS Code Long Descriptor
A6520 GRADIENT COMPRESSION GARMENT, GLOVE, PADDED, FOR NIGHTTIME USE, EACH
A6521 GRADIENT COMPRESSION GARMENT, GLOVE, PADDED, FOR NIGHTTIME USE, CUSTOM, EACH
A6522 GRADIENT COMPRESSION GARMENT, ARM, PADDED, FOR NIGHTTIME USE, EACH
A6523 GRADIENT COMPRESSION GARMENT, ARM, PADDED, FOR NIGHTTIME USE, CUSTOM, EACH
A6524 GRADIENT COMPRESSION GARMENT, LOWER LEG AND FOOT, PADDED, FOR NIGHTTIME USE, EACH
A6525 GRADIENT COMPRESSION GARMENT, LOWER LEG AND FOOT, PADDED, FOR NIGHTTIME USE, CUSTOM, EACH
A6526 GRADIENT COMPRESSION GARMENT, FULL LEG AND FOOT, PADDED, FOR NIGHTTIME USE, EACH
A6527 GRADIENT COMPRESSION GARMENT, FULL LEG AND FOOT, PADDED, FOR NIGHTTIME USE, CUSTOM, EACH
A6528 GRADIENT COMPRESSION GARMENT, BRA, FOR NIGHTTIME USE, EACH
A6529 GRADIENT COMPRESSION GARMENT, BRA, FOR NIGHTTIME USE, CUSTOM, EACH
A6530 GRADIENT COMPRESSION STOCKING, BELOW KNEE, 18-30 MMHG, EACH
A6533 GRADIENT COMPRESSION STOCKING, THIGH LENGTH, 18-30 MMHG, EACH
A6534 GRADIENT COMPRESSION STOCKING, THIGH LENGTH, 30-40 MMHG, EACH
A6535 GRADIENT COMPRESSION STOCKING, THIGH LENGTH, 40 MMHG OR GREATER, EACH
A6536 GRADIENT COMPRESSION STOCKING, FULL LENGTH/CHAP STYLE, 18-30 MMHG, EACH
A6537 GRADIENT COMPRESSION STOCKING, FULL LENGTH/CHAP STYLE, 30-40 MMHG, EACH
A6538 GRADIENT COMPRESSION STOCKING, FULL LENGTH/CHAP STYLE, 40 MMHG OR GREATER, EACH
A6539 GRADIENT COMPRESSION STOCKING, WAIST LENGTH, 18-30 MMHG, EACH
A6540 GRADIENT COMPRESSION STOCKING, WAIST LENGTH, 30-40 MMHG, EACH
A6541 GRADIENT COMPRESSION STOCKING, WAIST LENGTH, 40 MMHG OR GREATER, EACH
A6549 GRADIENT COMPRESSION GARMENT, NOT OTHERWISE SPECIFIED
A6552 GRADIENT COMPRESSION STOCKING, BELOW KNEE, 30-40 MMHG, EACH
A6553 GRADIENT COMPRESSION STOCKING, BELOW KNEE, 30-40 MMHG, CUSTOM, EACH
A6554 GRADIENT COMPRESSION STOCKING, BELOW KNEE, 40 MMHG OR GREATER, EACH
A6555 GRADIENT COMPRESSION STOCKING, BELOW KNEE, 40 MMHG OR GREATER, CUSTOM, EACH
A6556 GRADIENT COMPRESSION STOCKING, THIGH LENGTH, 18-30 MMHG, CUSTOM, EACH
A6557 GRADIENT COMPRESSION STOCKING, THIGH LENGTH, 30-40 MMHG, CUSTOM, EACH
A6558 GRADIENT COMPRESSION STOCKING, THIGH LENGTH, 40 MMHG OR GREATER, CUSTOM, EACH
A6559 GRADIENT COMPRESSION STOCKING, FULL LENGTH/CHAP STYLE, 18-30 MMHG, CUSTOM, EACH
A6560 GRADIENT COMPRESSION STOCKING, FULL LENGTH/CHAP STYLE, 30-40 MMHG, CUSTOM, EACH
A6561 GRADIENT COMPRESSION STOCKING, FULL LENGTH/CHAP STYLE, 40 MMHG OR GREATER, CUSTOM, EACH
A6562 GRADIENT COMPRESSION STOCKING, WAIST LENGTH, 18-30 MMHG, CUSTOM, EACH
A6563 GRADIENT COMPRESSION STOCKING, WAIST LENGTH, 30-40 MMHG, CUSTOM, EACH
A6564 GRADIENT COMPRESSION STOCKING, WAIST LENGTH, 40 MMHG OR GREATER, CUSTOM, EACH
A6565 GRADIENT COMPRESSION GAUNTLET, CUSTOM, EACH
A6566 GRADIENT COMPRESSION GARMENT, NECK/HEAD, EACH
A6567 GRADIENT COMPRESSION GARMENT, NECK/HEAD, CUSTOM, EACH
A6568 GRADIENT COMPRESSION GARMENT, TORSO AND SHOULDER, EACH
A6569 GRADIENT COMPRESSION GARMENT, TORSO/SHOULDER, CUSTOM, EACH
A6570 GRADIENT COMPRESSION GARMENT, GENITAL REGION, EACH
A6571 GRADIENT COMPRESSION GARMENT, GENITAL REGION, CUSTOM, EACH
A6572 GRADIENT COMPRESSION GARMENT, TOE CAPS, EACH
A6573 GRADIENT COMPRESSION GARMENT, TOE CAPS, CUSTOM, EACH
A6574 GRADIENT COMPRESSION ARM SLEEVE AND GLOVE COMBINATION, CUSTOM, EACH
A6575 GRADIENT COMPRESSION ARM SLEEVE AND GLOVE COMBINATION, EACH
A6576 GRADIENT COMPRESSION ARM SLEEVE, CUSTOM, MEDIUM WEIGHT, EACH
A6577 GRADIENT COMPRESSION ARM SLEEVE, CUSTOM, HEAVY WEIGHT, EACH
A6578 GRADIENT COMPRESSION ARM SLEEVE, EACH
A6579 GRADIENT COMPRESSION GLOVE, CUSTOM, MEDIUM WEIGHT, EACH
A6580 GRADIENT COMPRESSION GLOVE, CUSTOM, HEAVY WEIGHT, EACH
A6581 GRADIENT COMPRESSION GLOVE, EACH
A6582 GRADIENT COMPRESSION GAUNTLET, EACH
A6583 GRADIENT COMPRESSION WRAP WITH ADJUSTABLE STRAPS, BELOW KNEE, 30-50 MMHG, EACH
A6584 GRADIENT COMPRESSION WRAP WITH ADJUSTABLE STRAPS, NOT OTHERWISE SPECIFIED
A6585 GRADIENT PRESSURE WRAP WITH ADJUSTABLE STRAPS, ABOVE KNEE, EACH
A6586 GRADIENT PRESSURE WRAP WITH ADJUSTABLE STRAPS, FULL LEG, EACH
A6587 GRADIENT PRESSURE WRAP WITH ADJUSTABLE STRAPS, FOOT, EACH
A6588 GRADIENT PRESSURE WRAP WITH ADJUSTABLE STRAPS, ARM, EACH
A6589 GRADIENT PRESSURE WRAP WITH ADJUSTABLE STRAPS, BRA, EACH
A6593 ACCESSORY FOR GRADIENT COMPRESSION GARMENT OR WRAP WITH ADJUSTABLE STRAPS, NOT-OTHERWISE SPECIFIED
A6594 GRADIENT COMPRESSION BANDAGING SUPPLY, BANDAGE LINER, LOWER EXTREMITY, ANY SIZE OR LENGTH, EACH
A6595 GRADIENT COMPRESSION BANDAGING SUPPLY, BANDAGE LINER, UPPER EXTREMITY, ANY SIZE OR LENGTH, EACH
A6596 GRADIENT COMPRESSION BANDAGING SUPPLY, CONFORMING GAUZE, PER LINEAR YARD, ANY WIDTH, EACH
A6597 GRADIENT COMPRESSION BANDAGE ROLL, ELASTIC LONG STRETCH, PER LINEAR YARD, ANY WIDTH, EACH
A6598 GRADIENT COMPRESSION BANDAGE ROLL, ELASTIC MEDIUM STRETCH, PER LINEAR YARD, ANY WIDTH, EACH
A6599 GRADIENT COMPRESSION BANDAGE ROLL, INELASTIC SHORT STRETCH, PER LINEAR YARD, ANY WIDTH, EACH
A6600 GRADIENT COMPRESSION BANDAGING SUPPLY, HIGH DENSITY FOAM SHEET, PER 250 SQUARE CENTIMETERS, EACH
A6601 GRADIENT COMPRESSION BANDAGING SUPPLY, HIGH DENSITY FOAM PAD, ANY SIZE OR SHAPE, EACH
A6602 GRADIENT COMPRESSION BANDAGING SUPPLY, HIGH DENSITY FOAM ROLL FOR BANDAGE, PER LINEAR YARD, ANY WIDTH, EACH
A6603 GRADIENT COMPRESSION BANDAGING SUPPLY, LOW DENSITY CHANNEL FOAM SHEET, PER 250 SQUARE CENTIMETERS, EACH
A6604 GRADIENT COMPRESSION BANDAGING SUPPLY, LOW DENSITY FLAT FOAM SHEET, PER 250 SQUARE CENTIMETERS, EACH
A6605 GRADIENT COMPRESSION BANDAGING SUPPLY, PADDED FOAM, PER LINEAR YARD, ANY WIDTH, EACH
A6606 GRADIENT COMPRESSION BANDAGING SUPPLY, PADDED TEXTILE, PER LINEAR YARD, ANY WIDTH, EACH
A6607 GRADIENT COMPRESSION BANDAGING SUPPLY, TUBULAR PROTECTIVE ABSORPTION LAYER, PER LINEAR YARD, ANY WIDTH, EACH
A6608 GRADIENT COMPRESSION BANDAGING SUPPLY, TUBULAR PROTECTIVE ABSORPTION PADDED LAYER, PER LINEAR YARD, ANY WIDTH, EACH
A6609 GRADIENT COMPRESSION BANDAGING SUPPLY, NOT OTHERWISE SPECIFIED
A6610 GRADIENT COMPRESSION STOCKING, BELOW KNEE, 18-30 MMHG, CUSTOM, EACH

CMS established four not otherwise specified HCPCS codes to identify compression bandaging supplies, accessories, wraps, and compression garments that are not identified by a unique HCPCS code:

  • A6549 - GRADIENT COMPRESSION GARMENT, NOT OTHERWISE SPECIFIED
  • A6584 - GRADIENT COMPRESSION WRAP WITH ADJUSTABLE STRAPS, NOT OTHERWISE SPECIFIED
  • A6593 - ACCESSORY FOR GRADIENT COMPRESSION GARMENT OR WRAP WITH ADJUSTABLE STRAPS, NOT-OTHERWISE SPECIFIED
  • A6609 - GRADIENT COMPRESSION BANDAGING SUPPLY, NOT OTHERWISE SPECIFIED

Each compression bandaging supply, accessory, wrap, or compression garment without a unique HCPCS must be billed on a separate claim line with A6549, A6584, A6593, or A6609 and the appropriate units of service. Claims for A6549, A6584, A6593, and A6609 must include the following information in the narrative field of an electronic claim (NTE 2300 or NTE 2400) or Item 19 of a paper claim:

  • Description of the item (including the quantity represented by each unit of service (e.g., per inch, foot, or yard for supplies))
  • Manufacturer name
  • Product name and number
  • Supplier price list
  • HCPCS of related item (where applicable)

MODIFIERS

LT, RT, RA

The right (RT) and left (LT) modifiers must be used with gradient compression garments, related supplies and accessories when laterality is indicated (HCPCS codes A6520, A6521, A6522, A6523, A6524, A6525, A6526, A6527, A6530, A6533, A6534, A6535, A6552, A6553, A6554, A6555, A6556, A6557, A6558, A6565, A6572, A6573, A6574, A6575, A6576, A6577, A6578, A6579, A6580, A6581, A6582, A6583, A6584, A6585, A6586, A6587, A6588, A6594, A6595 and A6610). When the same code for bilateral items (left and right) is billed on the same date of service, bill each item on two separate claim lines using the RT and LT modifiers and 1 unit of service (UOS) on each claim line. Do not use the RTLT modifier on the same claim line and bill with 2 UOS. Claims billed without modifiers RT and/or LT, or with RTLT on the same claim line and 2 UOS, will be rejected as incorrect coding.

The RA modifier (REPLACEMENT OF A DME, ORTHOTIC OR PROSTHETIC ITEM) may only be used if the gradient compression garment or wrap is lost, stolen, or irreparably damaged. Replacement of the garments can only be made in accordance with the frequency limitations of once every six (6) months for daytime garments or wraps and once every two (2) years for nighttime garments.

For replacement claims, if only one (1) daytime garment or wrap is lost, stolen, or irreparably damaged, payment is allowed for three (3) replacements, but the frequency limitation clock of six (6) months would restart based on the date of service for the replacement claim. For replacement claims for a nighttime garment, two (2) replacements are allowed if only one nighttime garment or wrap is lost, stolen, or irreparably damaged and the frequency limitation clock of two years (24 months) would restart based on the date of service for the replacement claim.

ICD-10-CM CODES THAT SUPPORT MEDICAL NECESSITY

Payment for lymphedema compression treatment items is limited to the ICD-10-CM codes of lymphedema listed below. The presence of an ICD-10-CM code listed in this section is not sufficient by itself to assure coverage.

Code Description
I89.0 Lymphedema, not elsewhere classified
I97.2 Postmastectomy lymphedema syndrome
I97.89 Other postprocedural complications and disorders of the circulatory system, not elsewhere classified
Q82.0 Hereditary lymphedema

Publication History

December 8, 2023 Originally Published

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