Billing and Coding: Lymphedema Decongestive Treatment

We are providing clarification of coverage and documentation requirements for
lymphedema decongestive treatment based on Noridian medical review findings.
The two basic types of decongestive treatment are:  
  
 Manual Lymphatic Drainage (MLD) which stimulates the movement of fluids in
the tissues using gentle massage and;  
 Comprehensive Decongestive Therapy (CDT) which is a combination of MLD,
bandaging, skin care and exercises.

**Coverage Requirements**

Medicare will reimburse for necessary components of decongestive treatment
when the medical record supports

  * A diagnosis of lymphedema (not tissue edema due to other etiologies e.g., chronic venous insufficiency, congestive heart failure, acute infection).
  * Recent changes in the patient's condition
  * Prior unsuccessful therapies (e.g., elevation, bandaging, diuresis) reported to justify the need for skilled services.
  * Services were provided by a qualified clinician (i.e., physician, non-physician practitioner (NPP), qualified therapist, or appropriately supervised therapist assistant).
  * Services must be under accepted standards of medical practice and considered to be specific and effective treatment for the patient's condition.

**Limitations**  
  
The goal of therapy is not to achieve maximum volume reduction but to
ultimately transfer the responsibility for the care from the provider to the
patient and/or caregiver, generally within a 1-3 week time period. There is
only temporary benefit from the treatment unless the patient and/or caregiver
are able to complete treatments at home on an ongoing basis. The end of
treatment is not when the edema resolves or stabilizes but when the patient
and/or caregiver are able to continue the treatments at home.

**Skilled Level of Care**

The key issue is whether the skills of a therapist are needed, or whether the
services can be carried out by the patient and/or caregiver after sufficient
training. The medical record must clearly indicate the patient's condition
before, during, and after the therapy episode to support that the patient
significantly benefitted from ongoing therapy services and that the progress
was sustainable and of practical value when measured against the patient's
condition at the start of treatment. Documentation should indicate clear
objective evidence of improvement generally within the first week or 10 days
of therapy (e.g., changes in weight, extremity circumference).

**Maintenance Level of Care**

When it is reasonable to assume that ongoing services could reasonably be
carried out by the patient and/or appropriately trained caregiver(s), then the
services are considered to be at a maintenance level of care and no longer
require the skills of a qualified clinician. It is the patient's
responsibility to acquire caregiver assistance for carrying out the of the
home maintenance program when necessary. Generally, it is anticipated that an
efficient home maintenance program will be effective for a lifetime. However,
in the rare instance, when additional treatment for the same condition is
necessary, then the documentation must support reasonableness and medical
necessity for the additional services. For additional information, see the
Noridian article titled "Medical Necessity of Therapy Services".

**Coding Considerations**

  * Medically necessary hands-on MLD is a covered Medicare service and is coded using CPT 97140 for manual therapy.
  * There is no Medicare coverage for lymphedema compression bandage application as this is considered to be an unskilled service. This non-coverage extends to the application of high compression, multi-layered, sustained bandage systems (e.g., Profore, Dynaflex, Supress, coded with CPT 29581 or 29584.
  * Minutes spent applying compression bandaging without patient/caregiver education should not be billed as skilled therapy services.
  * However, Medicare will cover a brief period (e.g. three or fewer sessions if no new specific issues are identified), of patient/caregiver instruction in compression bandaging home management. Medical necessity for this education must be clearly documented and meet the code descriptor requirements for CPT 97535.
  * Note that high compression bandage application used for treatment of wounds may be appropriately coded with CPT 29581 or 29584. However, these codes should not be billed for unskilled lymphedema compression bandage application. For additional information, see the Noridian article titled "High Compression Bandage System Clarification."  
  

**Sources:**

  * **Federal Register (FR), Volume 76, Number 228, Part III, Section C-5**
  * **Internet Only Manual (IOM) _Medicare National Coverage Determinations Manual,_ Publication 100-03, Chapter 1, Part 4, Sections 270.5, 280.1, 280.6**
  * **IOM _Medicare Benefit Policy Manual,_ Publication 100-02, Chapter 15, Sections 220-230**
  * **IOM Medicare Claims Processing Manual, Publication 100-04, Chapter 5, Section 20(B)**
  * **Current Procedural Terminology Coding Manual**
  * **Social Security Act (SSA), Title 18, Section 1862(a)(1)(A)**