I 

111TH CONGRESS 

2D SESSION H. R. 4662 

To amend title XVIII of the Social Security Act to improve the diagnosis 

and treatment of lymphedema under the Medicare Program and to reduce 

costs under such program related to the treatment of complications 

of lymphedema, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

FEBRUARY 23, 2010 

Mr. KISSELL introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to the Committee on 

Ways and Means, for a period to be subsequently determined by the 

Speaker, in each case for consideration of such provisions as fall within 

the jurisdiction of the committee concerned 

A BILL 

To amend title XVIII of the Social Security Act to improve 

the diagnosis and treatment of lymphedema under the 

Medicare Program and to reduce costs under such program related to the treatment of complications of 

lymphedema, and for other purposes. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Lymphedema Diag5 nosis and Treatment Cost Saving Act of 2010’’. 


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1 SEC. 2. COVERAGE OF LYMPHEDEMA DIAGNOSIS AND 

2 TREATMENT SERVICES UNDER MEDICARE. 

3 (a) COVERAGE OF SERVICES.—Section 1861 of the 

4 Social Security Act (42 U.S.C. 1395x) is amended— 

5 (1) in subsection (s)(2)— 

6 (A) in subparagraph (DD), by striking 

7 ‘‘and’’ at the end; 

8 (B) in subparagraph (EE), by adding 

9 ‘‘and’’ at the end; and 

10 (C) by adding at the end the following new 

11 subparagraph: 

12 ‘‘(FF) lymphedema compression treatment 

13 items (as described in subsection (iii)) and 

14 lymphedema diagnosis and treatment services 

15 (as described in subsection (hhh)) if such serv16 ices are prescribed by and reviewed by a treat17 ing physician and performed by such physician 

18 or— 

19 ‘‘(i) a physical therapist or an occupa20 tional therapist who meets the quality re21 quirements of subsection (hhh)(2)(C); 

22 ‘‘(ii) a qualified professional, such as 

23 a physician, nurse practitioner, clinical 

24 nurse specialist, chiropractor, or physi25 cian’s assistant who is licensed or certified 

26 by the State in which the services are perVerDate Nov 24 2008 21:20 Feb 24, 2010 Jkt 089200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\H4662.IH H4662

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1 formed to perform therapy services and 

2 who meets the quality requirements of 

3 (hhh)(2)(C); or 

4 ‘‘(iii) a qualified person, such as a 

5 physical therapist assistant, occupational 

6 therapy assistant, licensed massage thera7 pist, licensed practical nurse, or licensed 

8 home health practitioner who meets the 

9 quality requirements of (hhh)(2)(C) pro10 viding such services are rendered under the 

11 direct supervision of a physical therapist or 

12 occupational therapist qualified in 

13 lymphedema treatment and management 

14 who meets the quality requirements of 

15 (hhh)(2)(C).’’; and 

16 (2) by adding at the end the following new sub17 sections: 

18 ‘‘(hhh) LYMPHEDEMA DIAGNOSIS AND TREATMENT

19 SERVICES.—(1) The term ‘lymphedema diagnosis and 

20 treatment services’ means, with respect to an individual 

21 and consistent with paragraph (3), differential diagnosis 

22 and treatment of lymphedema (regardless of cause) ac23 cording to the current standard of lymphedema diagnosis 

24 and treatment described in paragraph (2)(A) by, or under 

25 the direction of, a health care professional that is a cerVerDate Nov 24 2008 21:20 Feb 24, 2010 Jkt 089200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\H4662.IH H4662

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1 tified provider as described in paragraph (2)(B) in an out2 patient setting and that meets the quality standards de3 scribed in paragraph (2)(C), but only if the physician who 

4 is managing the individual’s lymphedema certifies that 

5 such services are needed under a comprehensive plan of 

6 care related to the individual’s diagnosed lymphedema. 

7 ‘‘(2) For purposes of paragraph (1): 

8 ‘‘(A) The current standard of lymphedema di9 agnosis and treatment described in this subpara10 graph is such standard as defined by the American 

11 Cancer Society and the International Society of 

12 Lymphology and called ‘complex decongestive ther13 apy’, a multi-modal therapy comprising manual 

14 lymph drainage, compression therapy, exercise, and 

15 skin care. Such standard consists of the initial phase 

16 of treatment which is performed by qualified health 

17 care professionals on an outpatient basis (Phase 1 

18 treatment) and the continuing maintenance phase 

19 (Phase 2 treatment) which is performed in a home 

20 setting by the patient, patient’s family, or patient’s 

21 aide after receiving instruction described in para22 graph (5). 

23 ‘‘(B) A qualified provider is a physician or 

24 lymphedema therapist knowledgeable of the diag25 nosis and current medical standard of treatment of 


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1 lymphedema, or any other individual or entity des2 ignated by the Secretary, that, in addition to pro3 viding lymphedema outpatient self-management 

4 training services (as defined in paragraph 

5 (3)(C)(iii)), provides other items or services for 

6 which payment may be made under this title. 

7 ‘‘(C)(i) Subject to clause (ii), the quality stand8 ards described in this subparagraph are quality 

9 standards established by the Secretary equivalent to 

10 the practice standards established by the 

11 Lymphology Association of North America. 

12 ‘‘(ii) In applying this subsection during the 3- 

13 year period beginning on the date of the enactment 

14 of this subsection, a therapist who has completed at 

15 least 135 hours of lymphedema treatment training 

16 and is certified by the training school is deemed to 

17 have met the requirement of clause (i), and may 

18 practice under a certified provider within a plan of 

19 care developed by the certified provider; regardless 

20 of whether the therapist meets the experience stand21 ards established by the Lymphology Association of 

22 North America. 

23 ‘‘(D) The term ‘lymphedema diagnosis’ means 

24 the differential diagnosis of the source of the pa25 tient’s edema and the identification of the specific 


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1 etiology in order to develop the lymphedema treat2 ment plan. Such term shall include diagnostic tools 

3 such as the lymphoscintigraphic functional test or 

4 other test the Secretary determines to be efficatious 

5 to directly observe lymphatic system function may be 

6 indicated if medical history or tests to rule out other 

7 causes are not adequate to provide a clear positive 

8 diagnosis of lymphedema. 

9 ‘‘(3) COVERAGE.—With respect to lymphedema diag10 nosis and treatment services coverage under this part, the 

11 following shall apply: 

12 ‘‘(A) MANUAL LYMPH DRAINAGE.— 

13 ‘‘(i) Lymphedema diagnosis and treatment 

14 services coverage under this part shall include 

15 an initial course of manual lymph drainage as 

16 part of complete decongestive therapy (Phase 1) 

17 when medically required by the qualified pro18 vider described in paragraph (2)(B). 

19 ‘‘(ii) The schedule and number of manual 

20 lymph drainage treatment sessions shall be de21 termined by the treating physician or 

22 lymphedema therapist as required by medical 

23 necessity, and not the limits governing rehabili24 tation therapy described in section 1833(g). 


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1 ‘‘(B) COMPRESSION BINDING SYSTEMS, GAR2 MENTS AND DEVICES.— 

3 ‘‘(i) For purposes of this part, the mate4 rials and aids used in lymphedema compression 

5 therapy— 

6 ‘‘(I) while physically resembling items 

7 in other benefit categories such as surgical 

8 dressings, durable medical equipment, 

9 splints and braces, orthotics and pros10 thetics described in subsections (s)(5), 

11 (s)(6), and (s)(9), do not serve the same 

12 medical function as such items in such 

13 other categories and have significantly dif14 ferent therapeutic characteristics and uses; 

15 and 

16 ‘‘(II) are specified in subsection (iii) 

17 as a separate benefit category. 

18 ‘‘(ii) Such coverage shall include any com19 pression garments, binding systems and devices 

20 described in subsection (iii) deemed by the pa21 tient’s qualified caregiver to be medically nec22 essary as part of the treatment of lymphedema. 

23 ‘‘(iii) Such coverage shall include replace24 ments when required to maintain their medi25 cally required compressive function or to accomVerDate Nov 24 2008 21:20 Feb 24, 2010 Jkt 089200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\H4662.IH H4662

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1 modate changes in the patient’s dimensions or 

2 medical condition. 

3 ‘‘(C) LYMPHEDEMA SELF-MANAGEMENT TRAIN4 ING.— 

5 ‘‘(i) IN GENERAL.— 

6 ‘‘(I) The initial course of treatment 

7 (phase 1) described in paragraph (2)(A), 

8 with respect to such services, shall include 

9 training of the patient and an aide or fam10 ily member as required to perform self11 treatment in a home setting, including any 

12 of the following home treatment modalities 

13 which are determined by the qualified pro14 vider to be medically required and are a 

15 part of the continuing maintenance phase 

16 (phase 2) home treatment plan described 

17 in paragraph (2)(A): 

18 ‘‘(aa) Self-manual lymph drain19 age (simple lymph drainage). 

20 ‘‘(bb) Compression bandaging. 

21 ‘‘(cc) Donning and care of com22 pression garments. 

23 ‘‘(dd) Performance of an appro24 priate decongestive exercise program. 


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1 ‘‘(ee) Use of specialized manually 

2 adjustable compression devices, don3 ning aids, and other required ancillary 

4 equipment; and if medically indicated. 

5 ‘‘(ff) Use of sequential gradient 

6 compression pneumatic pump. 

7 ‘‘(II) As part of such treatment, pa8 tient training shall include instruction on 

9 periodic self-measurements, skin care, indi10 cations of infection, and the steps to be 

11 taken if infection occurs. 

12 ‘‘(III) The term ‘lymphedema out13 patient self-management training services’ 

14 means educational and training services 

15 furnished to an individual diagnosed with 

16 lymphedema by a certified provider (as de17 scribed in paragraph (2)(B)) in an out18 patient setting but only if the physician 

19 who is managing the individual’s 

20 lymphedema condition certifies that such 

21 services are needed under a comprehensive 

22 plan of care related to the individual’s 

23 lymphedema condition. 

24 ‘‘(ii) CONSULTATION WITH ORGANIZATIONS

25 IN ESTABLISHING PAYMENT AMOUNTS FOR


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1 SERVICES PROVIDED BY PHYSICIANS.—In es2 tablishing payment amounts under section 1848 

3 for physicians’ services consisting of 

4 lymphedema outpatient self-management train5 ing services, the Secretary shall consult with 

6 appropriate organizations, including such orga7 nizations representing individuals or Medicare 

8 beneficiaries with lymphedema, in determining 

9 the relative value for such services under sec10 tion 1848(c)(2). 

11 ‘‘(D) MEASUREMENTS TO DEFINE TREATMENT

12 EFFICACY.—Periodic measurements shall be made to 

13 enable evaluation of the efficacy of the treatment 

14 plan and patient adherence, to modify the treatment 

15 plan or to determine the need for follow-up courses 

16 of treatment. 

17 ‘‘(E) FOLLOW-UP TREATMENT.—Such coverage 

18 shall provide for follow-up treatments whenever 

19 medically required to periodically validate home tech20 niques, to monitor progress against the written 

21 treatment plan, and to modify the treatment plan as 

22 required. 

23 ‘‘(F) DENIAL.—No individual other than a li24 censed physician or certified lymphedema therapist 

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1 volved in the care requested, may deny or modify re2 quests for authorization of health care services or 

3 materials described in subsection (iii) pursuant to 

4 this subsection. 

5 ‘‘(G) PROHIBITION OF ADDITIONAL TREAT6 MENT FEES.—No additional fees or deductibles may 

7 be assessed, with respect to such treatment, for com8 pliance with this title other than assessed for similar 

9 medical services. 

10 ‘‘(iii) LYMPHEDEMA COMPRESSION TREATMENT

11 ITEMS.— 

12 ‘‘(1) DEFINITION.—The term ‘lymphedema 

13 compression treatment item’ means compression 

14 therapy materials and supplies used daily in the 

15 medical treatment of lymphedema upon prescription 

16 of the treating physician or therapist, including— 

17 ‘‘(A) compression binding systems com18 prising, as medically required, short-stretch and 

19 medium-stretch compression bandages; cotton, 

20 synthetic, or foam padding; gauze or elastic fin21 ger and toe bandages; foam pads; and tubular 

22 bandages; 

23 ‘‘(B) compression garments and compres24 sion pads for compression treatment of 


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1 lymphedematous arms, legs, torso, face and 

2 neck, breast and chest, abdomen, and genitalia; 

3 ‘‘(C) manually-adjustable compression 

4 sleeves and padded directional flow sleeves for 

5 use on upper and lower limbs; 

6 ‘‘(D) orthotic shoes; and 

7 ‘‘(E) donning aids, bandage rollers, and 

8 other specialized items used with the items de9 scribed in subparagraphs (A) through (D). 

10 ‘‘(2) SPECIAL REQUIREMENT ON LYMPHEDEMA

11 PUMPS.—Such term shall include a pneumatic pump 

12 for the treatment of lymphedema only if the treating 

13 physician or therapist’s prescription for such pump 

14 is accompanied by a certificate of medical necessity 

15 which specifies as a minimum— 

16 ‘‘(A) the differential diagnosis of 

17 lymphedema and any related co-conditions such 

18 as venous insufficiency, peripheral arterial dis19 ease, lipedema, morbid obesity, myxedema, and 

20 any other condition which may be significant in 

21 the selection of a type, specification, and usage 

22 of the pump; and 

23 ‘‘(B) the physician’s or therapist’s judge24 ment of the type and specifications of the pump 

25 based on the patient’s medical necessity.’’. 


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1 (b) PAYMENT.— 

2 (1) LYMPHEDEMA OUTPATIENT SELF-MANAGE3 MENT TRAINING SERVICES INCLUDED AS PHYSI4 CIANS’ SERVICES.—Section 1861(s)(2)(S) of such 

5 Act (42 U.S.C. 1395x(s)(2)(S)) is amended by in6 serting ‘‘and lymphedema outpatient self-manage7 ment training services under subsection 

8 (hhh)(3)(C)’’ after ‘‘subsection (qq))’’. 

9 (2) LYMPHEDEMA COMPRESSION TREATMENT

10 ITEMS.— 

11 (A) IN GENERAL.—Section 1833(a) of 

12 such Act (42 U.S.C. 1395l(a)) is amended— 

13 (i) in paragraph (8), by striking at 

14 the end ‘‘and’’; 

15 (ii) in paragraph (9), by striking at 

16 the end the period and inserting a semi17 colon; and 

18 (iii) by adding at the end the fol19 lowing new paragraph: 

20 ‘‘(10) in the case of lymphedema compression 

21 treatment items described in section 1861(iii), the 

22 amount determined under section 1834(n); and’’. 

23 (B) PAYMENT DETERMINED.—Section 

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1 ed by adding at the end the following new sub2 section: 

3 ‘‘(n) PAYMENT FOR LYMPHEDEMA COMPRESSION

4 TREATMENT ITEMS.— 

5 ‘‘(1) GENERAL RULE FOR PAYMENT.— 

6 ‘‘(A) IN GENERAL.—With respect to a 

7 lymphedema compression treatment item de8 scribed in section 1861(iii) for which payment 

9 is determined under this subsection, subject to 

10 subparagraph (D), payment shall be made in an 

11 amount equal to 80 percent of the payment 

12 basis described in subparagraph (B). 

13 ‘‘(B) PAYMENT BASIS.—The payment 

14 basis described in this subparagraph, with re15 spect to a lymphedema compression treatment 

16 item described in section 1861(iii), is the actual 

17 charge for the item. 

18 ‘‘(C) EXCLUSIVE PAYMENT RULE FOR

19 HOME HEALTH AGENCIES.—This subsection 

20 shall constitute the exclusive provision of this 

21 title for payment for lymphedema compression 

22 treatment items described in section 1861(iii) 

23 under this part or under part A to a home 

24 health agency. 

25 ‘‘(D) EXCEPTIONS.— 


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1 ‘‘(i) Subparagraph (B) shall not apply 

2 to an item furnished by a public home 

3 health agency (or by another home health 

4 agency which demonstrates to the satisfac5 tion of the Secretary that a significant por6 tion of its patients are low income) free of 

7 charge or at nominal charges to the public. 

8 ‘‘(ii) Subparagraph (B) shall not 

9 apply to items that are furnished as an in10 cident to a physician’s professional service. 

11 ‘‘(2) SPECIAL PAYMENT RULES.— 

12 ‘‘(A) ALLOWABLE ITEMS.—To be eligible 

13 for payment under this subsection, an item de14 scribed in section 1861(iii) must— 

15 ‘‘(i) be ordered by a qualified physi16 cian or lymphedema therapist for treat17 ment of diagnosed lymphedema; 

18 ‘‘(ii) primarily and customarily be 

19 used to serve a medical purpose; 

20 ‘‘(iii) generally not be useful to a per21 son in the absence of an illness or injury; 

22 and 

23 ‘‘(iv) be appropriate for use in the 

24 home. 


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1 ‘‘(B) ALLOWABLE QUANTITIES.—In the 

2 case it is determined by the qualified physician 

3 or qualified lymphedema therapist involved that 

4 compression therapy demands daily compression 

5 as part of lymphedema treatment according to 

6 section 1861(hhh)(1), then payment may be 

7 made in accordance with this subsection for the 

8 following quantities— 

9 ‘‘(i) in the case of compression bind10 ing systems described in section 

11 1861(iii)(1)(A), 2 sets for each affected 

12 body part; 

13 ‘‘(ii) in the case of compression gar14 ments described in section 1861(iii)(1)(B), 

15 2 garments for each affected body part; 

16 ‘‘(iii) in the case of compression de17 vices described in section 1861(iii)(1)(C), 1 

18 each for each affected body part; and 

19 ‘‘(iv) in the case of compression ther20 apy aids described in section 

21 1861(iii)(1)(D), as determined by the 

22 qualified physician or qualified 

23 lymphedema therapist. 

24 ‘‘(C) ALLOWABLE USE.—Payment may be 

25 made under this subsection for a lymphedema 


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1 compression treatment item described in section 

2 1861(iii) only if such item— 

3 ‘‘(i) is prescribed by a certified pro4 vider as defined in section 

5 1861(hhh)(2)(B); 

6 ‘‘(ii) is used as part of a lymphedema 

7 treatment plan described in section 

8 1861(hhh)(1); 

9 ‘‘(iii) is used by a patient who has 

10 been instructed in lymphedema self-man11 agement described in section 

12 1861(hhh)(5); and 

13 ‘‘(iv) is used to treat a diagnosed con14 dition of chronic lymphedema. 

15 ‘‘(D) COMPRESSION RANGE.—The 

16 lymphedema compression treatment items for 

17 which payment may be made under this section 

18 must provide a compression no less than 

19 30mmHg and no greater than 60mmHg. 

20 ‘‘(E) QUALIFIED FITTERS.—The 

21 lymphedema compression treatment items for 

22 which payment may be made under this section 

23 must be measured and fitted by a qualified fit24 ter who is an individual who— 


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1 ‘‘(i) is a qualified lymphedema thera2 pist, as defined in section 1834(o)(2), who 

3 meets the quality standards of section 

4 1861(hhh)(2)(C); 

5 ‘‘(ii) in the case of a State that pro6 vides for the licensing of orthotists and 

7 prosthetists, is licensed in orthotics or 

8 prosthetics by the State in which the item 

9 is supplied; 

10 ‘‘(iii) in the case of a State that does 

11 not provide for the licensing of orthotists 

12 and prosthetists, is specifically trained and 

13 educated to provide or manage the provi14 sion of prosthetics and custom-designed or 

15 -fabricated orthotics, and is certified by the 

16 American Board for Certification in 

17 Orthotics and Prosthetics, Inc. or by the 

18 Board for Orthotist/Prosthetist Certifi19 cation, or is credentialed and approved by 

20 a program that the Secretary determines, 

21 in consultation with appropriate experts in 

22 orthotics and prosthetics, has training and 

23 education standards that are necessary to 

24 provide such prosthetics and orthotics; or 


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1 ‘‘(iv) is certified by the qualified man2 ufacturer of the item to be qualified to fit 

3 the particular garment or device. 

4 ‘‘(F) REQUIREMENTS FOR SUPPLIERS OF

5 COMPRESSION THERAPY ITEMS.—A supplier of 

6 the lymphedema compression treatment items 

7 described in this subsection must meet the re8 quirements of section 1834(j) in order to re9 ceive payment under this subsection. 

10 ‘‘(3) REPLACEMENT OF COMPRESSION THERAPY

11 ITEMS.— 

12 ‘‘(A) IN GENERAL.—Payment shall be 

13 made under this subsection, with respect to an 

14 individual, for the replacement of compression 

15 bindings, compression garments, or compression 

16 devices if an ordering physician determines that 

17 the provision of a replacement item, or repair of 

18 such an item, is necessary because of any of the 

19 following: 

20 ‘‘(i) A change in the physiological or 

21 medical condition of the individual. 

22 ‘‘(ii) A loss of required compression of 

23 the item that is not restorable by washing 

24 and drying. 


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1 ‘‘(iii) An irreparable change in the 

2 condition of the device, or in a part of the 

3 device. 

4 ‘‘(B) LENGTH OF REASONABLE USEFUL

5 LIFETIME.—The reasonable useful lifetime of a 

6 lymphedema compression treatment item de7 scribed in section 1861(iii) shall be as follows, 

8 except that, if the Secretary determines that, on 

9 the basis of prior experience in making pay10 ments for such an item under this title, such 

11 lifetimes are no longer appropriate with respect 

12 to a particular item, the Secretary shall estab13 lish an alternative reasonable lifetime for such 

14 item: 

15 ‘‘(i) COMPRESSION BINDING KIT.—In 

16 the case of compression binding systems 

17 described in section 1861(iii)(1)(A), the 

18 greater of 6 months or per manufacturer’s 

19 warrantee. 

20 ‘‘(ii) COMPRESSION GARMENTS.—In 

21 the case of compression garments de22 scribed in section 1861(iii)(1)(B), the 

23 greater of 4 months or per manufacturer’s 

24 warrantee. 


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1 ‘‘(iii) COMPRESSION DEVICES.—In the 

2 case of compression devices described in 

3 section 1861(iii)(1)(C), the greater of 3 

4 years or per manufacturer’s warrantee. 

5 ‘‘(iv) AIDS.—In the case of compres6 sion therapy aids described in section 

7 1861(iii)(1)(D), as required to maintain 

8 functional usefulness.’’. 

9 (C) SUPPLIER REQUIREMENTS.—Section 

10 1834(j)(5) of such Act (42 U.S.C. 1395m(j)(5)) 

11 is amended— 

12 (i) in subparagraph (E), by striking 

13 at the end ‘‘and’’; 

14 (ii) in subparagraph (F), by striking 

15 at the end the period an inserting ‘‘; and’’; 

16 and 

17 (iii) by adding at the end the fol18 lowing new subparagraph: 

19 ‘‘(G) lymphedema compression treatment 

20 items (as described in section 1861(iii)).’’. 

21 (3) LYMPHEDEMA DIAGNOSIS AND TREATMENT

22 SERVICES.— 

23 (A) IN GENERAL.—Section 1833(a) of 

24 such Act, as amended by paragraph (2)(A), is 


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1 further amended by adding at the end the fol2 lowing new paragraph: 

3 ‘‘(11) with respect to lymphedema diagnosis 

4 and treatment services (as defined in subsection 

5 (hhh)(1))— 

6 ‘‘(A) furnished by a qualified physical ther7 apist or qualified occupational therapist, as de8 fined in section 1834(o)(2)(A), the amounts de9 scribed in section 1834(k); or 

10 ‘‘(B) furnished by a lymphedema therapist, 

11 as defined by 1834(o)(2)(B), under direction of 

12 a qualified physical therapist or qualified occu13 pational therapist, the amounts described in 

14 section 1834(o).’’. 

15 (B) PAYMENT METHOD.—Section 1834 of 

16 such Act, as amended by paragraph (2)(B), is 

17 further amended by adding at the end the fol18 lowing new subsection: 

19 ‘‘(o) PAYMENT FOR OUTPATIENT LYMPHEDEMA DI20 AGNOSIS AND TREATMENT SERVICES.— 

21 ‘‘(1) IN GENERAL.—For purposes of section 

22 1833(a)(11)(B), in the case of lymphedema diag23 nosis and treatment services described in section 

24 1861(hhh) for which payment is determined under 

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1 fied lymphedema therapist (as defined in paragraph 

2 (2)) under the direction of a qualified physician 

3 therapist or qualified occupational therapist, the 

4 payment basis shall be 80 percent of the lesser of— 

5 ‘‘(A) the actual charge for the service; or 

6 ‘‘(B) the applicable fee schedule amount 

7 (as defined in paragraph (3)) for the services. 

8 ‘‘(2) QUALIFIED THERAPISTS.—For purposes of 

9 this subsection: 

10 ‘‘(A) IN GENERAL.—The term ‘qualified’, 

11 with respect to a physical therapist, occupa12 tional therapist, or lymphedema therapist, 

13 means that the physical therapist, occupational 

14 therapist, or lymphedema therapist meets the 

15 quality requirements described in section 

16 1861(hhh)(2)(C). 

17 ‘‘(B) LYMPHEDEMA THERAPIST.—The 

18 term ‘lymphedema therapist’ means any of the 

19 following individuals so long as such individual 

20 is legally authorized to practice by the State in 

21 which the lymphedema diagnosis and treatment 

22 service involved is performed and meets the 

23 quality requirements described in subparagraph 

24 (A): 


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1 ‘‘(i) A registered nurse, nurse practi2 tioner, family nurse practitioner or clinical 

3 nurse specialist (as described in section 

4 1861(aa)(5)). 

5 ‘‘(ii) A doctor of medicine or doctor of 

6 osteopathy (as described in section 

7 1861(r)(1). 

8 ‘‘(iii) A physician assistant (as de9 scribed in section 1861(aa)(5)). 

10 ‘‘(iv) A chiropractor. 

11 ‘‘(v) A licensed massage therapist. 

12 ‘‘(vi) A licensed home health practi13 tioner. 

14 ‘‘(3) APPLICABLE FEE SCHEDULE AMOUNT.— 

15 In this subsection, the term ‘applicable fee schedule 

16 amount’ means, with respect to services furnished in 

17 a year, the amount determined under the fee sched18 ule established under section 1848 for such services 

19 furnished during the year or, if there is no such fee 

20 schedule established for such services, the amount 

21 determined under the fee schedule established for 

22 such comparable services as the Secretary specifies. 

23 ‘‘(4) UNIFORM CODING.—For claims for serv24 ices for which the amount of payment is determined 

25 under this subsection, the claim shall include a code 


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25 

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1 (or codes) under a uniform coding system specified 

2 by the Secretary that identifies the services fur3 nished. 

4 ‘‘(5) RESTRAINT ON BILLING.—The provisions 

5 of subparagraphs (A) and (B) of section 

6 1842(b)(18) shall apply to lymphedema diagnosis 

7 and treatment services for which payment is made 

8 under this subsection in the same manner as they 

9 apply to services provided by a practitioner described 

10 in section 1842(b)(18)(C), except that in applying 

11 such subparagraphs the practitioner described shall 

12 be any practitioner described in paragraph (2)(B).’’. 

13 (C) EXCLUSION FROM CERTAIN THERAPY

14 SERVICES.—Section 1833(g)(4) of such Act (42 

15 U.S.C. 1395l(g)(4)) is amended by inserting 

16 ‘‘or to expenses incurred with respect to 

17 lymphedema diagnosis and treatment services 

18 (as defined in subsection (hhh)(1))’’ before the 

19 period at the end. 

20 (c) EFFECTIVE DATE.—The amendments made by 

21 this section shall apply to items and services furnished on 

22 or after the date that is 90 days from the date of the 

23 enactment of this Act. 

Æ 


srobinson on DSKHWCL6B1PROD with BILLS