Lymphedema Treatment Act Summary - January 22nd, 2024

The USMCA is committed to keeping you informed. In an effort to help stakeholders understand the nuances of the Lymphedema Treatment Act (LTA), we summarized the published, public information regarding the final rule, including links to helpful resources. 

Per the LTA final rule, coverage for the following items will be available for patients diagnosed with lymphedema—on an individual, claim-by-claim basis—beginning Jan. 1, 2024:

• Custom and standard compression garments, including daytime, wraps and nighttime products
• Bandages used during treatment phases (decongestive and/or maintenance)
• Accessories, including, but not limited to, donning and doffing aids, padding, fillers, linings, and zippers

The Centers for Medicare and Medicaid Services (CMS) have determined the following frequency allowance for patients (with applicable prescriptions):

• Daytime: three products (for each affected body part) every six months
• Nighttime: two products (for each affected body part) every two years
• Bandages: based on clinical need
• Accessories: based on clinical need

The January 2024 Fee Schedule is available online. Each year the prices will be updated based upon inflation factors. Beginning Jan. 1, 2025, and annually thereafter, these final payment amounts will be updated by the percentage change in the Consumer Price Index for All Urban Consumers for the 12-month period ending June of the preceding year. 

To bill Medicare for lymphedema compression treatment items, organizations must become enrolled Durable Medical Equipment, Orthotics, and Prosthetics (DMEPOS) suppliers. The fees are setup on a single payment structure for the garments and supplies covered inclusive of all training and fitting services. You cannot bill fitting or training; it must include supplies. Medical professionals who provide fitting services can enroll in Medicare as DMEPOS suppliers and receive bundled payment for garments and related supply services provided to beneficiaries. Learn more on the Supplier Enrollment page.

DMEPOS Supplier Enrollment Form 855s does not include compression items, but it is being updated. Contact the National Provider Enrollment contractors with questions (Palmetto or Novitas).

DMEPOS suppliers also are responsible for fitting and measuring services. USMCA received comments from some stakeholders and recommended that CMS support establishing an industry-standard licensing or certification process for fitting services. CMS responded that it would consider adding standards specific to suppliers of lymphedema compression treatment items to the DMEPOS quality standards in the future.

There are now 81 new HCPCS codes; 78 are lymphedema specific, and 3 are existing A codes with updated descriptors specific to surgical dressings. The rule also outlines the process for creating additional codes if needed. View the complete list of HCPCS codes.

Pricing, Data Analysis and Coding (PDAC) registration is not required. A list of what products do require registration is available online here. Coding verification is a voluntary process that allows manufacturers/distributors to request a coding decision on a DMEPOS item. More information is available on the PDAC website.

To be eligible for coverage, a patient must have a lymphedema diagnosis and prescription for compression products. Coverage begins Jan. 1, 2024. There is no retroactive coverage.

A Durable Medical Equipment (DME) Medicare Administrative Contractor (MAC) is a private healthcare insurer with geographic jurisdiction to process DMEPOS claims for Medicare Fee-For-Service (FFS) beneficiaries. Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury.

The DME MACs pathways for determining what is “reasonable and necessary” 

• National Coverage Determination (NCD)
• Local Coverage Determination (LCD)
• Claim Determination in the Absence of a Medical Policy

In the absence of a coverage determination (i.e., medical policy), claims will be reviewed on a claim by claim basis by the DME MACs. The USMCA recently hosted a virtual meeting with the DME MACs to advocate for fair and accessible coverage decisions and to share existing research and clinical perspectives from a certified lymphedema physical therapist and a vascular surgeon. 

The two DME MACs, Noridian and CGS, recently published an article with insight into the coding and billing procedures for compression items used in treating lymphedema for each jurisdiction. 

• Jurisdiction A: CT, DE, MA, ME, MD, NH, NJ, NY, PA, RI, VT, Washington D.C 
• Jurisdiction B: IL, IN, KY, MI, MN, OH, and WI 
• Jurisdiction C: AL, AR, CO, FL, GA, LA, MS, NM, NC, OK, PR, SC, TN, TX, VI, VA, and WV
• Jurisdiction D:  Am. Samoa, Guam, N. Mariana Is., AK, AZ, CA, HI, ID, IA, KS, MO, MT, NE, NV, ND, OR, SD, UT, WA, WY

Healthcare providers and billers can find more information from CMS about coverage for lymphedema compression via the links below.  

• Lymphedema Compression Treatment Items
• Medicare Learning Network (MLN) Implementation Article

Board of Certification/Accreditation (BOC) accredits businesses that provide DME, allowing them to bill third-party payors, including CMS. With more than 35 years of credentialing experience, BOC has streamlined the accreditation process and provided a number of helpful resources regarding supplier enrollment on their website. 

USMCA developed these helpful tools:

• Fast Facts Update 1-22-2024 
• Webinars on the LTA Final Rule 

USMCA will continue their advocacy and collaboration efforts to support patient access and the implementation of the Lymphedema Treatment Act. Stay tuned for updates and thank you for being an integral part of our community.