As a billing service, the billing specialists at Healthcare Management Solutions are often questioned regarding Medicare coverage for items prescribed for use in treating Lymphedema. Provided in this issue is a summary of Medicare coverage for commonly billed items for the treatment of lymphedema.
Lymphedema Pumps – These items are also known as Pneumatic Compression Devices and are covered by Medicare for use in the home under two conditions:
1. The patient has undergone a four-week trial of conservative therapy and the treating physician determines that there has been no significant improvement or if significant symptoms remain after the trial. (Conservative therapy must include use of an appropriate compression bandage system or compression garment, exercise, and elevation of the limb.
2. Pneumatic compression devices are covered in the home setting for the treatment of Chronic Venous Insufficiency (CVI) of the lower extremities only if the patient has one or more venous stasis ulcer(s) which have failed to heal after a six-month trial of conservative therapy directed by the treating physician. (Conservative therapy must include use of an appropriate compression bandage system or compression garment, exercise, and elevation of the limb.)
When billing for pneumatic compression devices, CMN 04.04B must be submitted with the initial claim. Documentation from the attending physician should be kept on file detailing the conservative therapy.
Bras (L8000) - These items are covered by Medicare for patients who have had a mastectomy (ICD-9-CM diagnosis codes V45.71, 174.0-174.9, or 233.0).
Mastectomy Sleeves (L8010) – These items are not covered by Medicare as they do not meet the definition of a prosthesis. Many commercial payers do provide reimbursement for these items.
Gloves/Gauntlets (A6549) – These items are not covered by Medicare as they do not meet the definition of a surgical dressing. Many commercial payers do provide reimbursement for these items.
When billing for items that Medicare has statutorily excluded as non-covered, consider using the Advance Beneficiary Notice of Noncoverage to advise patients of any financial liability that may be incurred. Additional information regarding the use of the ABN can be found on CMS website at www.cms.hhs.gov/BNI/02_ABN.asp –
Dwayne Thomas, Operations Manager, Healthcare Management Solutions, Inc.
www.hmsbillingservice.com.