AMARILLO, TX – There are at least five million Americans with Lymphedema, and approximately half of them are Medicare beneficiaries. At the beginning of 2024, the Centers for Medicare and Medicaid Services (“CMS”) began to cover lymphedema compression treatment for Medicare Part B patients. In the Consolidated Appropriations Act, CMS established a new Medicare DMEPOS benefit category for standard and custom-fitted compression garments and additional lymphedema compression treatment items to service medical purposes.
The lymphatic system is part of the human circulatory system. Lymphedema is swelling due to a buildup of lymph fluid in the body. It develops when a body region lacking lymphatic vessels and lymph nodes overloads with lymphatic fluid. Infections such as cellulitis and sepsis may occur from lymphedema. Compression garments are effective in reducing and/or preventing the progression of lymphedema in the arm and leg, which can prevent infection and sepsis.
Previously, there was no benefit category, so Medicare did not cover compression garments. With this expansion, CMS has added two new indicators to the HCPCS file for lymphedema compression treatment items.
Medicare will now pay for standard and custom-fitted lymphedema compression treatment items for each affected body part. The cope of the new benefit includes:
- Standard daytime gradient compression garments
- Custom daytime gradient compression garments
- Nighttime gradient compression garments
- Gradient compression wraps
- Accessories, such as zippers, linings, paddings, or fillers, necessary for the effective use of a gradient compression garment or wrap
- Compression bandaging systems and supplies
Custom-fitted or non-standard garments are shaped to fit the exact dimensions of the affected extremity of the beneficiary to give an accurate gradient compression to treat lymphedema. Payment for all necessary gradient compression is different between nighttime and daytime use. During the day, the compression garments have a higher gradient compression, while at night, there is a milder compression, and the garments are meant to be less snug against the skin.
Medicare will deny payment if suppliers submit a claim for lymphedema treatment items that do not have an appropriate diagnosis for lymphedema. Suppliers can bill for lymphedema compression treatment items for more than one body part or area per patient, and they can also bill for both daytime and nighttime garments for the same body part or area per patient.
The compression treatment items can be replaced once every six months for three gradient compression garments or wraps with adjustable straps per affected extremity or part of the body. Once every two years, two nighttime garments per affected extremity or part of the body can be replaced.
Medicare will pay for treatment items when (i) the patient has Medicare Part B coverage, (ii) the patient has lymphedema and will use the item to primarily and customarily treat the lymphedema, and (iii) an authorized practitioner prescribes the item.
CMS is utilizing new codes for billing and retaining existing codes. CMS has also recognized that additional refinements may be necessary to the HCPCS codes, so it has directed interested parties to look into participating in the public HCPCS process.
Jeffrey S. Baird, JD, is chairman of the Health Care Group at Brown & Fortunato, PC, a law firm based in Texas with a national health care practice. He represents pharmacies, infusion companies, HME companies, manufacturers, and other health care providers throughout the United States. Baird is Board Certified in Health Law by the Texas Board of Legal Specialization and can be reached at (806) 345-6320 or [email protected].
Jacque K. Steelman, JD is an attorney with the Health Care Group at Brown & Fortunato, PC, a law firm based in Texas with a national health care practice. She represents pharmacies, infusion companies, HME companies, manufacturers, and other health care providers throughout the United States. Steelman can be reached at (806) 345-6316 or [email protected].
AAHOMECARE’S EDUCATIONAL WEBINAR
Cash-Only Retail: How to Succeed
Presented by: Jeffrey S. Baird, Esq., Brown & Fortunato
Tuesday, April 16, 2024
1:30-2:30 p.m. CENTRAL TIME
The DME industry primarily serves the elderly. This means that most DME suppliers are dependent on traditional Medicare and Medicare Advantage for most of their revenue. But as DME suppliers know from experience, it can be challenging to be so tied to Medicare. This is where retail comes in. There are 78 million Baby Boomers who are retiring at the rate of 10,000 per day. Many Boomers are willing to pay cash for “Cadillac” items rather than being limited to the “Cavalier” items paid for by Medicare. This program will present the legal parameters within which DME suppliers can move into the retail space. The issues to be presented will include the following:
- Whether the retail business should be (i) under the supplier’s existing Tax ID # or (ii) operated by a separate legal entity.
- State DME licensure.
- Selling Medicare-covered items at a discount off the Medicare allowable.
- Obtaining physician prescriptions.
- Collection and payment of sales tax.
- Qualification as a “foreign” corporation.
- Required notification to a Medicare beneficiary even though the supplier does not have a PTAN.
Register for Cash-Only Retail: How to Succeed on Tuesday, April 16, 2024, 1:30-2:30 p.m. CT, with Jeffrey S. Baird, Esq., Brown & Fortunato.
Members: $99
Non-Members: $129