Lymphedema Compression Treatment Items – Correct Coding and Billing – Revised
Joint DME MAC Publication
This Correct Coding and Billing publication is effective for claims with dates of service on or after January 1, 2024.
This publication provides billing and coding guidance pertinent to lymphedema compression treatment items, based on the Centers for Medicare & Medicaid Services’ (CMS’) Final Rule CMS-1780-F.
Information on initial and replacement coverage per the Final Rule:
Gradient compression garments, related supplies and accessories are covered only for the treatment of lymphedema (see ICD-10-CM Codes that Support Medical Necessity below). Claims for gradient compression garments, related supplies and accessories for non-lymphedema diagnoses will be denied as noncovered.
A quantity of three (3) daytime garments or wraps per body area are allowed once every six (6) months.
A quantity of two (2) nighttime garments per body area are allowed once every two (2) years (24 months).
Replacement of the garments can only be made in accordance with the frequency limitations of once every six (6) months for daytime garments or wraps and once every two (2) years for nighttime garments.
Claims for gradient compression garments or wraps billed in excess of the frequency limitations outlined above will be denied as not reasonable and necessary unless replacements are needed in cases of loss, theft, or irreparable damage. In addition, payment can be made for a new set of garments or wraps if determined to be reasonable and necessary due to a change in the beneficiary’s medical or physical condition that warrants a new size or type of garment or wrap. Payment is made for replacement of an entire new set of three daytime garments or wraps and/or two nighttime garments in cases of loss, theft, irreparable damage, or change in medical or physical condition and the six month and/or two year replacement frequency begins anew at the time the replacement items are furnished.
Medicare covers custom fitted (custom or non-standard) gradient compression garments. Custom fitted gradient compression garments are uniquely sized and shaped to fit the exact dimensions of the affected extremity of an individual to provide accurate gradient compression to treat lymphedema. Examples of scenarios where a custom fitted gradient compression garment might be used (not all-inclusive) are:
- If the circumference of the proximal portion of the limb is significantly greater than the distal limb;
- If the skin/tissue has folds or contours requiring a specific type of knitting pattern;
- Beneficiary is unable to tolerate the fabric composition of a standard garment.
There must be documentation in the beneficiary’s medical record necessitating the use of a custom fitted gradient compression garment versus an off-the-shelf standard gradient compression garment. The patient’s medical record is not limited to the physician’s office records. It may include hospital, nursing home, or HHA records and records from other health care professionals, such as lymphedema treatment professionals. This documentation must be made available to the DME MAC upon request.
Compression bandaging supplies furnished during Phase 1 (acute or decongestive therapy) and Phase 2 (maintenance phase of therapy) are covered when medically necessary for the treatment of lymphedema. The therapists and other suppliers furnishing bandaging systems must be enrolled DMEPOS suppliers in order to be paid for furnishing these items. The justification for the quantity of supplies needed and the frequency of replacement must be documented in the beneficiary’s medical record and made available to the DME MAC upon request.
Accessories (e.g., zippers, linings, padding or fillers, etc.) necessary for the effective use of a lymphedema compression treatment item are covered when medically necessary for the treatment of lymphedema. The justification for the quantity of supplies needed and the frequency of replacement must be documented in the beneficiary’s medical record and made available to the DME MAC upon request.
Payment for all necessary services associated with furnishing gradient compression garments and wraps, including fitting and measurements, is included in the national payment amounts made to the supplier of the item.
HCPCS CODES
Group 1 Codes:
| HCPCS Code | Long Descriptor |
|---|---|
| A6515 | GRADIENT COMPRESSION WRAP WITH ADJUSTABLE STRAPS, FULL LEG, EACH, CUSTOM |
| A6516 | GRADIENT COMPRESSION WRAP WITH ADJUSTABLE STRAPS, FOOT, EACH, CUSTOM |
| A6517 | GRADIENT COMPRESSION WRAP WITH ADJUSTABLE STRAPS, BELOW KNEE, EACH, CUSTOM |
| A6518 | GRADIENT COMPRESSION WRAP WITH ADJUSTABLE STRAPS, ARM, EACH, CUSTOM |
| A6519 | GRADIENT COMPRESSION GARMENT, NOT OTHERWISE SPECIFIED, FOR NIGHTTIME USE, EACH |
| A6520 | GRADIENT COMPRESSION GARMENT, GLOVE, PADDED, FOR NIGHTTIME USE, EACH |
| A6521 | GRADIENT COMPRESSION GARMENT, GLOVE, PADDED, FOR NIGHTTIME USE, CUSTOM, EACH |
| A6522 | GRADIENT COMPRESSION GARMENT, ARM, PADDED, FOR NIGHTTIME USE, EACH |
| A6523 | GRADIENT COMPRESSION GARMENT, ARM, PADDED, FOR NIGHTTIME USE, CUSTOM, EACH |
| A6524 | GRADIENT COMPRESSION GARMENT, LOWER LEG AND FOOT, PADDED, FOR NIGHTTIME USE, EACH |
| A6525 | GRADIENT COMPRESSION GARMENT, LOWER LEG AND FOOT, PADDED, FOR NIGHTTIME USE, CUSTOM, EACH |
| A6526 | GRADIENT COMPRESSION GARMENT, FULL LEG AND FOOT, PADDED, FOR NIGHTTIME USE, EACH |
| A6527 | GRADIENT COMPRESSION GARMENT, FULL LEG AND FOOT, PADDED, FOR NIGHTTIME USE, CUSTOM, EACH |
| A6528 | GRADIENT COMPRESSION GARMENT, BRA, FOR NIGHTTIME USE, EACH |
| A6529 | GRADIENT COMPRESSION GARMENT, BRA, FOR NIGHTTIME USE, CUSTOM, EACH |
| A6530 | GRADIENT COMPRESSION STOCKING, BELOW KNEE, 18-30 MMHG, EACH |
| A6533 | GRADIENT COMPRESSION STOCKING, THIGH LENGTH, 18-30 MMHG, EACH |
| A6534 | GRADIENT COMPRESSION STOCKING, THIGH LENGTH, 30-40 MMHG, EACH |
| A6535 | GRADIENT COMPRESSION STOCKING, THIGH LENGTH, 40 MMHG OR GREATER, EACH |
| A6536 | GRADIENT COMPRESSION STOCKING, FULL LENGTH/CHAP STYLE, 18-30 MMHG, EACH |
| A6537 | GRADIENT COMPRESSION STOCKING, FULL LENGTH/CHAP STYLE, 30-40 MMHG, EACH |
| A6538 | GRADIENT COMPRESSION STOCKING, FULL LENGTH/CHAP STYLE, 40 MMHG OR GREATER, EACH |
| A6539 | GRADIENT COMPRESSION STOCKING, WAIST LENGTH, 18-30 MMHG, EACH |
| A6540 | GRADIENT COMPRESSION STOCKING, WAIST LENGTH, 30-40 MMHG, EACH |
| A6541 | GRADIENT COMPRESSION STOCKING, WAIST LENGTH, 40 MMHG OR GREATER, EACH |
| A6549 | GRADIENT COMPRESSION GARMENT, NOT OTHERWISE SPECIFIED, FOR DAYTIME USE, EACH |
| A6552 | GRADIENT COMPRESSION STOCKING, BELOW KNEE, 30-40 MMHG, EACH |
| A6553 | GRADIENT COMPRESSION STOCKING, BELOW KNEE, 30-40 MMHG, CUSTOM, EACH |
| A6554 | GRADIENT COMPRESSION STOCKING, BELOW KNEE, 40 MMHG OR GREATER, EACH |
| A6555 | GRADIENT COMPRESSION STOCKING, BELOW KNEE, 40 MMHG OR GREATER, CUSTOM, EACH |
| A6556 | GRADIENT COMPRESSION STOCKING, THIGH LENGTH, 18-30 MMHG, CUSTOM, EACH |
| A6557 | GRADIENT COMPRESSION STOCKING, THIGH LENGTH, 30-40 MMHG, CUSTOM, EACH |
| A6558 | GRADIENT COMPRESSION STOCKING, THIGH LENGTH, 40 MMHG OR GREATER, CUSTOM, EACH |
| A6559 | GRADIENT COMPRESSION STOCKING, FULL LENGTH/CHAP STYLE, 18-30 MMHG, CUSTOM, EACH |
| A6560 | GRADIENT COMPRESSION STOCKING, FULL LENGTH/CHAP STYLE, 30-40 MMHG, CUSTOM, EACH |
| A6561 | GRADIENT COMPRESSION STOCKING, FULL LENGTH/CHAP STYLE, 40 MMHG OR GREATER, CUSTOM, EACH |
| A6562 | GRADIENT COMPRESSION STOCKING, WAIST LENGTH, 18-30 MMHG, CUSTOM, EACH |
| A6563 | GRADIENT COMPRESSION STOCKING, WAIST LENGTH, 30-40 MMHG, CUSTOM, EACH |
| A6564 | GRADIENT COMPRESSION STOCKING, WAIST LENGTH, 40 MMHG OR GREATER, CUSTOM, EACH |
| A6565 | GRADIENT COMPRESSION GAUNTLET, CUSTOM, EACH |
| A6566 | GRADIENT COMPRESSION GARMENT, NECK/HEAD, EACH |
| A6567 | GRADIENT COMPRESSION GARMENT, NECK/HEAD, CUSTOM, EACH |
| A6568 | GRADIENT COMPRESSION GARMENT, TORSO AND SHOULDER, EACH |
| A6569 | GRADIENT COMPRESSION GARMENT, TORSO/SHOULDER, CUSTOM, EACH |
| A6570 | GRADIENT COMPRESSION GARMENT, GENITAL REGION, EACH |
| A6571 | GRADIENT COMPRESSION GARMENT, GENITAL REGION, CUSTOM, EACH |
| A6572 | GRADIENT COMPRESSION GARMENT, TOE CAPS, EACH |
| A6573 | GRADIENT COMPRESSION GARMENT, TOE CAPS, CUSTOM, EACH |
| A6574 | GRADIENT COMPRESSION ARM SLEEVE AND GLOVE COMBINATION, CUSTOM, EACH |
| A6575 | GRADIENT COMPRESSION ARM SLEEVE AND GLOVE COMBINATION, EACH |
| A6576 | GRADIENT COMPRESSION ARM SLEEVE, CUSTOM, MEDIUM WEIGHT, EACH |
| A6577 | GRADIENT COMPRESSION ARM SLEEVE, CUSTOM, HEAVY WEIGHT, EACH |
| A6578 | GRADIENT COMPRESSION ARM SLEEVE, EACH |
| A6579 | GRADIENT COMPRESSION GLOVE, CUSTOM, MEDIUM WEIGHT, EACH |
| A6580 | GRADIENT COMPRESSION GLOVE, CUSTOM, HEAVY WEIGHT, EACH |
| A6581 | GRADIENT COMPRESSION GLOVE, EACH |
| A6582 | GRADIENT COMPRESSION GAUNTLET, EACH |
| A6583 | GRADIENT COMPRESSION WRAP WITH ADJUSTABLE STRAPS, BELOW KNEE, EACH |
| A6584 | GRADIENT COMPRESSION WRAP WITH ADJUSTABLE STRAPS, NOT OTHERWISE SPECIFIED |
| A6585 | GRADIENT COMPRESSION WRAP WITH ADJUSTABLE STRAPS, ABOVE KNEE, EACH |
| A6586 | GRADIENT COMPRESSION WRAP WITH ADJUSTABLE STRAPS, FULL LEG, EACH |
| A6587 | GRADIENT COMPRESSION WRAP WITH ADJUSTABLE STRAPS, FOOT, EACH |
| A6588 | GRADIENT COMPRESSION WRAP WITH ADJUSTABLE STRAPS, ARM, EACH |
| A6589 | GRADIENT PRESSURE WRAP WITH ADJUSTABLE STRAPS, BRA, EACH |
| A6593 | ACCESSORY FOR GRADIENT COMPRESSION GARMENT OR WRAP WITH ADJUSTABLE STRAPS, NOT-OTHERWISE SPECIFIED |
| A6594 | GRADIENT COMPRESSION BANDAGING SUPPLY, BANDAGE LINER, LOWER EXTREMITY, ANY SIZE OR LENGTH, EACH |
| A6595 | GRADIENT COMPRESSION BANDAGING SUPPLY, BANDAGE LINER, UPPER EXTREMITY, ANY SIZE OR LENGTH, EACH |
| A6596 | GRADIENT COMPRESSION BANDAGING SUPPLY, CONFORMING GAUZE, PER LINEAR YARD, ANY WIDTH, EACH |
| A6597 | GRADIENT COMPRESSION BANDAGE ROLL, ELASTIC LONG STRETCH, PER LINEAR YARD, ANY WIDTH, EACH |
| A6598 | GRADIENT COMPRESSION BANDAGE ROLL, ELASTIC MEDIUM STRETCH, PER LINEAR YARD, ANY WIDTH, EACH |
| A6599 | GRADIENT COMPRESSION BANDAGE ROLL, INELASTIC SHORT STRETCH, PER LINEAR YARD, ANY WIDTH, EACH |
| A6600 | GRADIENT COMPRESSION BANDAGING SUPPLY, HIGH DENSITY FOAM SHEET, PER 250 SQUARE CENTIMETERS, EACH |
| A6601 | GRADIENT COMPRESSION BANDAGING SUPPLY, HIGH DENSITY FOAM PAD, ANY SIZE OR SHAPE, EACH |
| A6602 | GRADIENT COMPRESSION BANDAGING SUPPLY, HIGH DENSITY FOAM ROLL FOR BANDAGE, PER LINEAR YARD, ANY WIDTH, EACH |
| A6603 | GRADIENT COMPRESSION BANDAGING SUPPLY, LOW DENSITY CHANNEL FOAM SHEET, PER 250 SQUARE CENTIMETERS, EACH |
| A6604 | GRADIENT COMPRESSION BANDAGING SUPPLY, LOW DENSITY FLAT FOAM SHEET, PER 250 SQUARE CENTIMETERS, EACH |
| A6605 | GRADIENT COMPRESSION BANDAGING SUPPLY, PADDED FOAM, PER LINEAR YARD, ANY WIDTH, EACH |
| A6606 | GRADIENT COMPRESSION BANDAGING SUPPLY, PADDED TEXTILE, PER LINEAR YARD, ANY WIDTH, EACH |
| A6607 | GRADIENT COMPRESSION BANDAGING SUPPLY, TUBULAR PROTECTIVE ABSORPTION LAYER, PER LINEAR YARD, ANY WIDTH, EACH |
| A6608 | GRADIENT COMPRESSION BANDAGING SUPPLY, TUBULAR PROTECTIVE ABSORPTION PADDED LAYER, PER LINEAR YARD, ANY WIDTH, EACH |
| A6609 | GRADIENT COMPRESSION BANDAGING SUPPLY, NOT OTHERWISE SPECIFIED |
| A6610 | GRADIENT COMPRESSION STOCKING, BELOW KNEE, 18-30 MMHG, CUSTOM, EACH |
| A6611 | GRADIENT COMPRESSION WRAP WITH ADJUSTABLE STRAPS, ABOVE KNEE, EACH, CUSTOM |
CMS has established five not otherwise specified HCPCS codes to identify compression bandaging supplies, accessories, wraps, and compression garments that are not identified by a unique HCPCS code:
- A6519 – GRADIENT COMPRESSION GARMENT, NOT OTHERWISE SPECIFIED, FOR NIGHTTIME USE, EACH
- A6549 – GRADIENT COMPRESSION GARMENT, NOT OTHERWISE SPECIFIED, FOR DAYTIME USE, EACH
- A6584 – GRADIENT COMPRESSION WRAP WITH ADJUSTABLE STRAPS, NOT OTHERWISE SPECIFIED
- A6593 – ACCESSORY FOR GRADIENT COMPRESSION GARMENT OR WRAP WITH ADJUSTABLE STRAPS, NOT-OTHERWISE SPECIFIED
- A6609 – GRADIENT COMPRESSION BANDAGING SUPPLY, NOT OTHERWISE SPECIFIED
Each compression bandaging supply, accessory, wrap, or compression garment without a unique HCPCS must be billed on a separate claim line with A6519, A6549, A6584, A6593, or A6609 and the appropriate units of service. Claims for A6519, A6549, A6584, A6593, and A6609 must include the following information in the narrative field of an electronic claim (NTE 2300 or NTE 2400) or Item 19 of a paper claim:
- Description of the item (including the quantity represented by each unit of service (e.g., per inch, foot, or yard for supplies))
- Manufacturer name
- Product name and number
- Supplier price list
- HCPCS of related item (where applicable)
MODIFIERS
LT, RT, RA
The right (RT) and left (LT) modifiers must be used with gradient compression garments, related supplies and accessories when laterality is indicated (HCPCS codes A6515, A6516, A6517, A6518, A6520, A6521, A6522, A6523, A6524, A6525, A6526, A6527, A6530, A6533, A6534, A6535, A6552, A6553, A6554, A6555, A6556, A6557, A6558, A6565, A6572, A6573, A6574, A6575, A6576, A6577, A6578, A6579, A6580, A6581, A6582, A6583, A6584, A6585, A6586, A6587, A6588, A6594, A6595, A6610, and A6611). When the same code for bilateral items (left and right) is billed on the same date of service, bill each item on two separate claim lines using the RT and LT modifiers and 1 unit of service (UOS) on each claim line. Do not use the RTLT modifier on the same claim line and bill with 2 UOS. Claims billed without modifiers RT and/or LT, or with RTLT on the same claim line and 2 UOS, will be rejected as incorrect coding.
The RA modifier (REPLACEMENT OF A DME, ORTHOTIC OR PROSTHETIC ITEM) may only be used if the gradient compression garment or wrap is lost, stolen, or irreparably damaged. Replacement of the garments can only be made in accordance with the frequency limitations of once every six (6) months for daytime garments or wraps and once every two (2) years for nighttime garments.
For replacement claims, if only one (1) daytime garment or wrap is lost, stolen, or irreparably damaged, payment is allowed for three (3) replacements, but the frequency limitation clock of six (6) months would restart based on the date of service for the replacement claim. For replacement claims for a nighttime garment, two (2) replacements are allowed if only one nighttime garment or wrap is lost, stolen, or irreparably damaged and the frequency limitation clock of two years (24 months) would restart based on the date of service for the replacement claim.
ICD-10-CM CODES THAT SUPPORT MEDICAL NECESSITY
Payment for lymphedema compression treatment items is limited to the ICD-10-CM codes of lymphedema listed below. The presence of an ICD-10-CM code listed in this section is not sufficient by itself to assure coverage.
| Code | Description |
|---|---|
| I89.0 | Lymphedema, not elsewhere classified |
| I97.2 | Postmastectomy lymphedema syndrome |
| I97.89 | Other postprocedural complications and disorders of the circulatory system, not elsewhere classified |
| Q82.0 | Hereditary lymphedema |