all about the why header

All about the “why”

The Lymphedema Treatment Act provides lymphedema patients with the critical components needed for lymphedema treatment. But how does one get their patient LTA coverage? A lymphedema diagnosis and prescription from a licensed clinician is required for benefits coverage.

But the requirements do not end there. In fact, the more therapists can detail their specific patients’ needs, the better the treatment can be. Therapists need to explain the why behind their patients’ ailment.

CMS will offer the following coverage for Medicare eligible patients under a lymphedema diagnosis:

  • 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).
  • CMS will pay 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.

Codes for lymphedema Diagnosis:

Code Description
I89.0Lymphedema, not elsewhere classified
I97.2Postmastectomy lymphedema syndrome
I97.89Other postprocedural complications and disorders of the circulatory system, not elsewhere classified
Q82.0Hereditary lymphedema

When evaluating a patient for coverage, therapists must focus on several “whys”. The more detailed the notes, the easier the process will be for needed coverage. A thorough explanation of the patient’s condition and why they will benefit from needed garments is key. Even the verbiage regarding accessory needs is important. CMS requires accessories be billed under a different code and even on a separate line. A complete why narrative must be present in the medical records explaining the need for these accessories.

Here are several questions that can lead your evaluation with your patients for proper coverage:

  • Why is the garment medically necessary?
  • Why will the garment(s) benefit my patient?
  • Why do they need a custom garment and not a ready-to-wear (if preferred)?
  • Why they may need an accessory like silicone top band?
  • Why they need multiple garments?

The more notes, the better. Be clear in your why and provide thorough documentation, to help your patients secure the coverage allotted to them from the LTA.

* Use of HCPCS codes should be verified by the responsible billing parties in accordance with all published guidelines.

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