By: Robert "Bob" Weiss, MS, Legislation Committee and LE Advocate
Local Coverage Decisions (LCDs) are Medicare's way of passing down decisions made at the national level to the local Medicare jurisdictions. These LCDs are written by the regional Medicare Contractors and Fiscal Intermediaries and interpret the national decisions and changes in regulations in terms of treatment practice and billing at the local level. Two recent LCD revisions for California announced by the California Medicare Contractor NHIC are of interest to lymphedema patients. They are both positive, which is refreshing when one considers other recent Medicare decisions and changes in policy.
Removal Of Therapy Caps For Lymphedema Treatment.
The $1740 annual limit on therapy that was re-imposed effective January 1, 2006 was removed for a number of medical conditions in March 2006, and this removal is reflected in the LCD change. Every lymphedema patient who requires treatment should read this LCD in order to familiarize him/herself of his/her rights to treatment. Some of the guidelines as given in the Southern California LCD allow 12-18 visits during a 4-6 week period, each visit involving 2-3 units of care (up to 53 minutes/session), and daily visits during the first week in moderate to severe cases. Visits include bandaging instruction. Exercise component of CDT is performed under a different procedural code, and not part of the MLD. Approximately 3 visits for pneumatic pump instruction for home use is covered in this LCD. I did not find any reference to lifetime limits, which I have seen in other LCDs. [reference SoCal LCD L20755, NoCal LCD L20578]
Lymphedema As A Co-Condition To Obesity That Supports Medical Necessity For Bariatric Surgery.
The inclusion of the diagnosis of "Other Lymphedema" was added as one of the co-conditions to morbid obesity (BMI >35) satisfying the criteria to cover Bariatric surgery. [Reference: SoCal LCD L19119, NoCal LCD L19117]
Compression Garment Coding Changes.
On 1/1/2003 CMS added items A6501 through A6512 Compression Burn garments, which included sleeves, stockings, and body garments. Payment category was "12=surgical dressings", presumably secondary dressings used in conjunction with a primary dressing which is in direct contact with the skin. Coverage of secondary dressings is contingent to there being a primary dressing to cover the open wound. These conditions do not hold for lymphedema.
The latest change of 1/3/2006 adds A6513 Compression Burn garment, mask, face and neck also in payment category 12=surgical dressing, and A6530 through A6549 Gradient compression stockings, all in payment category 12=surgical dressing. This appears to be a re-numbering of what used to be codes L8100 through L8239, which were deleted from the HCPCS effective 1/1/2006. This is more than a clerical change, and amounts to a reclassification of these items from "prosthetics and orthotics" to "surgical dressings". Previously stated Medicare policy is that Medicare does not recognize compression therapy as a covered benefit category, but compression garments are commonly used in wound therapy and burn therapy as secondary dressings.
In the HCPCS 2006 Jurisdiction List, Surgical Dressings A6530-A6549 Compression Gradient Stockings are placed in DME Regional Carrier's jurisdiction. [Reference: Medlearn Matters MM4194] This change of benefit category for compression garments used in the treatment of lymphedema was not explained, nor was there any legal or medical evidence presented in support. No National Coverage Analysis or Decision was made public explaining this change.
The 2006 Fee Schedule (2/24/2006) lists only A6531 Compression Stocking Below Knee 30-40 mmHg and A6532 Compression Stocking Below Knee 34-50 mmHg as Surgical Dressings with reimbursement rates $36.78-43.27 and $51.82-60.96 respectively. Presumably the absence of any other items indicates that only below-knee compression stockings will be covered (as secondary surgical dressings).
State Bill Activities
New York holds the spotlight this month. In addition to the bills in the Assembly and Senate for the comprehensive diagnosis and treatment of lymphedema (A5003A Cohen and S3015A Fuschillo), the provision of compression sleeves (A5911 Kolb) and last year's passage of a lymphedema wellness education and outreach law (A7398 Carrozza and S4832 Padavan), on May 2, 2006 Assemblywoman Adele Cohen and a host of Co-Sponsors and Multiple Sponsors have introduced four new lymphedema bills: A11077 mandates physician reporting of lymphedema and lymphatic diseases, creation of a registry and a lymphedema and lymphatic diseases advisory board; A11078 creates a lymphedema registry and mandates informed consent for cancer patients; A11079 creates the lymphedema and lymphatic diseases research and education fund; and A11080 creates a lymphedema and lymphatic diseases grants program. New York residents are urged to contact your State representatives and urge them to support these bills.