General Information
Source Article ID
N/A
Article ID
A52959
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Lymphedema Decongestive Treatment
Article Type
Billing and Coding
Original Effective Date
10/01/2015
Revision Effective Date
01/01/2018
Revision Ending Date
N/A
Retirement Date
N/A
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CMS National Coverage Policy
N/A
Article Guidance
Article Text We are providing clarification of coverage and documentation requirements for lymphedema decongestive treatment based on Noridian medical review findings. The two basic types of decongestive treatment are: • Manual Lymphatic Drainage (MLD) which stimulates the movement of fluids in the tissues using gentle massage and; Coverage Requirements Medicare will reimburse for necessary components of decongestive treatment when the medical record supports Limitations The goal of therapy is not to achieve maximum volume reduction but to ultimately transfer the responsibility for the care from the provider to the patient and/or caregiver, generally within a 1-3 week time period. There is only temporary benefit from the treatment unless the patient and/or caregiver are able to complete treatments at home on an ongoing basis. The end of treatment is not when the edema resolves or stabilizes but when the patient and/or caregiver are able to continue the treatments at home. Skilled Level of Care The key issue is whether the skills of a therapist are needed, or whether the services can be carried out by the patient and/or caregiver after sufficient training. The medical record must clearly indicate the patient’s condition before, during, and after the therapy episode to support that the patient significantly benefitted from ongoing therapy services and that the progress was sustainable and of practical value when measured against the patient’s condition at the start of treatment. Documentation should indicate clear objective evidence of improvement generally within the first week or 10 days of therapy (e.g., changes in weight, extremity circumference). Maintenance Level of Care When it is reasonable to assume that ongoing services could reasonably be carried out by the patient and/or appropriately trained caregiver(s), then the services are considered to be at a maintenance level of care and no longer require the skills of a qualified clinician. It is the patient's responsibility to acquire caregiver assistance for carrying out the of the home maintenance program when necessary. Generally, it is anticipated that an efficient home maintenance program will be effective for a lifetime. However, in the rare instance, when additional treatment for the same condition is necessary, then the documentation must support reasonableness and medical necessity for the additional services. For additional information, see the Noridian article titled "Medical Necessity of Therapy Services". Coding Considerations Sources:
• Comprehensive Decongestive Therapy (CDT) which is a combination of MLD, bandaging, skin care and exercises.