With expanded provisions for lymphedema treatment under Medicare now law, the U.S. Centers for Medicare & Medicaid Services is taking its first steps to flesh out how it will handle the changes. Those changes, strongly advocated by APTA, establish Medicare coverage for lymphedema-related pressure garments.
APTA was involved with the development of the new rules during stakeholder feedback sessions, and convened a workgroup comprised of APTA member clinicians from the Lymphedema Special Interest Group within APTA Oncology to provide guidance to CMS. The new benefit is set to take effect Jan. 1, 2024.
“I am thrilled that APTA has been able to advocate on both the legislative and regulatory fronts in development of this landmark new benefit category for lymphedema compression garments," said APTA President Roger Herr, PT, MPA. "This benefit is a critical first step for patients with lymphedema, but there's more work to be done to ensure that physical therapists are appropriately recognized and compensated for the work they perform during compression therapy.”
The proposed coverage policies were included as part of CMS' proposed 2024 home health payment rule, which also covers durable medical equipment. The policies generally apply to gradient compression garments. Here's an overview of the major proposals.
Compression is key — but this benefit is about items.
Items covered under the new benefit must use compression, and CMS’ benefit is limited by law to coverage for items only, not services. Still, CMS acknowledges the unique role that therapists play in providing necessary, associated services including measuring, fitting, and training, and has requested stakeholder feedback on several options for paying for associated services.
Fitting and measuring-related payment? It depends.
Because fitting and measuring approaches can vary, CMS proposed two paths. In one approach, suppliers of pressure garments would ensure that all fitting, training, and adjustment services are provided and paid for as part of furnishing the item; or in instances in which those services are provided by a non-supplier such as a PT or occupational therapist, the supplier would provide payment to that provider. Alternatively, when PTs provide these services directly, CMS would consider paying separately for the fitting, and then back-paying for the garment amount.
For lymphedema only.
While the benefit applies to compression items related to all lymphedema diagnoses, the items can only be used to treat lymphedema, not other injuries or illnesses.
Coverage beyond gradient compression garments.
In addition to coverage for gradient compression garments, the new benefit would cover ready-to-wear, non-elastic gradient compression wraps and compression bandaging systems in phase-one decongestive treatment.
Accessories are also covered.
APTA and other stakeholders emphasized the importance of covering accessories that are critical in the provision of effective compression therapy. CMS followed this guidance and proposes coverage for accessories including donning and doffing aids, liners, zippers, padding, and fillers.
Replacements allowed — within limits.
In an acknowledgment that compression items need to be replaced regularly, CMS proposes to pay for up to two daytime garments per affected extremity to be replaced every six months, and one nighttime garment per affected extremity every 12 months.
Payment rates proposed at Medicaid rate plus 20%.
CMS proposes that where available, all items necessary for furnishing a compression garment would be paid at the Medicaid rate plus an additional 20%. Where those rates aren't available, providers would use the average of retail prices and payment amounts established by TRICARE. If neither is available, payment would be based on the average of retail prices alone.
Calls for comments.
In the proposal, CMS also seeks input from providers and organizations on which compression bandaging items should be covered, as well as if professional services should be covered under another benefit category, such as outpatient physical therapy services or physician services.
