A Summary of the Final Rule on the Lymphedema Treatment Act Recently Released by CMS

Published in Government and Regulatory on November 03, 2023

CMS has released their final rule regarding the implementation of the Lymphedema Treatment Act, which outlines how they intend to begin covering compression garments and related accessories for patients diagnosed with lymphedema. The full 65-page document can be viewed here. (beginning on page 350). Below is a summary of some of the key provisions of the final rule:

Covered items: The following items will be covered by Medicare beginning January 1, 2024 for patients diagnosed with lymphedema:

• both standard and custom fitted gradient compression garments
• gradient compression wraps with adjustable straps
• compression bandaging systems
• other items determined to be lymphedema compression treatment items

Frequency limitations: Medicare will cover:

• 3 (three) daytime garments or wraps with adjustable straps for each affected limb or area of the body, replaced every 6 months.
• 2 (two) nighttime garments for each affected limb or area of the body, replaced once every 2 years.
  • *These limitations are higher than what was originally suggested in the proposed rule, and industry stakeholder comments played a key role in raising the frequency limitations that were finalized.

HCPCS Codes: There are a couple tables contained within the final rule, namely tables FF-A 1 and FF-A 2, which outline the codes that will be used to represent many of the compression related products used to treat patients with lymphedema.

• CMS is keeping several of the existing compression codes that several of you may already be familiar with (A6530-A6549 range). These are outlined in Table FF-A 1 on page 372.
• CMS is creating 57 new HCPCS codes to better represent additional lymphedema related compression products. These new HCPCS codes have yet to be determined, but the descriptions of each new code can be found in Table FF-A 2 on page 389.
• CMS is creating 9 additional new A-codes to replace 9 existing S-codes (S8420-S8428) that currently represent compression sleeves, gloves, gauntlets, wraps, and bandages.

Pricing/Reimbursement: CMS has not yet finalized the full fee schedule for all of the compression codes. They have, however, provided some example pricing for some codes in table FF-A 3 (page 398). They also stated that “Final payment amounts will be determined in accordance with the methodology as previously detailed based on the most recent data available in late 2023 and will most likely be higher than these example payment amounts.” They also stated that they will use available pricing data from Medicaid, VHA, TRICARE, and internet retailers in establishing allowables for these items.

VGM will continue to monitor the information that is released regarding this topic, and will provide you with additional updates as appropriate. Please don’t hesitate to reach out to our Government and Regulatory team at 800-642-6065 if you have additional questions.