I understand the RA modifier definition and need clarification as it relates to billing for replacement of lymphedema compression garments only based on "the patient's change of condition" and not related to loss, stolen or garment having irreparable damage.
"The RA modifier (REPLACEMENT OF A DME, ORTHOTIC OR PROSTHETIC ITEM) may only be used if the gradient compression garment or wrap is lost, stolen, or irreparably damaged. Replacement of the garments can only be made in accordance with the frequency limitations of once every six (6) months for daytime garments or wraps and once every two (2) years for nighttime garments." PDAC - Retired - Lymphedema Compression Treatment Items - Correct Coding and Billing - Revised
Recently, I attended a webinar regarding lymphedema therapy which provided information that the Lymphedema Act 2024 was amended on April 1, 2025 Lymphedema Compression Treatment Items - Correct Coding and Billing - Revised - JD DME - Noridian which allowed billing for a new set of garments if "there is a change in the patient's condition resulting in the need for a garment of another size. If this replacement occurs, it restarts the six-month clock on another set of replacements". This statement was provided by the APMA website on April 7, 2025, DME MACs Clarify Replacing Lymphedema Compression Garments - APMA MAIN
But the above definition of the RA modifier does not include the above statement regarding "change in the patient's condition". But the APMA stated "the RA modifier should be used for the replacement claim if the claim is being submitted because the original(s) were lost, stolen, or irreparably damaged".
Recently, I have been seeing denials from Medicare for HCPCS code A6583-GRADIENT COMPRESSION WRAP WITH ADJUSTABLE STRAPS, BELOW KNEE, EACH with the use of the -RA modifier when the patient needed replacement garments due to a "change in the patient's condition". Please clarify why I am seeing these denials.
This sounds like the Same or Similar issue as there is with AFO.
The Lymphedema Act does allow for 3 stockings for each anatomical site every six months
for daytime use and 2 stockings every 2 years for each anatomical site when used for night time use.
The act will allow for an additional items if the patient's condition(s) changes.
You are correct in that the RA modifier is only to be used if the device being replaced is lost, stolen or irreparably damaged. That is not the case here.
Unfortunately, there is no specific modifier to indicate that the patient's condition(s) has changed.
Hence, you will need to submit the claim knowing it will be denied and then appeal it under the "Same or Similar" ruling. This is identical to if the patient condition or diagnosis changes and they require a different type of AFO.
There is a letter of instruction from all four DME MAC Medical Directors providing suppliers with more information on the Same/Similar Issue.
It can be found on any of the four DME MAC websites. Here is a link from JD: https://med.noridianmedicare.com/web/jddme/policies/dmd-articles/2020/same-or-similar-denials-for-orthoses-and-the-appeals-process
Your documentation should spell out specifically what has changed necessitating replacements. Examples include measurements from previous vs. current examinations which document that the patient's condition has improved substantially such that the previous stockings will no longer provide compression (too large) and that a smaller stocking is needed. Identifying photos supporting these measurements such also be provided.
CMS and the DME MAC medical directors have repeatedly refused to provide relief on this issue by providing a specific modifier bypass of the limits on coverage. Their rationale is that there is an appeals process by which Medicare does allow additional coverage if the patient's diagnosis or condition changes.