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On April 1, 2025, Joint DME MAC Publication . This Correct Coding and Billing publication is effective for claims with dates of service on or after January 1, 2024. Lymphedema Compression Treatment Items – Correct Coding and Billing – Revised https://cgsmedicare.com/jc/pubs/news/2023/12/cope147943.html This publication provides billing and coding guidance pertinent to lymphedema compression treatment items, based on the Centers for Medicare & Medicaid Services' (CMS') Final Rule CMS-1780-F. Information on initial and replacement coverage per the Final Rule: Gradient compression garments, related supplies and accessories are covered only for the treatment of lymphedema (see ICD-10-CM Codes that Support Medical Necessity below). Claims for gradient compression garments, related supplies and accessories for non-lymphedema diagnoses will be denied as noncovered. A quantity of three (3) daytime garments or wraps per body area are allowed once every six (6) months. A quantity of two (2) nighttime garments per body area are allowed once every two (2) years (24 months). 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. Claims for gradient compression garments or wraps billed in excess of the frequency limitations outlined above will be denied as not reasonable and necessary unless replacements are needed in cases of loss, theft, or irreparable damage. In addition, payment can be made for a new set of garments or wraps if determined to be reasonable and necessary due to a change in the beneficiary's medical or physical condition that warrants a new size or type of garment or wrap. Payment is made for replacement of an entire new set of three daytime garments or wraps and/or two nighttime garments in cases of loss, theft, irreparable damage, or change in medical or physical condition and the six month and/or two year replacement frequency begins anew at the time the replacement items are furnished. Medicare covers custom fitted (custom or non-standard) gradient compression garments. Custom fitted gradient compression garments are uniquely sized and shaped to fit the exact dimensions of the affected extremity of an individual to provide accurate gradient compression to treat lymphedema. Examples of scenarios where a custom fitted gradient compression garment might be used (not all-inclusive) are: If the circumference of the proximal portion of the limb is significantly greater than the distal limb; If the skin/tissue has folds or contours requiring a specific type of knitting pattern; Beneficiary is unable to tolerate the fabric composition of a standard garment. There must be documentation in the beneficiary's medical record necessitating the use of a custom fitted gradient compression garment versus an off-the-shelf standard gradient compression garment. The patient's medical record is not limited to the physician's office records. It may include hospital, nursing home, or HHA records and records from other health care professionals, such as lymphedema treatment professionals. This documentation must be made available to the DME MAC upon request. Compression bandaging supplies furnished during Phase 1 (acute or decongestive therapy) and Phase 2 (maintenance phase of therapy) are covered when medically necessary for the treatment of lymphedema. The therapists and other suppliers furnishing bandaging systems must be enrolled DMEPOS suppliers in order to be paid for furnishing these items. The justification for the quantity of supplies needed and the frequency of replacement must be documented in the beneficiary's medical record and made available to the DME MAC upon request. Accessories (e.g., zippers, linings, padding or fillers, etc.) necessary for the effective use of a lymphedema compression treatment item are covered when medically necessary for the treatment of lymphedema. The justification for the quantity of supplies needed and the frequency of replacement must be documented in the beneficiary's medical record and made available to the DME MAC upon request. Payment for all necessary services associated with furnishing gradient compression garments and wraps, including fitting and measurements, is included in the national payment amounts made to the supplier of the item. 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. For replacement claims, if only one (1) daytime garment or wrap is lost, stolen, or irreparably damaged, payment is allowed for three (3) replacements, but the frequency limitation clock of six (6) months would restart based on the date of service for the replacement claim. For replacement claims for a nighttime garment, two (2) replacements are allowed if only one nighttime garment or wrap is lost, stolen, or irreparably damaged and the frequency limitation clock of two years (24 months) would restart based on the date of service for the replacement claim.

I am in Novitas Medicare, and when I use pain for my diagnosis in toes paired with B35.1 for the nails, bill CPT 11721 and the EMR automatically adds Q8 isn't this wrong?

For Medicare (or any insurance for that matter), how often can a patient, WITH class findings, be treated for very painful plantar xerotic lesions? No nails, just debridement. Does this still qualify as RFC with a 61 day global even though nails are not being debrided?

I am concerned that if you have a diabetic patient without complications, Type 2, E11.9 and they take no medication do insurance carriers still require an additional Z Code?

If a podiatrist, acting as a DME supplier, is ordering non custom diabetic shoes (HCPCS code A5500) with need for a non-custom insert(s) (HCPCS code A5512) and on the vendor order form has checked off a custom molded diabetic insert(s) (HCPCS code A5513/A5514) by mistake. The podiatrist did not obtain any scan or mold of the feet. Which most likely is not a problem, but during the comprehensive diabetic foot exam by the primary care physician (MD/DO) who is treating the patient for diabetes indicates the patient requires a custom molded insert rather than non-custom inserts as originally intended by the prescribing podiatrist. Since the MD/DO most likely reviewed either the DPM's progress notes, shoe prescription, or vendor order form, then the request for a custom mold set of inserts was recommended. The concern is that the vendor refuses to provide the non-custom inserts based on the above information that they received from the MD/DO because if the patient does not receive the inserts recommended by the MD/DO based on the progress note, then the DPM and vendor could be subject to a Medicare DMERC audit. If it is true, then please clarify.

I am told CMS has a MLN article on documentation and reviews, can you provide that link?

How do I know if a particular CPT allows for an additional surgical assistance allowance? 2nd if the hospital is providing the assistant can I bill their services to Medicare?

Does open treatment of a metatarsal fracture, 28485 require fixation, and if so, does this CPT code only stipulate that it be used for internal fixation?

Can you clarify as to when you can use CPT code 28470: closed treatment of a metatarsal fracture. What does the code include regarding application of splints, dressings, and use of an ambulatory boot if needed. Are they included in the use of this code? What is the global for this code? If you see this patient for follow up and need to bill an E/M code, then what is the modifier needed to indicate that the visit has nothing to do with the fracture?

I am thinking of addding an associate to my practice and want to "incentivize" them to perform certain services. A bonus if you will, based on RVU, and performance. As part of my review, I have seen that DME is particulalry problematic as there are certain Stark Laws regulating incentenvizing certain services, "Designated Health Services". What do I do to stay compliaint with these issues and still be able to offer bonuses for performance?

In your opinion can a provider choose to only bill the higher fee CPT associated with a CCI? In the example I am citing the column 2 code is paid at a higher rate than the column 1 code. The doctor wants to document that both procedures were performed but only bill for the higher rate procedure. The biller wants to bill for the higher rate (Column II) procedure but not document that the lower rate procedure (Column I code). I Imagine this brings up both potential professional liabillity issues and ethical billing issues. Do you have any suggestions?