Program directors, nurses, therapists, physicians, and nonphysician practitioners (NPPs) who work in hospital-owned outpatient wound management provider-based departments (PBDs) send many questions to this author about providing, coding, and billing for lymphedema treatment. Therefore, this author requested and was granted an interview with a lymphedema educator who works in a PBD. Following is a transcript from the interview with Jodi Boory, BSN, RN, CRRN, CHRN, CWCA, OMS, a clinician at the University of Pittsburgh Medical Center Wound Healing Services.
Kathleen Schaum: Thank you for agreeing to share your knowledge about providing, coding, and billing for lymphedema in a PBD! To begin, please itemize the major International Classification of Diseases, 10th Revision codes that typically describe patients with lymphedema.
Jodi Boory: Sure. The most common codes that describe outpatients who are treated for lymphedema are
- I97.2 Lymphedema syndrome, postmastectomy,
- I89.0 Lymphedema, and
- Q82.0 Primary (congenital) lymphedema.
K.S.: What treatments are typically provided to outpatients with lymphedema?
J.B.: Lymphedema treatments focus on reducing the swelling and controlling the pain and include light exercises that move the affected limb and encourage lymph fluid drainage; wrapping the arm or leg to encourage lymph fluid to flow back toward the trunk of the body;i a special massage technique called manual lymphatic drainage (MLD) that encourages the flow of lymph fluid out of the arm or leg; pneumatic compression (a sleeve worn over the affected arm or leg that connects to a pump that intermittently inflates the sleeve and moves lymph fluid away from the fingers or toes);ii and compression garments or devices.iii
K.S.: I have heard the term “comprehensive decongestive therapy” used by professionals to describe the treatment they provide for lymphedema. Is it the same or different from the treatments you just described?
J.B.: Complete decongestive therapy (CDT), also called comprehensive decongestive therapy, is the universally accepted treatment of lymphedema; it involves combining therapies with lifestyle changes. This intensive program combines many of the different treatment approaches that I just mentioned.
K.S.: Will you please describe a typical CDT program?
J.B.: A typical CDT program consists of two phases: reductive and maintenance CDT. Reductive CDT focuses on removing the extra lymph out of the affected part of the body to reduce visible swelling and other symptoms of lymphedema. Although treatment plans are tailored to the individual, the lymphedema therapist generally provides MLD, short-stretch compression bandaging (with or without the use of foam pads and chip bags), and exercise sessions for each patient 5 days a week. Although daily visits to a lymphedema therapist can be time-consuming, inconvenient, and expensive (if not fully covered by insurance), they are considered a mainstay of lymphedema treatment. If cost is an issue, the lymphedema therapist may be able to tailor these sessions to three times per week if medically indicated.
During this phase, the patients typically wear their bandages around the clock and only remove them for showering/bathing and MLD sessions. The lymphedema therapist teaches the patients (1) how to apply their bandages correctly and (2) how to do their exercises. This phase can last from 3 to 8 weeks, depending on how long it takes to reduce the swelling and improve other symptoms affecting the skin. The lymphedema therapist uses measurements and/or visual examination of the affected area to decide when the first phase has accomplished everything possible to reduce the lymphedema symptoms.
Maintenance CDT teaches patients to maintain, on their own, the results of the initial intensive reductive phase. Although individual treatment plans vary, patients can expect to perform maintenance CDT for many years or even for the rest of their life. This includes compression sleeves and garments: getting fitted for them, learning how to correctly put them on, wearing them, and caring for them. This also includes self-care steps, such as protecting the affected body part from cuts, injury, overuse, extreme temperatures, and other situations that can increase the risk of lymphedema and lymphedema flare-ups; learning the signs and symptoms of infection; and designing and then following an exercise and/or weight control plan.
Lymphedema therapists also teach their patients how to perform MLD on their own. The patients must follow their therapist’s guidelines on how and when to perform MLD. Doing more MLD than is recommended or being aggressive with the massage strokes for MLD could be harmful. In addition, if patients develop any infections or areas of irritation on their skin, they must avoid those places during MLD.
K.S.: Which medical professionals can qualify to become a certified lymphedema therapist?
J.B.: To become a certified lymphedema therapist, a candidate must possess a current and unrestricted US state professional license or registration or equivalent Canadian provincial or territorial license or registration as an RN, occupational therapist, certified occupational therapy assistant, physical therapist, physical therapist assistant, medical doctor, doctor of osteopathic medicine, doctor of chiropractic, NPP, massage therapist, or certified athletic trainer.
K.S.: What type of course work is required to perform CDT?
J.B.: To qualify for entry into the CDT program, the candidate must provide proof of completion for
- 12 credit hours of basic science (ie, 192 clock hours) and
- 3 credit hours (48 clock hours) of a college-level human anatomy, physiology, and/or pathology course from an accredited college or university. A copy of the transcript must be submitted with the CDT program application.
Once accepted into the CDT program, the qualified professional must complete course work (consisting of one-third theoretical instruction and two-thirds practical laboratory work and documentation of 135 classroom hours) from no more than four consecutive or cumulative courses from one training program.
K.S.: Now let’s turn our attention to coding for the components of CDT. What Current Procedural Terminology (CPT)iv codes are used to code and bill to the Medicare program?
J.B.: Four CPT codes are available to bill Medicare when the various components of CDT are performed:
- 97016, for sequential pneumatic compression device patient education;
- 97110, for decongestive exercises;
- 97140, for manual lymph drainage and compression bandaging; and
- 97535, for self-care management training.
K.S.: Great! Now the big question is: Which professional(s) can bill the Medicare program for CDT provided to outpatients?
J.B.: Medicare has designated all of the CDT procedure codes as “always therapy” services, regardless of who performs them. Those codes always require a therapy modifier (-GP, -GO, or -GN) to indicate that they are furnished under a physical therapy, occupational therapy, or speech-language pathology plan of care. Therefore, the components of CDT can only be provided by and billed by lymphedema-qualified physicians, NPPs, and therapists who can write the therapy plan of care.
K.S.: I suspect the “always therapy” designation of the codes prevents PBDs from allowing RNs, massage therapists, and certified athletic trainers to perform CDT.
J.B.: Your suspicions are correct. The PBDs can only bill Medicare for CDT if it is performed under a therapy plan of care written by a physician, NPP, or therapist. Most physicians and NPPs prefer to refer the work to a therapist. Therefore, if PBDs wish to offer CDT, they must have a CDT-qualified therapist on staff. In addition, they must have a treatment room that can be available for over an hour for each CDT session.
K.S.: Then should I assume that CDT is usually completed in outpatient rehabilitation centers?
J.B.: You are correct. However, if the patient is also receiving skilled care from a home health agency, the Medicare program will not pay the rehabilitation center at the same time. In that case, the patient will either receive his/her treatment from a CDT-qualified therapist employed by the home health agency, pay for the CDT out of pocket, or discontinue his/her home health agency care and receive his/her CDT from an outpatient rehabilitation center.
K.S.: Is it correct to assume that Medicare covers the treatment of lymphedema?
J.B.: Yes, the Medicare Benefit Policy Manual states “Skilled therapy services may be necessary to improve a patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration of the patient’s condition.”1 This is certainly applicable to a progressive condition such as lymphedema.
K.S.: Have any of the Medicare Administrative Contractors written Local Coverage Determinations and/or coding articles that provide guidelines for lymphedema therapists?
J.B.: Noridian Healthcare Solutions, Inc, discusses CDT in several coverage documents. Local Coverage Articles A52959 and A55710, entitled Lymphedema Decongestive Treatment, describe coverage and documentation requirements for two basic types of decongestive treatment: MLD and CDT. Lymphedema therapists should carefully read these coverage articles. Following are a few key points from the articles:2,3
- “Documentation should support a diagnosis of lymphedema and not tissue edema due to other etiologies, eg, chronic venous insufficiency, congestive heart failure, acute infections, etc.”
- “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- to 3-week time period. There is only temporary benefit from the treatment unless the patient and/or caregiver can complete treatments at home on an ongoing basis. The end of treatment is not when the edema resolves or stabilizes but when the patients and/or caregivers are able to continue their treatment at home.”
- “Medically necessary hands-on MLD is a covered Medicare service and is coded using CPT 97140 for manual therapy.”
- “There is no Medicare coverage for lymphedema compression bandage application as this is an unskilled service. Medicare will, however, cover a brief period (eg, three or fewer sessions if no new specific issues are identified) of patient/caregiver instruction in compression bandaging home management. Medical necessity for this education must be clearly documented and meet the code descriptor requirements for CPT 97535.”
- “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 at a maintenance level of care and are no longer reimbursable by Medicare.”
Local Coverage Article A53287, entitled High Compression Bandage System Clarification, states:4
- “Providers should note that the treatment of lymphedema with the application of high-compression bandage systems continues to be noncovered by Medicare. However, a brief period, ie, three or fewer sessions if no new specific issues are identified, of patient and/or caregiver education for home management of lymphedema with compression wrap applications may be medically necessary and reimbursable. Medical necessity for the education must be clearly indicated in the patient’s record and must meet the code descriptor requirements for CPT 97535, supporting home management training.”
Noridian also provides an educational note:
- “97140 should not be reported for any type of manual therapy provided during the same patient encounter in the same anatomic region where a multilayer compression system is applied.”
K.S.: Jodi, thank you for this valuable information. Do you have any final thoughts to share with our readers?
J.B.: The management of lymphedema therapy is a daily process that can be expensive for the patient but is a vital part of his/her wellness. If left untreated, open wounds, difficulty with ambulation, and frequent infections can result. The patient MUST wear his/her compression garments/devices every day and follow the instructions of his/her lymphedema therapist to prevent negative outcomes and to maintain wellness. When educating patients with lymphedema, I liken the need for daily lymphedema care to the need for managing high BP by following their provider’s instructions and by taking BP medication every day.
Finally, I appreciate that many medical professionals understand that CDT is a vital component of the management of lymphedema and are eligible to take, and often do take, the CDT course. However, I want to remind readers that completion of the CDT course does not make every graduate eligible to provide and bill for CDT for Medicare beneficiaries. Remember, Medicare covers CDT only when provided by physicians, NPPs, and therapists.