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LYMPHEDEMA  INSURANCE CODES

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Insurance Codes for Lymphedema

http://www.lymphedemapeople.com/wiki/doku.php?id=insurance_codes_for_lymphedema

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ICD-9, CPT codes for lymphedema

Covered ICD-9-CM Edema or Lymphedema Codes

     125.0-125.9      Filarial lymphedema
     457.0                Post-mastectomy lymphedema syndrome
     457.1                Other lymphedema (praecox, secondary, acquired/chronic,    elephantiasis)
     457.2                Lymphangitis
     457.8                Other noninfectious disorders of lymphatic channels (chylous disorders)
     624.8                Vulvar lymphedema
     729.81              Swelling of limb
     757.0                Congenital lymphedema (of legs), chronic hereditary, ideopathic hereditary
     782.3                Edema of Legs-Acute traumatic edema

HCPCS Procedure Codes

Procedure A manipulation of the body to give a treatment or perform a test; more broadly, any distinct service a doctor renders to a patient. All distinct physician services have ‘procedure codes’ in various payment schemes.

     97001 or 97003 initial evaluation by a physical or an occupational therapist, or an   Evaluation and Management CPT Code for physicians.
     97002 or 97004 re-evaluation by a physical or an occupational therapist,  or an     E valuation and Management CPT Code for physicians.
     97110  Therapeutic exercises
     97016  Vasopneumatic Pump
     97124  Massage therapy for edema of an extremity
     97140  Manual therapy, manual lymphatic drainage (15 minute units)
     97150  Group therapy
     97504  Orthotic training/fitting
     97530  Therapeutic activities, restoration of impaired function
     97535  Self-care home management training, instruction on bandaging,  exercises, and   self-care
     97703  Checkout for orthotic or prosthetic use

Cellulitis Codes

Cellulitis ICD-9 codes for Outpatient Treatment:
Infections of skin and subcutaneous tissue  (680-686)
   Cellulitis and abscess (681.00-682.9)
     682.0      Other cellulitis and abscess, face
     682.1      Other cellulitis and abscess, neck
     682.2      Other cellulitis and abscess, trunk
     682.3      Other cellulitis and abscess, upper arm and forearm
     682.4      Other cellulitis and abscess, hand, except fingers and thumb
     682.5      Other cellulitis and abscess, buttock
     682.6      Other cellulitis and abscess, leg, except foot
     682.7      Other cellulitis and abscess, foot, except toes
     682.8      Other cellulitis and abscess, other specified sites
     682.9      Other cellulitis and abscess, unspecified site (diffuse) (with lymphangitis)

Item Codes

The items and supplies listed below are considered “incident to” a physician service and are not separately reimbursable. However, if these supplies are given to a patient as a take home supply, the claim should be submitted to the DMERC.

Code Description
    
    
A4454               Tape
    A4460               Elastic bandage (e.g. compression bandage). Use this code to report compression bandages associated with lymphatic drainage
                              (CIM 60-9, MCM 2133, ASC)
     A4465               Non-elastic binder for extremity. Use for Reid, CircAid, ArmAssist, etc                               manually-adjustable sleeves and leggings. Medicare jurisdiction DME                               regional carrier (CIM 60-9, MCM 2133, ASC)
     A4490-4510   Surgical Stockings
    
A4490          Surgical Stockings above knee length (each)
     A4495          Surgical Stockings thigh length (each)
     A4500          Surgical Stockings below knee length (each)
     A4510          Surgical Stockings full length (each)
     A4649          Miscellaneous Surgical Supplies, Compression bandaging kit
     E0650-0652     Pneumatic Compressor and Appliances
     E0650               Pneumatic Compressor, non-segmental home model
     E0651          Pneumatic Compressor, segmental home model, without calibrated                                         gradient pressure
     E0652          Pneumatic Compressor, segmental home model, with calibrated                                         gradient pressure
     E0655-0673     Arm and Leg Appliances used with Pneumatic Compressor
     L0100-L4398      Orthotics
     L2999          Lower Limb Orthosis, not otherwise specified
     L3999          Upper Limb Orthosis, not otherwise specified
     L4205          Repair of orthotic device, labor, per 15 minutes
     L4210          Repair of orthotic device, repair or replace minor parts
     L5000-L5999   Lower Limb
     L6000-L7499   Upper Limb
     L8000-8490     Prosthetics
     L8010              Mastectomy Sleeve, Ready-Made
     L8100-L8239   Elastic supports
     L8100-8195     Elastic Supports, elastic stockings various lengths & weights
     L8210             Gradient compression stocking, custom made
     L8220             Gradient compression stocking/sleeve, Lymphedema, Custom
     L8239             Gradient stocking, not otherwise specified. Carrier discretion.

         
         
From Appendix A Glossary of Medicare Terminology and Acronyms

    
Durable Medical Equipment (DME) Medical equipment that can stand repeated use and is appropriate for use in the home, such as wheelchairs, canes, walkers, and oxygen delivery equipment.
     Durable Medical Equipment Regional Carrier (DMERC) The Medicare carriers that process claims for durable medical equipment, prosthetics, orthotics, and supplies
    
      
                                      
     HCFA 1490S Form — Patient’s request for Medicare payment. Replaces HCFA 1490 for beneficiaries.
     HCFA 1500A Form — Uniform health insurance claim form. Request for Payment form. This form replaces HCFA 1490 effective 09/01/81
     HCFA 1554 Form — Hospital component fees.

Special thanks to Bob Weiss for sending these in

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End-Diastolic Pneumatic Compression Therapy

http://www.hgsa.com/professionals/policy/z62.html

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Insurance for Breast Cancer Patients - Lymphedema

If you are a breast cancer survivor, be sure to cite the Women's Health and Cancer Rights Act (WHCRA) of 1998 that was signed into law on October 21, 1998 by the 105th Congress. It is called Public Law #105-277. It appears as provision Title IX under Subtitle IV of a much larger Omnibus bill, HR 4328. It is, in fact, this bill that passed, which included the WHCRA, and mandates that all insurance companies provide coverage for "prostheses and physical complications of mastectomy including lymphedemas."

INSURANCE COVERAGE TOOLS

I have compiled some healthcare insurance codes and healthcare conditions as relating to Lymphedema coverage. PLEASE NOTE, These conditions, codes, rulings etc are different from state to state, insurance plan to inusurance plan and are constantly changing. Proper documentation and codes may be crucial in getting treatment covereage. Please check with your insusuer on the requirements and restrictions as it concerns lymphedema treatment. The codes and medical language should be an asset to your physician  or therapist in putting together the request for treatment/therapy coverage or appealing a declination. 

 

Conditions For Insurance Coverage (taken from various state medicare sources sources): This coverage policy was developed to provide medical necessity guidelines for complex decongestive physiotherapy for lymphedema.

1. There is a physician documented diagnosis of lymphedema: and the physician specifically orders CDP 2. The patient is symptomatic for lymphedema, with limitation of function related to self care, mobility and/or safety. 3. The patient or patient caregiver has the ability to understand and comply with home care continuation of treatment regimen. 4. The services are being performed by a health care professional who has received specialized training in this form of treatment

ICD-9 diagnosis codes:

457.0 - Post-mastectomy Lymphedema Syndrome

457.1 - Other lymphedema

757.0 - Hereditary edema of the legs (congenital lymphedema)

CPT Codes:

97001 - Physical therapy evaluation

97002 - Physical therapy re-evaluation

97003 - Occupational therapy evaluation

97004 - Occupational therapy re-evaluation

97110 - Therapeutic procedure, one or more areas, each 15 minutes: therapeutic exercises to develop strength and endurance, range of motion and flexibility

97140 - Manual therapy techniques (e.g. mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes

97535 - Self-care/home management training (e.g., activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of adaptive equipment)direct one on one contact by provider, each 15 minutes

Getting Insurance Coverage - Not Always Easy

Suggestions on Getting Insurance Coverage for Lymphedema Treatment

1. BE PERSISITANT! the squeaky wheel gets the oil.I always made several calls to my insurance 800 number, amazingly if I asked the same thing of four different service reps I got four different answers. Find someone you trust and that is helpful and ask for that one person.

2. Document Everything: Take names and dates, every call you make. Insurance agents have selective amnesia about coverage.

3. Put it in writing. Follow up phone calls with letters. Overstate the obvious and make quotes when available. CC as many doctors, company executives that you possibly can , this lets the insurance company know you mean business.

4. Educate your Primary Care Physician: I had a draft of a letter asking for coverage that I gave to my primary care physician so that it made it easier for him to write the insurance company. I gave him issues of the NLN newsletter and copies of articles on LE. When it comes to LE, you probably know more than most primary care doctors do but they are to embarrassed to admit that.

5. Complain to your Human Resources Director: your company pays a lot of money for your policy, let the HR Director know you are getting the run around. See if they can put you in direct contact with the most senior person at the Insurance company. Show them your documentation of phone calls and letters to show how you have been working to get coverage.

6. Change insurance companies: make sure the new carrier does not have the dreaded pre-existing condition clause. Investigate all your insurance options. You may have to pay a little more for better insurance but they may cover all your expenses. In some cases the cheaper HMOs offer more lenient LE coverage. Ask your LE specialist what insurance companies have been paying for treatments.

7. Change Primary Care Doctors: find an advocate! If you are not getting the help or support you need to get coverage find another doctors. There are many great doctors who unfortunately are poor administrators. Find a doctor who will follow up with the insurance company for you, they all hate dealing with the bureaucracy but it is part of their job.

8. Assume Nothing: Insurance companies think they have all the answers and will send you to who they consider to be the expert, often a Vascular Surgeon or Massage Therapist who has not been trained specifically for Lymphedema. Save your self the time and call and find out what specific treatments they give LE patients: if they 't have the answer don't bother to go. MLD and CPT are specific treatments and massage therapists must be trained by the reputed schools. If the therapist just gives you a massage like you have a sports injury it is useless, in fact some massages can worsen the situation. As for Vascular Surgeons, for the most part LE has nothing to do with the vascular system and there is really no effective surgery, they usually don't have much to say on the subject.

9. Try Again. Policies change, personnel changes, keep trying as they will NEVER call you and let you know it has changed in your favor!

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Edema, Diagnostic Swelling Codes

http://www.eatonhand.com/coding/icd905.htm

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Complex Decongestive Physiotherapy

The lymphatic system has two primary immunologic functions:
activating the inflammatory response and controlling infections. In addition, the lymphatic system drains protein-containing fluid from
the tissue and conducts it in a unidirectional flow to the circulatory system. When there is a blockage in this drainage, the result is the swelling of a body part, often an extremity. This is referred to as lymphedema, an abnormal accumulation of lymph fluid.

Lymphedema is categorized as primary or secondary. Primary lymphedema is defined as impaired lymphatic flow due to lymph vessel aplasia, hypoplasia, or hyperplasia. This type is an inherited deficiency in the lymphatic channels of unknown origin. Secondary lymphedema is caused by known precipitating factors. The most common causes in the United States are surgical removal of the lymph nodes (i.e., in connection with a mastectomy), fibrosis
secondary to radiation, and traumatic injury to the lymphatic
system. Filariasis is the leading cause of lymphedema throughout
much of the tropical world.

Currently, lymphedema can be treated by many methods such as: Compressive garments, wrapping, elevation, surgery, pneumatic compression devices or Complex Decongestive Physiotherapy (CDP). This policy addresses only the CDP method.

Complex Decongestive Physiotherapy has been referred to by
several terms including: non- invasive complex lymphedema therapy (CLT), early conservative lymphedema management, complicated physiotherapeutics, manual lymphedema treatment (MLT), multi-
modal lymphedema therapy, and palliative lymphedema therapy.
For purposes of consistency, the term CDP will be used.

Each CDP session normally consists of four phases:

It is expected that physical therapy education sessions would usually
last for 1 to 2 weeks, with the patient attending 3-5 times per week, depending on the progress of the therapy. After that time, there should have been enough teaching and instruction that the care could be continued by the patient or patient caregiver in the home setting. The maximum benefits of treatment are not expected unless the patient continues treatment at home.

The physical therapy billed in conjunction with the manual lymph drainage therapy will be subject to all national and local policies for physical therapy.

The coverage of the physical therapy would only be allowed if all of the following conditions have been met:

The physical therapy services for CDP must be provided either by or under the direct personal supervision of the physician or independently practicing therapist.

CPT Codes
97001     Physical therapy evaluation
97002     Physical therapy re-evaluation
97003     Occupational therapy evaluation
97004     Occupational therapy re-evaluation
|
97110     Therapeutic procedure, one or more areas, each 15 minutes;
                therapeutic exercises to develop strength and endurance,
                range of motion and flexibility

97140      Manual therapy techniques (eg, mobilization/manipulation,
                manual lymphatic drainage, manual traction), one or more   
                regions, each 15 minutes
97535       Self care/home management training (e.g., activities of daily
                 living (ADL) and compensatory training, meal preparation,
                 safety procedures, and instructions in use of adaptive
                 equipment) direct one on one contact by provider, each 15
                 minutes

ICD-9 Codes That Support Medical Necessity
457.0     Postmastectomy lymphedema syndrome
457.1     Other lymphedema
757.0     Hereditary edema of the legs (congenital lymphedema)

Coding Guidelines
It is expected that procedure code 97140 will be utilized when the
manual lymph drainage is performed, procedure code 97535 for the instruction of bandaging, exercises and self care, and procedure code 97110 when performing the individual exercises.

When an initial evaluation or periodic re-evaluation is performed, separate reimbursement may be made. For these evaluations,
physical and occupational therapists should use codes 97001, 97002, 97003, and 97004, and physicians should use the applicable Evaluation and Management codes.

It is not appropriate to automatically bill with an evaluation and management service each time a patient goes for the physical therapy treatment. An evaluation and management should not be used unless
all of the components of the visit have been met.

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HCPCS MODIFIER:

EY - No physician or other health care provider order for this item or service

E0650

PNEUMATIC COMPRESSOR, NON-SEGMENTAL HOME MODEL

E0651

PNEUMATIC COMPRESSOR, SEGMENTAL HOME MODEL WITHOUT CALIBRATED GRADIENT PRESSURE

E0652

PNEUMATIC COMPRESSOR, SEGMENTAL HOME MODEL WITH CALIBRATED GRADIENT PRESSURE

E0655

NON-SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, HALF ARM

E0660

NON-SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, FULL LEG

E0665

NON-SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, FULL ARM

E0666

NON-SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, HALF LEG

E0667

SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, FULL LEG

E0668

SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, FULL ARM

E0669

SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, HALF LEG

E0671

SEGMENTAL GRADIENT PRESSURE PNEUMATIC APPLIANCE, FULL LEG

E0672

SEGMENTAL GRADIENT PRESSURE PNEUMATIC APPLIANCE, FULL ARM

E0673

SEGMENTAL GRADIENT PRESSURE PNEUMATIC APPLIANCE, HALF LEG

Coding Guidelines

Pneumatic compression devices consist of an inflatable garment for the arm or leg and an electrical pneumatic pump that fills the garment with compressed air. The garment is intermittently inflated and deflated with cycle times and pressures that vary between devices.

A non-segmented pneumatic compressor (E0650) is a device which has a single outflow port on the compressor. The fact that the air from the single tube may be transmitted to a sleeve/appliance with multiple compartments or segments (E0671-E0673) does not affect the coding of the compressor.

A segmented pneumatic compressor (E0651, E0652) is a device which has multiple outflow ports on the compressor which lead to distinct segments on the appliance which inflate sequentially. A segmented device without calibrated gradient pressure (E0651) is one in which either (a) the same pressure is present in each segment or (b) there is a predetermined pressure gradient in successive segments but no ability to individually set or adjust pressures in each of several segments. In an E0651 device the pressure is usually set by a single control on the distal segment. A segmented device with calibrated gradient pressure (E0652) is characterized by a manual control on at least three outflow ports which can deliver an individually determined pressure to each segmental unit. The fact that the tubing and/or appliance is capable of achieving a pressure gradient does not classify the compressor as E0652 because this is not a calibrated gradient pressure.

Segmental gradient pressure pneumatic appliances (E0671-E0673) are appliances/sleeves which are used with a non-segmented pneumatic compressor (E0650) but which achieve a pressure gradient through the design of the tubing and/or air chambers.

A non-segmented pneumatic compressor (E0650) is used with appliances/sleeves coded by E0655-E0666 or E0671-E0673. Segmented pneumatic compressors (E0651 or E0652) are used with appliances/sleeves coded by E0667-E0669.

When a foot or hand segment is used in conjunction with a leg or arm appliance respectively, there should be no separate bill for this segment. It is considered included in the code for the leg or arm appliance.

Suppliers should contact the Statistical Analysis Durable Medical Equipment Regional Carrier (SADMERC) for guidance on the correct coding of these items.

Documentation Requirements

Section 1833(e) of the Social Security Act precludes payment to any provider of services unless "there has been furnished such information as may be necessary in order to determine the amounts due such provider" (42 U.S.C. section 13951(e)). It is expected that the patient's medical records will reflect the need for the care provided. The patient's medical records include the physician's office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be available to the DMERC upon request.

An order for each item billed must be signed and dated by the treating physician, kept on file by the supplier, and made available to the DMERC upon request. Items billed to the DMERC before a signed and dated order has been received by the supplier must be submitted with an EY modifier added to each affected HCPCS code.

A Certificate of Medical Necessity (CMN) which has been completed, signed, and dated by the treating physician must be kept on file by the supplier and made available to the DMERC on request. The CMN may act as a substitute for a written order if it contains all of the required elements of an order. The CMN for (pneumatic compression pumps) is HCFA Form 846. The initial claim must include a copy of the CMN.

If question #3 on the CMN ("Does the patient have chronic venous insufficiency with venous stasis ulcers?") is answered "Yes", documentation supporting the medical necessity for the device should include a signed and dated statement from the treating physician indicating:

1) the location and size of venous stasis ulcer(s),

2) how long each ulcer has been continuously present,

3) whether the patient has been treated with a compression bandage system or compression garment, appropriate dressings for the ulcer(s), exercise and limb elevation for the past 6 months,

4) whether the patient has been seen regularly by a physician for treatment of venous stasis ulcer(s)during the past 6 months.

If E0652 is billed, additional documentation supporting the medical necessity for this device must include a signed and dated statement from the ordering physician indicating:

1) the treatment plan including the pressure in each chamber, and the frequency and duration of each treatment episode,

2) whether a segmented compressor without calibrated gradient pressure (E0651) or a non-segmented compressor (E0650) with a segmented appliance (E0671-E0673) had been tried and the results,

3) why the features of the system that was provided are needed for this patient,

4) the name, model number, and manufacturer of the device.

Questions pertaining to medical necessity on any form used to gather the above information may not be completed by the supplier or anyone in a financial relationship with the supplier. The information on the form must be supported by documentation in the patient's medical record which would be available to the DMERC upon request. If this additional information is present, the claim will generally have to be filed hard copy.

Refer to the Supplier Manual for more information on documentation requirements.

*link no longer valif**

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Complete Decongestive Therapy

http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0076_coveragepositioncriteria_complex_lymphedema_therapy.pdf

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Complex Decongestive Physiotherapy

Date of Revision: 7/26/02   

Description

The lymphatic system has two primary immunologic functions: activating the inflammatory response and controlling infections. In addition, the lymphatic system drains protein-containing fluid from the tissue and conducts it in a unidirectional flow to the circulatory system.  When there is a blockage in this drainage, the result is the swelling of a body part, often an extremity.  This is referred to as lymphedema, an abnormal accumulation of lymph fluid. 

Lymphedema is categorized as primary or secondary.  Primary lymphedema is defined as impaired lymphatic flow due to lymph vessel aplasia, hypoplasia, or hyperplasia.  This type is an inherited deficiency in the lymphatic channels of unknown origin.  Secondary lymphedema is caused by known precipitating factors.  The most common causes in the United States are surgical removal of the lymph nodes (e.g., in connection with a mastectomy), fibrosis secondary to radiation, and traumatic injury to the lymphatic system.  Filariasis is the leading cause of lymphedema throughout much of the tropical world. 

Currently, lymphedema can be treated by many methods such as: Compressive garments, wrapping, elevation, surgery, pneumatic compression devices or Complex Decongestive Physiotherapy (CDP).  This policy addresses only the CDP method. 

Complex Decongestive Physiotherapy has been referred to by several terms including: non-invasive complex lymphedema therapy (CLT), early conservative lymphedema management, complicated physiotherapeutics, manual lymphedema treatment (MLT), multi-modal lymphedema therapy, and palliative lymphedema therapy.  For purposes of consistency, the term CDP will be used. 

Each CDP session normally consists of four phases: 

Indications and Limitations of Coverage and/or Medical Necessity 

As mentioned earlier, CDP consists of skin care, manual lymph drainage, compression wrapping, and exercises.  Although there is no means for the carriers to allow payment of the total treatment via one treatment code, payment will be allowed for the physical therapy services associated with the treatment.  Other services such as skin care and the supplies associated with the compression wrapping are included in the physical therapy services performed during each session. 

The goal of this therapy is not to achieve maximum volume reduction, but to ultimately transfer the responsibility of the care from the clinic, hospital, or doctor, to home care by the patient, patient’s family or patient’s caregiver.  Unless the patient is able to continue therapy at home, there is only temporary benefit from the treatment.   

The endpoint of treatment is not when the edema resolves or stabilizes, but when the patient and/or their cohort are able to continue the treatments at home.  Patients who do not have the capacity or support system to accomplish these skills in a reasonable time are not good candidates for Complex Decongestive Physiotherapy.  

It is expected that physical therapy education sessions would usually last for 1 to 2 weeks, with the patient attending 3-5 times per week, depending on the progress of the therapy.  After that time, there should have been enough teaching and instruction that the patient or patient caregiver in the home setting could continue the care.  The maximum benefits of treatment are not expected unless the patient continues treatment at home.  

The physical therapy billed in conjunction with the manual lymph drainage therapy will be subject to all national and local policies for physical therapy.

The coverage of the physical therapy would only be allowed if all of the following conditions have been met: 

Currently, services for lymphedema are covered by the lymphedema pump. Some providers are proposing noninvasive Complex lymphedema therapy as an alternative to pumps.  A patient requiring both modes of treatment should be rare.  In addition, it is not expected that PT and OT would be performed concurrently; (i.e., both PT and OT providing the therapeutic exercise portion of the session) 

The physical therapy services for CDP must be provided either by or under the direct personal supervision of the physician or independently practicing therapist. 

CPT/HCPCS Codes 

97001

Physical therapy evaluation

97002

Physical therapy re-evaluation

97003

Occupational therapy evaluation

97004

Occupational therapy re-evaluation

97110

Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility

97140

Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes

97535

Self care/home management training (e.g., activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact by provider, each 15 minutes

ICD-9 Codes that Support Medical Necessity

457.0

Post mastectomy lymphedema syndrome

457.1

Other lymphedema

757.0

Hereditary edema of legs (congenital lymphedema)

Reasons for Denials 

Noncovered ICD-9 Codes

Any diagnosis codes not listed in the "ICD-9 Codes That Support Medical Necessity" section of this policy. 

Coding Guidelines 

It is expected that procedure code 97140 will be utilized when the manual lymph drainage is performed, procedure code 97535 for the instruction of bandaging, exercises and self-care, and procedure code 97110 when performing the individual exercises. 

When an initial evaluation or periodic re-evaluation is performed, separate reimbursement may be made.  For these evaluations, physical and occupational therapists should use codes 97001, 97002, 97003, and 97004, and physicians should use the applicable Evaluation and Management codes. 

It is not appropriate to automatically bill with an evaluation and management service each time a patient goes for the physical therapy treatment.  An evaluation and management should not be used unless all of the components of the visit have been met. 

Documentation Requirements 

The medical record documentation maintained by the provider must clearly document the medical necessity of the services being performed. 

The documentation for the initial evaluation and treatment must include the following: 

The documentation for any subsequent treatment must include: 

Other Comments 

Terms Defined

Filariasis - A chronic disease due to one of the filarial species.  Inflammatory elephantiasis results from filariasis or local infection of the lymph nodes. 

Elephantiasis - A chronic infectious condition characterized by pronounced hypertrophy of the skin and subcutaneous tissues resulting from obstruction of the lymphatic vessels. 

Lymphedema - Edema due to obstruction of lymphatics  

previous link no longer available

for furthre information:

http://www.medicarenhic.com/cpt_agree.shtml

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Additional Codes

S8420

Gradient pressure aid (sleeve and glove combination), custom made

S8421

Gradient pressure aid (sleeve and glove combination), ready made

S8428

Gradient pressure aid gauntlet), ready-made

S8429

          Gradient pressure exterior wrap

A6264

Gauze, non-elastic, non-sterile, per linear yard

A6263

Gauze, elastic, non-sterile, all types, per linear yard

S8430

Padding for compression bandage, roll

S8430

Padding for compression bandage, roll

S8431

Compression bandage, roll

S8422

Gradient pressure aid (sleeve), custom made, medium weight

S8423

Gradient pressure aid (sleeve), custom made, heavy weight

S8424

Gradient pressure aid (sleeve), ready made

S8425

Gradient pressure aid (glove) custom made, medium weight

S8426

Gradient pressure aid (glove), custom made, heavy weight

S8427

Gradient pressure aid (glove),ready made

HCPC Level II Code

L8220 Elastic support, elastic stocking, lymphedema

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See Also

LYMPHEDEMA INSURANCE BILLING GUIDELINES

http://www.lymphedemapeople.com/thesite/lymphedema_insurance_billing_guidelines.htm

Lymphedema Letter of Medical Necessity

http://www.lymphedemapeople.com/thesite/lymphedema_letter_of_medical_necessity.htm

Lymphedema How to Appeal Insurance Denials

http://www.lymphedemapeople.com/thesite/lymphedema_how_to_appeal_insurance_denials.htm

How to fight your insurance company

http://www.lymphedemapeople.com/forum/topic.asp?TOPIC_ID=845

State Insurance Commissioners 

http://www.lymphedemapeople.com/thesite/lymphedema_advocacy_insurance_comm.htm

Insurance Coverage for the Treatment of Lymphedema

http://www.lymphedemapeople.com/thesite/lymphedema_insurance_coverage_for_treatment.htm

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Healthcare Claims Processing Medical Bliling Errors

http://www.all-things-medical-billing.com/healthcare-claim-processing.html

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Most Common Reasons for Claims Errors

Fiscal Intermediaries (FIs) are now required to report the most common reasons for claims errors submitted by providers. Unlike denials, which must be appealed, RTP’d claims should be corrected and resubmitted. While less labor intensive than appeals, resubmissions still have a cost and affect the bottom line. We will review the top 5 reasons from one FI in the third quarter of 2004, which have various work flow implications for solving the problems.

The Common Working File (CWF) contains utilization edits performed on all incoming claims to protect the integrity and ensure the accuracy of CWF's beneficiary utilization data. Some edits require the beneficiary name submitted match exactly to the name contained on the Master Record, accessed with the Health Insurance Claim (HIC) Number. The number one reason for RTPs was the following error:

30715 THE PATIENT LAST NAME AND/OR FIRST INITIAL SUBMITTED DOES NOT MATCH THE BENEFICIARY NAME ON FILE. VERIFY NAME AND HIC NUMBER ON COMMON WORKING FILE

Another top five error, 30723, is essentially the same error after a follow up submission from providers submitting via Electronic Media Claims. For claims initially RTP’d with 30715, providers have to change the name on Claim Page 5 if they agree with the change made by FISS on Claim Page 1. If the patient’s name is not corrected, the claim will RTP to the provider with Reason Code 30723.

Clearly, these two errors are clerical in nature. Not enough attention is being paid to beneficiary Medicare cards, or the information is being entered incorrectly into the billing systems. A quality assurance program that addresses clerical accuracy is essential to avoid these costly errors.

More difficult to manage than straight forward clerical mistakes is proper chargemaster description (CDM) management. Below is a top five error related to invalid HCPCS services either based on date or associated revenue code:

32402 INVALID HCPCS CODE USED WITH THIS REVENUE CODE OR HCPCS IS NOT VALID ON THE DATE FOR WHICH THE SERVICES WERE PROVIDED.

Once a problem is remedied for any individual claim, there should be a process in place to reflect these changes back into the CDM. Related to the above error is another in the top five, 32206, which addresses inappropriate revenue code use based on bill type, insurer, or payment system:

32206 EITHER THE REVENUE CODE IS INVALID FOR THE BILL TYPE (OR) THE REVENUE CODE SHOWS COVERED CHARGES THAT ARE NOT VALID FOR THE BILL TYPE (OR) THE REVENUE CODE IS FOR SERVICES NOT COVERED BY MEDICARE (OR) THE REVENUE CODE 623 IS BILLED WITH ASC SERVICES (OR) IF REVENUE CODE 002 IS PRESENT, THIS INDICATES THAT A LINE ITEM WAS BILLED WITHOUT A REVENUE CODE.

Another aspect of CDM maintenance is making sure that services are submitted with the appropriate number of units. One top five code is related to this issue:

59101 THIS CODE MAY NOT BE BILLED MORE THAN ONE UNIT PER DAY. PLEASE MAKE THE APPROPRIATE ADJUSTMENT AND RESUBMIT THE CLAIM.

Here there is a frequency limitation of one service per day. This should be one of the easier units and frequency limitation issues to address. Again, individual claim adjustments must feedback into CDM maintenance.

The last two codes are related to the individual/patient relationship codes and are essentially the same (and actually add up to six total error codes). HIPAA was responsible for changes in patient relationship codes and apparently these have not been noted in some billing systems:

16605 INVALID PAYER ID AND PATIENT RELATIONSHIP COMBINATION.

16604 PATIENT RELATIONSHIP FOR MSP CODE IS INVALID OR INCONSISTENT WITH OTHER INFORMATION ON CLAIM.

Updating billing systems to reflect these new relationship codes is essential. The Medicare transmittal describing these changes is available at:

**Link no longer available**

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Updated/Reviewed Jan. 16, 2012