Suppliers will need CMS-Deemed DMEPOS Accreditation to be eligible for Medicare reimbursement.
By: JaNay Covin, MPH – Legislative & Advocacy Affairs Specialist, BOC
On January 1, 2024, Medicare Part B coverage will include a new benefit category specifically tailored for lymphedema compression treatment items. This is a win for patients with this condition and the providers who care for them. Here’s what you need to know about the coverage expansion:
Lymphedema Product Coverage
- New Benefit Category: Medicare Part B will cover lymphedema compression treatment items including: standard and custom-fitted gradient compression garments, wraps, compression bandaging systems, and related accessories.
- Eligibility: Medicare Part B coverage is available to patients diagnosed with lymphedema and prescribed these items by certain healthcare professionals.
- What’s Covered: The coverage includes custom- and standard-fit daytime and nighttime garments, gradient compression wraps with adjustable straps, bandaging supplies for all treatment phases, and various accessories such as donning aids and zippers.
- Frequency Allowances: The policy specifies the timing and cadence of allowable replacements for many products (i.e. three sets of daytime garments every six months and two sets of nighttime garments every two years,) while bandaging supplies and other accessories are subject to individual case assessment.
- Eligibility Criteria: Patients must have a lymphedema diagnosis and a prescription for the compression supplies for a supplier to dispense and be reimbursed for the items.
- Coverage Start Date: Coverage begins on January 1, 2024, with no retroactive claims allowed for items purchased or ordered before this date.
- Medicare Payment: Beginning January 1, 2024, payment will be made to enrolled Medicare DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies) suppliers. The payment rate is 80% of the lesser of the actual charge, or a set payment amount calculated as the average Medicaid fee schedule amount plus 20%. If Medicaid data is not available, average internet prices or TRICARE rates will be used. CMS will issue a fee schedule to clarify payments.
- Annual Adjustments: Payment amounts will be adjusted annually based on the Consumer Price Index for Urban Consumers (CPI-U) percentage change. Updates will be made through the HCPCS (Healthcare Common Procedure Coding System) process as new items are introduced.
Coding and Reimbursement Rates
- New Codes: 57 new codes, specific to lymphedema compression supplies, will be introduced, bringing the total to 78 codes for lymphedema/compression.
- Future Updates: The list of codes and corresponding reimbursement rates will be released soon, per CMS.
Important Implications for Suppliers and Healthcare Practitioners
- Current DMEPOS Suppliers: Facilities currently enrolled in the DMEPOS benefit can add this new product category by contacting their accreditation organizations and adding the category to their CMS enrollment application.
- New Suppliers: Healthcare practitioners and others interested in providing these reimbursable products need to earn DMEPOS accreditation as part of the DMEPOS PTAN (Provider Transaction Number) process protocol.
The process of earning accreditation may be new to healthcare practitioners currently treating patients with diagnoses of lymphedema. The Board of Certification/Accreditation (BOC) is one of eight CMS-deemed accreditation organizations authorized to provide this required credential. We welcome the opportunity to guide interested practitioners/suppliers through the accreditation process. For more information visit the resource page: BOC Lymphedema/Compression Accreditation. The BOC Lymphedema/Compression Supplier Enrollment Guide outlines the steps to become a supplier so that you can offer all of the reimbursable products in the expanded Medicare Part B list to the patients in your communities.
This expansion of Medicare Part B coverage marks a significant step in providing necessary and specialized treatment for individuals with lymphedema. It ensures appropriate access, quality, and payment for these essential medical supplies, enhancing the quality of life for many.