CMS Pub. 100-04, ch. 20, § 181.1

Payment for lymphedema compression treatment items is made in a lump sum payment

for standard or custom daytime gradient compression garments, nighttime gradient

compression garments, gradient compression wraps with adjustable straps, accessories

necessary for the effective use of gradient compression garments and wraps with

adjustable straps, compression bandaging supplies, and other lymphedema

compression treatment items described in section 145 of chapter15 of the Medicare

Benefit Policy Manual.

A national Medicare allowed payment amount is established for each lymphedema

compression treatment item and is updated on an annual basis. Payment is based on 80

percent of the lesser of the supplier’ s actual charge or the national Medicare allowed

payment amount for the item.

In accordance with regulations at 42 CFR §414.1660, if a new HCPCS code is added

for a lymphedema compression treatment item, CMS and/or DME MACs make efforts

to determine whether the item has a pricing history. If there is a pricing history, the

previous payment amounts for the previous code(s) are mapped to the new code(s) to

ensure continuity of pricing. When the code for an item is divided into several codes for

the components of that item, the total of the separate payment amounts established for

the components must not be higher than the payment amount for the original item.

When there is a single code that describes two or more distinct complete items (for

example, two different but related or similar items), and separate codes are

subsequently established for each item, the payment amounts that applied to the single

code continue to apply to each of the items described by the new codes. When the codes

for the components of a single item are combined in a single global code, the payment

amounts for the new code are established by totaling the payment amounts used for the

components (that is, use the total of the payment amounts for the components as the

payment amount for the global code). When the codes for several different items are

combined into a single code, the payment amounts for the new code are established

using the average (arithmetic mean), weighted by allowed services, of the payment

amounts for the formerly separate codes.

National Medicare payment amounts for new lymphedema compression treatment items

that do not have a pricing history are established using the public meeting process and

procedures described in regulations at 42 CFR §414.1670. If a new code for a

lymphedema compression treatment item that does not have a pricing history takes

effect before the national payment amount is established using the public meeting

process, until the national payment amount is established for the code/item, the DME

MACs consider what an appropriate payment amount is for the item on an individual,

claim-by-claim basis and may consider using pricing for similar items that already

have established payment amounts.