Clinical Coverage Topics

1. What conditions must be met for massage therapy (CPT code 97124) to be covered for the treatment of lymphedema?
2. Is treatment for lymphedema via therapeutic exercises (CPT code 97110), massage therapy (CPT code 97124), and/or manual therapy (CPT code 97140) expected to continue for an indefinite period of time?
3. Does Medicare allow subsequent treatment for lymphedema after the initial treatment period has ended?
4. Can therapy for lymphedema be successful if the patient is unable to carry out the treatments at home?
5. Should the application of regular bandages (i.e., ACE wraps) used in the treatment of lymphedema be billed separately as a strapping procedure?
6. Should therapeutic exercise that is done as a component of the treatment plan for lymphedema be billed as CPT code 97140?
7. What documentation should be maintained by the provider to document the medical necessity of services performed in relation to lymphedema therapy?

1. What conditions must be met for massage therapy (CPT code 97124) to be covered for the treatment of lymphedema?

   There must be a physician documented diagnosis of lymphedema; the patient must be symptomatic for lymphedema with a limitation of function; the patient or a caregiver must have the ability to understand and comply with the home treatment regimen; and the services must be performed by a physician and/or licensed physical therapist who has received specialized training in this form of treatment.

   Date Posted: 01/07/2008

   Go to Top

2. Is treatment for lymphedema via therapeutic exercises (CPT code 97110), massage therapy (CPT code 97124), and/or manual therapy (CPT code 97140) expected to continue for an indefinite period of time?

   No.  It is expected that the physician/physical therapist treatment would last for one to two weeks, depending on the progress of the therapy.  One to two weeks should be enough time to teach and instruct the patient or patient caregiver to continue the care in the home setting.

   Date Posted: 01/07/2008

   Go to Top

3. Does Medicare allow subsequent treatment for lymphedema after the initial treatment period has ended?

   Yes.  A patient may require additional lymphedema decongestant massage following a minor event such as trauma, local infection, or therapeutic injections.  For any subsequent treatment, the same coverage criteria as that of the initial treatment must be met.

   Date Posted: 01/07/2008

   Go to Top

4. Can therapy for lymphedema be successful if the patient is unable to carry out the treatments at home?

   No.  The maximum benefits of treatment are not possible unless the patient continues treatment at home. Literature supports that manual lymphedema therapy is effective when performed for one hour three times per week.

   Date Posted: 01/07/2008

   Go to Top

5. Should the application of regular bandages (i.e., ACE wraps) used in the treatment of lymphedema be billed separately as a strapping procedure?

   No.  Regular bandages such as ACE wraps are not to be billed as a strapping procedure (i.e., Unna boot- CPT code 29580). An Unna boot cannot be applied or removed by the patient in the home setting.

   Date Posted: 01/07/2008

   Go to Top

6. Should therapeutic exercise that is done as a component of the treatment plan for lymphedema be billed as CPT code 97140?

   No.   Therapeutic exercise performed as part of the treatment plan for lymphedema should be billed using CPT code 97110, which includes the education on the exercise program to the patient and/or caregiver. 

   Therapeutic exercise is considered reasonable and necessary if the patient is having weakness, pain, contracture, stiffness (secondary to coordination deficits, spasticity, or injury), abnormal posture, muscle imbalance or the patient needs to improve mobility, stretching, strengthening, coordination, control of extremities, dexterity, range of motion, or endurance. At least one of these conditions must be present and documented in the medical records. Documentation for therapeutic exercise must show objective functional loss of joint motion, strength, mobility (e.g., degrees of motion, strength grades, and levels of assistance) and endurance.

   Date Posted: 01/07/2008

   Go to Top

7. What documentation should be maintained by the provider to document the medical necessity of services performed in relation to lymphedema therapy?

   The following information should be maintained by the provider to document the medical necessity of services for lymphedema:

   • a physician documented diagnosis of lymphedema; 
   • a statement as to the ability of the patient/caregiver to follow through with the continuation of treatment on a long term home treatment plan;a history and physical which addresses the cause of the lymphedema and any prior treatment;
   • symptoms that necessitate treatment;
   • measurement of the body part/extremity prior to treatment;
   • report of the progress of the therapy including additional measurements, expected outcome of treatment and the expected duration of treatment; and
   • response of the patient/caregiver to education and their ability to take over the responsibilities of the treatments.

   Date Posted: 01/07/2008

   Go to Top