Dedicated to Lymphedema Patients and the Therapists Who Treat Them
Dedicated to Lymphedema Patients and the Therapists Who Treat Them
CALL TO ACTION
IMPACT OF UPCOMING MEDICARE REIMBURSEMENT CHANGES ON LYMPHEDEMA TREATMENT PRACTICE
I have grave concerns about upcoming Medicare therapist outcome-related reimbursement changes, due as early as 2017, and their potential impact on access to timely quality treatment for lymphedema patients.
The universally accepted treatment of lymphedema, called "complex decongestive therapy" involves hands-on physical therapy performed by licensed therapists who are specially trained in lymphatic protocols. In Medicare this comprises manual lymph drainage and compression bandaging (Current Procedural Terminology® CPT code 97140*), decongestive exercises (CPT 97110), self-care management training (CPT 97535), sequential pneumatic compression device patient education (CPT 97016), and compression garment measurement and fitting (not covered)]. Therefore, Medicare treatment of beneficiaries with lymphedema, with or without functional impairment, falls within the purview of PTs, OTs and SLPs, and is reported with CPT 97xxx codes.
Lymphedema is a systemic condition that results in functional impairment when allowed to reach its later stages involving skin and tissue changes, swelling, pain and inflammation. Recent research (see references below) suggests that early treatment of lymphedema, even before it is clinically evident or disabling, can avoid vast amounts of healthcare costs. However, therapists are faced with the problem of determining the effectiveness of therapy with standardized musculoskeletal measurement tools that are insensitive to the condition being treated unless and until that condition has become serious enough to cause a functional disability. Use of "Other" G-Code sets when the condition being treated does not fall into the four function-related G-Code sets is not the entire solution to the problem. The problem is that there are no objective or subjective measurement tools accepted by APTA or AMA or CMS with which to determine severity of pre-clinical lymphedema, or effectiveness of preventive lymphedema treatment in the absence of functional disability.
Reimbursement changes from a service provided to an outcome achieved model in Medicare can only succeed when outcomes are measurable. But the outcome tools currently used in physical therapy (e.g. AM-PAC, FOTO, OPTIMAL, NOMS, Quick DASH, LEFS, etc.) are geared toward measurement of musculoskeletal disabilities, and are largely insensitive to changes in severity that might result from effective therapy of a chronic medical condition such as lymphedema in its early stage. There are a number of instruments discussed in the literature that might be appropriate for this role, e.g. the Lymphedema Life Impact Scale (LLIS) that includes a calculator for converting results to a G-code severity code. There are also new devices emerging that can measure pre-clinical lymphedema and the response to manual intervention.
And just to be clear as to the coverage by Medicare of pre-clinical lymphedema, we may note that Sec. 1862 of the Social Security Act. [42 U.S.C. 1395y] provides that payment may be made under part A or part B for any expenses incurred for items or services which are reasonable and necessary for the diagnosis or treatment of illness or injury. Furthermore, the Medicare Benefit Policy Manual CMS Pub. 100-02, Chapter 15, §220.2 states in part "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." This is certainly applicable to a progressive condition such as lymphedema, wherein sustained swelling due to lymph stasis (lymphedema) is known to produce inflammation, tissue changes including fat deposition, collagen generation leading to fibrosis, and immune system dysfunction. Therapy services are not limited to rehabilitation.
I introduced this issue to the American Lymphedema Framework Project (ALFP) at a Steering Committee meeting on August 13, 2012. The need was transmitted to the American Physical Therapy Association (APTA) who was working at that time with AMA on therapy outcomes measurement. The issue was also discussed as part of my instructional session [H7] "Unraveling the Mysteries of Insurance" at the National Lymphedema Network's 10th International Conference on September 7, 2012.
To my knowledge there are no activities in progress addressing the situation of measurement of outcomes of disease treatment when there is no disability. If this issue is not addressed, we may soon be in a situation where lymphedema therapists may no longer be reimbursed by Medicare for lymphedema services because they will have no accepted means of documenting effectiveness of therapy until the condition has been allowed to grow to an irreversible and debilitating stage, when treatment is vastly more expensive.
I believe that we are headed for a disaster for lymphedema therapists and lymphedema patients if we do not modify the current course of action in defining an outcome-related reimbursement policy for therapists. As a discussion starter, I would urge reading of my presentation "Functional outcomes measurement in the absence of disability: the lymphedema example" on my LymphActivist's Site at
I am available to consult with any non-profit individual or organization to help remedy this critical situation.
Robert Weiss, MS
Independent Lymphedema Patient Advocate
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Boccardo, F. M., Ansaldi, F., Bellini, C., Accogli, S., Taddei, G., Murdaca, G., … Campisi, C. (2009). Prospective evaluation of a prevention protocol for lymphedema following surgery for breast cancer. Lymphology, 42(1), 1–9.
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Zhang, L., Fan, A., Yan, J., He, Y., Zhang, H., Zhang, H., … Xin, M. (2016). Combining Manual Lymph Drainage with Physical Exercise after Modified Radical Mastectomy Effectively Prevents Upper Limb Lymphedema. Lymphatic Research and Biology, 00(00), lrb.2015.0036. http://doi.org/10.1089/lrb.2015.0036
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