It is our intent to keep the legistative issues surrounding lymphedema in the forefront.  Because of certain Medicare rulings, total lymphedema management is jeopardized.  The following articles are presented for your review.  We encourage anyone to write to their local Congressmen/women or Representatives and ask for their support in changing the rules. 

The following articles can be found at the National Lymphedema Network (NLN, www.lymphnet.org)

• Medicare coverage of Compression Items - Jan. 2007
• Progress on the Medicare coverage Front - Oct. 2006
• Lymphedema Legislative Update - Feb 2006
• Medicare Cap Legislation Update
• Change to Medicare Reimbursement Ruling
• Lymphedema Legislative Summary - April 2005

Joanna Burgess RN, BSN (left) and Carol L. Johnson OTR/L pose with Congressman David Price, an advocate of lymphedema care who, along with other members of Congress, supports the efforts being made on the revision of congressional legislation relating to lymphedema and Medicare.

The following position paper was written by Carol L. Johnson OTR/L
Download a copy of this appeal in Adobe Acrobat format.

The appeal that is included below was written on March 28th, 2005 in response to a ruling that was adopted by Medicare on January 1, 2005 and implemented on March 1, 2005 to allow sufficient time for physicians to adjust their practices. The history behind the ruling came about as a result of Physicians employing therapists in an outpatient setting who were using Physical Therapy billing codes but who were not physical therapists; for example: “exercise physiologists, chiropractors, athletic trainers, kinesiotherapists and other individuals”. They were not working under the supervision of a Physical Therapist. The rule recognized that some of these “nontherapist health care practitioners were well –trained professionals and dedicated to the provision of quality treatment for their patients. However, their training is not in PT (Physical Therapy), OT (Occupational Therapy), or SLP (Speech and Language Pathology), but in the other disciplines for which they are licensed or accredited.” The claims were being billed as “incident to” the physician, the PT, or the OT. But “Medicare defines PT, OT and SLP as services that require the skills of a physical therapist, occupational therapist or speech-language pathologist. Therapy codes are priced based on the salaries and expenses of therapists and we expect that therapy claims are made for services of therapists.” Therefore, Nurses that are not clinical specialists or nurse practitioners (Masters level of education) and massage therapists can no longer bill Medicare for the lymphedema therapy that many been able to bill because they were working under a supervising physician, PT or OT.

Appeal to: Payor Relations Committee Report – December 2004
Medicare 2005 Physician Fee Schedule Final Rule (November 3, 2004)

Executive Summary

This appeal is written in response to a rule change in the Medicare regulations concerning the supervision of skilled health professionals working under the supervision of qualified and licensed individuals in their specialty of Medicine, Physical Therapy (PT) and Occupational Therapy (OT).

The Issue: Lymphedema patients will be denied appropriate access to skilled lymphedema massage therapy.

The Solution: Allow certified massage therapists and nurses with 135 hours of training in a certified lymphedema program to use the CPT/HCPCS Codes appropriate for the treatment of lymphedema under the Combined Decongestive Physiotherapy (CDP) codes. These specially trained personnel would work under the supervision of an OT, PT, or Physician.

Background

Lymphedema is a medical condition that causes swelling of any region of the body because of an inadequately functioning lymphatic system. Lymphedema frequently occurs in patients who have been treated for cancer involving lymph node dissection and/or radiation therapy. Lymphedema also can occur from vascular diseases, traumatic injuries, and severe infections. These are examples of secondary lymphedema or acquired lymphedema. Primary lymphedema is another edema in which there is a congenital malformation of the lymphatic system. Whatever the cause, the result is chronic edema resulting in a decreased quality of life, whether it be mild or severe. When untreated, lymphedema is frequently the cause of chronic infections (cellulitis) which requires intervention with antibiotics and at times hospitalization. Untreated lymphedema has also contributed to changes in skin quality and condition, chronic wounds, decreased mobility, disability from work, amputations and in severe cases, a devastating form of cancer, Lymphangiosarcoma.

Lymphedema in this country has been largely under-diagnosed by the medical community and is grossly mismanaged by many physicians. Lymphedema is usually a diagnosis of last resort when all other diagnoses are ruled out. Frequently patients suffer though on a very frustrating, exhaustive, and expensive hunt for the reason for their condition. Most patients will recount stories that their diagnosis was made only after being seen by multiple physicians who were either not able to make a diagnosis or employed a treatment that resulted in a catastrophic result (i.e., amputation).

Certified Lymphedema therapists significantly impact this population of patients by providing a safe and very effective treatment for this chronic condition by employing a treatment called Combined Decongestive Physiotherapy (CDP), also known as Combined Decongestive Therapy (CDT). CDP combines multiple modalities to create the best way to control and manage lymphedema. It has become the standard of care for lymphedema. This technique was started in Europe over 80 years ago by Dr. Emil Vodder. Dr. Ethel and Michael Foldi continued this work and today the best trained certified therapists in lymphedema management are certified using the Vodder and Foldi techniques. Convincing research exists to support that this is the only effective form of therapy for the treatment of lymphedema. Due to the lack of medical doctors specializing in lymphedema (Lymphologists), CDT was not recognized in the United States until approximately 1990. It was at this time that the prevalent practicing therapists in the U.S. for lymphedema were massage therapists. Even today, there are few physicians who understand the etiology and physiology of the condition. Further, most physicians are unaware that treatment is available. There are several reasons for this lack of understanding: Lymphedema is only briefly mentioned in the curricula of medical schools. Funding for research on the lymphatic system is very small. Drugs are ineffective in treating the condition. There is also a long-standing belief that nothing can be done for people who have lymphedema. Unfortunately, lymphedema tends to be treated as a quality of life issue rather than a true medical condition. Thus it has not attained a priority for treatment in the medical community. However, there is a trained and working body of therapists in the United States who have taken the initiative to gain advanced training which goes beyond the scope of their basic license as Nurses, Physical, Occupational, or Massage Therapists. Additionally, there is an even smaller number of therapists who have become nationally certified through the Lymphology Association of North America (L.A.N.A.), which standardizes the knowledge and care in the United States about lymphedema. “The Lymphology Association of North America (LANA) is a non-profit organization comprised of professionals in the field of health care: physicians, nurses, massage therapists, occupational therapists, and physical therapists who are experienced in the field of lymphology and lymphedema. These professionals have recognized the need for a national certification examination for lymphedema therapists, which test their knowledge relative to the treatment of lymphedema. This organization was established in 2002 to standardize the treatment of lymphedema and to provide the medical community a way to recognize those individuals who have met the highest standards for care. Only those who have met the strictest of training and practice are allowed to sit for the exam and to be certified as a LANA therapist. A large majority of these therapists are massage therapists and nurses.

The Issue

Billing: Medicare patients have been able to receive outpatient treatment for their lymphedema under the ICD-9 (Diagnosis) codes of 457, 457.1, and 757. The CPT/HCPCS codes applicable for use for these diagnoses are listed as codes for Complex Decongesive Physiotherapy (CDP) Massage Therapists and Nurses were authorized to use these codes prior to March 2005 if they had been working under the supervision of a physician, or, in some states, the supervision of an Occupational or Physical Therapist, depending upon their practice guidelines for their state. They were billing for services performed “Incident to” physician, physical therapy or occupational services.

As mentioned above, Physical and Occupational Therapists do not receive this specialized lymphedema training in their basic course of study, nor is it part of their basic licensure. To appropriately treat lymphedema, an OT or PT must complete advanced training in the treatment of lymphedema at one of four schools that offer this training in the United States. It should be noted that Nurses and Massage Therapists take the same advanced courses to become certified as lymphedema therapists (CLT). To date, there are not enough PT’s and OT’s who have had advanced training in the treatment of lymphedema. But yet by virtue of having a degree and license in OT or PT, they can bill for lymphedema care using these codes and be reimbursed for their services. It is dangerous for the lymphedema patient to be treated by therapists who are not certified to do this work.

Changes to billing guidelines: In summary:
The Centers for Medicare and Medicaid Services (CMS) released the final rule for the Medicare 2005 physician fee schedule on November 3, 2004. This rule was to take effect on January 1, 2005 . To allow sufficient time for physicians to adjust their practices, CMS delayed implementation of the policy until manual instructions were published on or after March 1, 2005.

The final rule will prevent the billing for services when Nurses or Massage Therapists perform Combined Decongestive Therapy using manual therapy and bandaging codes for billing even when they are supervised by a physician or Occupational Therapist. The position of CMS is that those therapists who are not OTs or PTs are trained in other disciplines for which they are licensed or accredited. “Medicare defines PT (and) OT… as services that require the skills of a physical therapist or an occupational therapist. Therapy codes are priced based on the salaries and expenses of therapists and they expect that therapy claims are made for services of therapists.”

In this very specialized area of therapy, where the vast majority of OTs and PTs don’t have the skills to perform this treatment because it is not part of the basic license, an exception should be made to allow Massage Therapists and Nurses with specialized training in CDT to continue to bill for their services as “incident to” occupational or physical therapy or physician services. The massage therapists and nurses do not and are not to perform therapy beyond the scope of the lymphedema diagnosis.

Because there is a small workforce of qualified therapists available to do this work in the U.S., this Medicare Rule severely restricts the availability of adequate lymphedema health care to our senior citizens, penalizes the therapists who have made it their ambition to care for this very underserved population of patients, and will undoubtedly increase the complications, infections, hospitalizations, and costs to patients when they cannot find therapists to treat them or when they received inappropriate therapies. When treatment is available and performed correctly, it decreases swelling, infections, wounds, amputations, and hospitalization; it decreases medical costs; and improves the quality of life.
Isn’t this to the benefit of our Medicare system? In the long run, Medicare will pay more for patients who have received no treatment or inappropriate treatment.

Solution

Pass a Federal bill or amendment that would change the Medicare 2005 Physician Fee Schedule Final Rule to allow Certified Massage Therapists and Nurses who have at least 135 hours of training in a certified lymphedema program to use the CPT/HCPCS Codes appropriate for the treatment of lymphedema under the Combined Decongestive Physiotherapy (CDP) codes. The bill or amendment would stipulate that the certified lymphedema therapists are to be closely supervised (in the same physical location and be available for immediate physical intervention within the service delivery site) by a physician, Certified Physical or Occupational Therapist in Lymphedema treatment and management and be allowed to use “incident to” services for their billing.

Summary

Massage Therapists and Nurses are part of a very small workforce in this country who have specialized in the treatment of lymphedema. The new ruling from Medicare on the 2005 Physician Fee Schedule on November 3, 2004 (effective March 1, 2005) will severely impact the delivery of quality health services for lymphedema patients in the United States. With the close supervision of Massage Therapists and Nurses by physicians, Certified in the treatment of lymphedema, PT’s, or OT’s, using the billing codes designated for OT and PTs, this segment of health professionals can continue to meet the needs for underserved population of patients.

Lymphedema in this country is a condition that is poorly diagnosed. It is a treatable condition. Lymphedema is costly to the Medicare program when not treated properly and affects millions of people who have cancer, venous diseases, traumatic injury, and even congenital abnormalities. Proper healthcare delivery is vital, Economic considerations are paramount in caring for our senior citizens, and the Medicare system will benefit from allowing Nurses and Massage Therapists to continue to care for senior citizens with lymphedema.

Prepared by:
Carol L. Johnson OTR/L LANA
(919) 493-1170
lymflo@aol.com

For information on legislation related to Lymphedema, visit www.lymphedema-legislation.com.

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