Medicare Changes in 2011 Relevant to Lymphedema

By Robert (Bob) Weiss, MS, LE Legislative Advocate

My column in this issue will be a change of pace from the last few issues. Certainly the item that has consumed us in the last year has been Representative Kissell's Lymphedema Diagnosis and Treatment Cost Saving Act of 2010, H.R. 4662. The revised bill that will be introduced in the 2011 session of Congress is in process while I write the column, and its status and final form are not yet known.

It is an appropriate time, however, to discuss the changes to Medicare in 2011 that will have an impact on lymphedema patients and treatment providers. Since I am not authorized to speak for Medicare or give advice on Medicare policies, billing, rules, etc., please consider the following the observations and opinions of a layman. They are meant to alert the reader of an area where there has been a change. No action should be taken before the details are verified by an authorized Medicare Contractor.

The Centers for Medicare and Medicaid Services (CMS) has long been attempting to reduce waste and fraud in Medicare payments. Their Comprehensive Error Rate Testing (CERT) program has uncovered a national paid claims error rate of 7.8% (November 2009 data) involving 24 billion dollars in claims. Coding and documentation errors such as incorrect coding, insufficient or missing documentation, and missing physician signatures have all been cited as error sources. This situation will not be improving soon for lymphedema billings and claims because of CMS's lack of action to fix inadequacies in the coding for lymphedema diagnoses, therapy, and treatment items.

Recovery of past "improper payments" of claims will be attempted by Recovery Audit Contractors (RACs) who have been contracted to identify and correct (read "collect") these "over payments." Some of the readers of this column have already been subjected to these audits.

Medicare has been computerizing the entire claims process over the last few years, and increasingly discourages submittal of paper claims. This has the great advantage of streamlining the entire system, but makes more difficult the processing of claims in non-routine areas such as lymphedema. Some of the expanded "editing" software effective in 2011 affects the ordering or referring provider and the DMEPOS (durable medical equipment, prosthetics, orthotics and supplies) supplier. The software will check each claim to ensure that the service was provided by a provider who was enrolled in Medicare and listed in a central listing (Provider Enrollment Chain and Ownership System or PECOS) and that any order or referral was within the provider's registered area of practice. The supplier is verified to be enrolled in Medicare and registered with a central DMEPOS registry.

The bottom line for the lymphedema patient is that if you wish to ever be reimbursed for your bandages and garments, make sure that the physician who writes the prescription is enrolled in Medicare and the supplier from whom you purchase is on the list of Medicare-enrolled suppliers. They are required to file a claim for your purchases, and can do so directly on the Medicare computer network. You may search to see if your provider is registered in the National Provider Register at and you may search for a Medicare supplier close to you at

The timing windows for filing claims for reimbursements for services and items have been changed by the Patient Protection and Affordable Care Act (PPACA). Claims for reimbursement for services must be filed no later than 1 year from the date of service. I would strongly suggest that every Medicare Beneficiary check his or her quarterly Medicare Summary Notice (MSN) for services or items purchased during the reported period. If they do not appear, then contact your provider or supplier to make sure that they file a claim even if they claim that "Medicare does not cover the service or item." The only way you can appeal denial of a claim is if the claim is filed within a year of the date of service.

A very disturbing change that has gone into effect this year is a change to a billing procedures called Multiple Procedure Payment Reduction (MPPR). This policy originated from a Government Accountability Office (GAO) report GAO-09-647 issued in July 2009 called MEDICARE PHYSICIAN PAYMENTS: Fees Could Better Reflect Efficiencies Achieved When Services Are Provided Together. The motivation for this study was that "Medicare's physician fees may not always reflect efficiencies that occur when a physician performs multiple services for the same patient on the same day, and some resources required for these services do not need to be duplicated." Further, "GAO recommends that the Acting Administrator, CMS, ensure that physician fees reflect efficiencies occurring when services are commonly furnished together."

CMS is adopting a MPPR policy for therapy services in 2011 in order to more appropriately recognize the efficiencies when combinations of therapy services are furnished together. The policy states that the MPPR for "always" therapy services (e, g, therapeutic exercise, manual therapy, self-care management) will reduce by 25 percent the payment for the practice expense component of the second and subsequent therapy services furnished by a single provider to a beneficiary on a single date of service. Since publication of the 2011 Medicare Physician Fee Schedule (MPFS) final rule, this policy has been modified by the Physician Payment and Therapy Relief Act of 2010. Per this Act, CMS will apply the CY 2011 MPFS final rule policy of a 25 percent MPPR to therapy services furnished in outpatient settings and a 20 percent therapy MPPR will apply to therapy services furnished in clinician's office settings.

And finally, the outpatient annual therapy caps were slightly raised from $1860 to $1870 in 2011, and the exception policy extended until December 31, 2011.

Robert "Bob" Weiss, M.S.
NLN LE Legislative Advocate