In this topic, the term "compression garments" is used to refer to both gradient compression garments and compression burn garments, unless otherwise stated.
For ForwardHealth reimbursement purposes, the following types of compression garments are defined below:
Non-custom gradient compression garments (for example, Jobst, SigVarus, Venes) are defined as any garment that meets the definition of a valid HCPCS procedure code and has a gradient pressure of 18 mmHg or more. Circumferential and length measurements are required for fitting. A signed and dated physician's prescription is required prior to dispensing the garment; see the Prescription Requirements section below for more information.
Allowable HCPCS procedure codes for non-custom gradient compression garments include the following: A6530–A6541, A6545, S8421, S8424, S8427, and S8428. The provider is required to use the specific code that meets the definition of the HCPCS code. For example, if a below-knee 18–30 mmHg garment is being ordered, the correct code to use is A6530.
Reimbursement for non-custom gradient compression garments includes the following:
Custom gradient compression garments are defined as garments that are uniquely sized and/or shaped and custom made to fit the exact dimensions of the affected extremity (when the body part or segment is an atypical shape) or are fabricated with a unique fabric or material, and provide accurate and consistent gradient compression to manage the member's symptoms. Providers are reminded to review the definition of non-custom gradient compression garments to determine which procedure code is allowable for reimbursement. The process of taking measurements does not in itself justify the use of a "custom" or "not otherwise specified" procedure code, as measurements are required to order any compression garment described with procedure codes A6501–A6549 and S8420–S8429. When a garment meets the description of a specific code, the provider is required to use the specific code.
Circumferential and length measurements are required for fitting. Garments with liners, zippers, or reinforced areas alone are not considered as meeting the definition of a custom gradient compression garment.
A signed and dated physician's prescription is required prior to dispensing the garment; see the Prescription Requirements section below for more information.
The following are examples of custom gradient compression garments:
Allowable HCPCS procedure codes for custom gradient compression garments include the following: A6549, S8420, S8422, S8423, S8425, and S8426.
A "custom" or "not otherwise specified" compression garment procedure code cannot be billed for any of the following alone:
Non-elastic binders (for example, CircAid, LegAssist, Reid Sleeve) are defined as garments that provide continuous compression using adjustable hook and loop or buckle straps. Circumferential and length measurements are required for fitting. A signed and dated physician's prescription is required prior to dispensing the garment; see the Prescription Requirements section below for more information.
HCPCS procedure code S8429 is allowed for non-elastic binder compression garments for upper and lower extremities.
Compression burn garments are custom compression garments that are uniquely sized and/or shaped and custom made to fit the exact dimensions of the affected extremity and provide accurate and consistent compression to manage the member's burn symptoms. Circumferential and length measurements are required for fitting. A signed and dated physician's prescription is required prior to dispensing the garment; see the Prescription Requirements section below for more information.
Providers submitting claims for compression burn garments should use the same claim instructions and follow the same claim attachment requirements as when submitting claims for not otherwise specified gradient compression garments (such as those for procedure code A6549).
Allowable HCPCS procedure codes for compression burn garments include A6501–A6513.
Over-the-counter garments are defined as any garments with a pressure less than 18 mmHg. ForwardHealth does not cover over-the-counter garments purchased with or without a prescription (for example, elastic stockings, surgical leggings, anti-embolism stockings T.E.D. hose, support hose) or garments with 15–20 mmHg or 12–15 mmHg gradient compression. If certain conditions are met, a provider may collect payment from a member for these noncovered services.
Bandages and dressings are not covered as a separately reimbursable DME service.
Medical necessity is defined in Wis Admin. Code § DHS 101.03(96m). Individually fitted prescription gradient compression garments (stockings, sleeves, gauntlets, gloves) and non-elastic binders are generally considered medically necessary and, unless the established life expectancy has been exceeded, do not require PA for members who have any of the following medical conditions:
Individually fitted prescription burn compression garments are generally considered medically necessary and, unless the established life expectancy has been exceeded, do not require PA for members who have any of the following medical conditions:
If a member has a diagnosis not included in the lists above, providers may submit a PA request to ForwardHealth. Refer to Prior Authorization for Burn and Gradient Compression Garments for more information on PA requirements.
In addition to the medical necessity requirements for gradient compression garments, non-elastic binders (for example, LegAssist, CircAid) may be additionally medically necessary for members who meet the following criteria:
The use of compression garments for members with severe peripheral arterial disease or septic phlebitis is generally contraindicated. Gradient compression garments should be used with caution in the case of decreased or absent sensation in the extremity, allergy to the compression material, moderate peripheral arterial disease, or infection in the extremity. Reimbursement for compression garments for any of these medical conditions requires submission of a PA request if one of these contraindications is present.
ForwardHealth has established a life expectancy of three garments per rolling 12-month period for all covered compression garments except compression burn garments. Providers may issue new garments only when a new garment is medically necessary. It is medically necessary to replace a garment when the garment's integrity cannot be restored or repaired. PA is not required for these garments until greater than three garments per procedure code, per rolling 12-month period, is medically necessary.
Eight compression burn garments (per body segment) are allowed without PA per rolling 12-month period when medically necessary. Coverage for a series of compression burn garments will end two years from the first DOS. If a member requires two different compression burn garments per body segment, the provider should submit both compression burn garment procedure codes on one claim with the required supporting documentation. PA is not required for these garments until greater than eight garments per procedure code, per rolling 12 months, is medically necessary.
Compression garments are reimbursable to allowable provider types when fit, ordered, and dispensed by one of the following:
A written prescription must be signed and dated by the physician and completed prior to the dispensing DOS. The physician prescription must include the following:
A verbal order is not acceptable unless it is reduced to writing, includes the elements stated above, and is valid for the DOS. A prescription is considered valid for one year from the signed date unless otherwise specified in the prescription.
A claim submitted with a physician's prescription that does not include all of the required elements may be denied or, if payment has been made, it may be recouped. The following are examples in which a claim may be denied or a payment subsequently reduced or recouped:
Providers are reminded that all claims submitted must be supported by records maintained by the provider in accordance with Wis. Admin. Code § DHS 106.02(9)(e)1. In addition, the provider record must include confirmation of delivery of the service or item to the member. For DME, the DOS is the date the item is delivered to the member.
The following POS codes are allowable for providers billing for compression garments.
| POS Code | Description |
|---|---|
| 01 | Pharmacy |
| 04 | Homeless Shelter |
| 05 | Indian Health Service Free-Standing Facility |
| 06 | Indian Health Service Provider-Based Facility |
| 07 | Tribal 638 Free-Standing Facility |
| 08 | Tribal 638 Provider-Based Facility |
| 11 | Office |
| 12 | Home |
| 13 | Assisted Living Facility |
| 14 | Group Home |
| 19 | Off Campus—Outpatient Hospital |
| 31 | Skilled Nursing Facility |
| 32 | Nursing Facility |
| 33 | Custodial Care Facility |
| 49 | Independent Clinic |
| 50 | Federally Qualified Health Center |
| 54 | Intermediate Care Facility/Individuals with Intellectual Disabilities | 72 | Rural Health Clinic |
| 99 | Other Place of Service |