For Dates of Service Before January 1, 2018

Requirements for Compression Garments

In this topic, the term "compression garments" is used to refer to both gradient compression garments and compression burn garments, unless otherwise stated.

The following table contains information required on claims submissions for compression garments.

¹A "Yes" in this column indicates claim attachments are required with this procedure code. Refer to the Claim Attachment Requirements section below for more information.

²A "Yes" in this column indicates the compression garment must be billed with an RA modifier if the provider is replacing the member's compression garment using measurements currently on file.

³When a member has one of the allowable diagnoses listed for the procedure code, PA is required only if the life expectancy has been exceeded. If the member has an allowable diagnosis for the requested procedure code, the diagnosis code must be entered in the claim's primary diagnosis field. If the member has a diagnosis not included in the listed allowable diagnoses, providers may submit a PA request.

*This code range requires a seventh character. These characters can be "A" for initial encounter, "D" for subsequent encounter, or "S" for sequela. This seventh character must always be preceded by six characters. If more characters are needed for the code to contain seven, an "X" should be used as a placeholder (e.g., T20.00XA).

Claim Attachment Requirements

The use of a "custom" or "not otherwise specified" procedure code for a gradient compression garment on a claim should only be used in exceptional cases. For "custom" or "not otherwise specified" gradient compression garments, each attachment must document why a "custom" or "not otherwise specified" procedure code was used instead of a non-custom compression garment procedure code. All compression burn garments are considered custom and therefore also require attachments to be submitted with the claim.

When using procedure codes marked with a "Yes" under "Claim Attachment" in the table above, ForwardHealth requires the following attachments when submitting claims:

• The physician prescription. Refer to Prescription Requirements for more information.
• The form or document used to record the measurements used for the garment order/fabrication, which includes:
  • The date the measurements were taken or date(s) the measurements were re-affirmed, if applicable. If a provider re-affirms the previous measurements, ForwardHealth recommends the provider sign and date the same form used in the previous order if the previous measurements remain accurate.
  • The name and credentials of the individual taking or affirming the measurements (i.e., the certified fitter, ABC-certified orthotist or prosthetist, or licensed physical therapist or occupational therapist).
  • The provider's justification for the use of a "custom" or "not otherwise specified" procedure code. To justify use of a custom or not otherwise specified procedure code, ForwardHealth recommends identifying the extremity's circumferential measurement that did not allow fitting the member with a garment represented by a specified code by circling the measurement on the form, adding a notation in the margin of the measurement or order form, and/or including a narrative as an additional record. One example of when a custom compression garment may be justified is when the body part or segment is an atypical shape. However, a body part or segment that is simply larger than average would not justify a custom or not otherwise specified compression garment and a specified procedure code should be used on the claim (and attachments should not be submitted).
• The provider invoice with the specific garment(s) clearly identified.

Modifiers RT and LT Required on Claims

Providers are required to include modifier RT and/or LT on claims submitted for the procedure codes marked with "Yes" under "RT and/or LT Modifier Required?" in the table (A6504–A6508, A6530–A6538, A6549, and S8420–S8429). Modifier RT is used to reference a garment applied to a right extremity. Modifier LT is used to reference a garment applied to a left extremity. Procedure codes A6504–A6508, A6530–A6538, A6549, and S8420–S8429 are incomplete without modifier RT or LT.

If there is a bilateral need, providers are required to submit two separate details on claims, with modifier RT on one detail line and modifier LT on a second detail line. ForwardHealth will not accept modifier 50 (Bilateral) for processing claims for compression garments.

Claims for pantyhose, waist-high garments, vests, panties, or facial masks should not include the RT and LT modifiers.

Modifier RA for Custom Compression Garment Reorders

If a provider is replacing a member's compression garment using measurements currently on file, the provider is required to use the RA modifier. However, if the garment is being replaced based on new measurements, even if there is no change to the measurements currently on file, the providers should not use the RA modifier.

The use of the RA modifier does not change the requirement to submit supporting documentation with the claim for custom and not otherwise specified procedure codes. Refer to Claim Attachment Requirements for more information.

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.

Provider records that do not support the procedure codes listed on the claim are subject to claim denial, reduction in reimbursement, or recoupment.

Claim Submittal Recommendations

If a member requires two different compression garments per body segment, the provider should submit both compression garment procedure codes on one claim with the required supporting documentation.

If a member requires more than one compression garment (e.g., one arm, two legs, and a non-elastic wrap), the provider is urged to submit all the member's required compression garments on one claim, rather than submitting one claim for each garment. While ForwardHealth supports a provider's flexibility in submitting claims, submitting claims as suggested may reduce denials for insufficient documentation (i.e., insufficient to either support the claim or to refute the apparent duplication of services).

Refer to Prior Authorization for Burn and Gradient Compression Garments for information on PA.