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.
| Procedure Code | Claim Attachment?1 | RT and/or LT Modifier Required? | Reorder (RA) Modifier?2 |
Allowable ICD Diagnosis Codes Without Prior Authorization3 | |
| A6501 |
Yes |
No | Yes | T30.0, T30.4 | |
| A6502 |
Yes |
No | Yes | T20.00XA*–T20.79XS* (Excluding codes with "9" as the sixth character), T26.21XA*–T26.22XS*, T26.41XA*–T26.42XS* | |
| A6503 |
Yes |
No | Yes | T20.00XA*–T20.79XS* (Excluding codes with "9" as the sixth character), T26.21XA*–T26.22XS*, T26.41XA*–T26.42XS*, T26.51XA*–T26.52XS* | |
| A6504 |
Yes |
Yes | Yes | T23.001A*–T23.792S* (Excluding codes with "9" as the sixth character) | |
| A6505 |
Yes |
Yes | Yes | T22.00XA*–T22.092S* (Excluding codes with "9" as the sixth character), T22.111A*–T22.192S* (Excluding codes with "9" as the sixth character), T22.211A*–T22.493S* (Excluding codes with "9" as the sixth character), T22.511A*–T22.592S* (Excluding codes with "9" as the sixth character), T22.611A*–T23.792S* (Excluding codes with "9" as the sixth character) | |
| A6506 |
Yes |
Yes | Yes | T22.00XA*–T22.092S* (Excluding codes with "9" as the sixth character), T22.111A*–T22.192S* (Excluding codes with "9" as the sixth character), T22.211A*–T22.493S* (Excluding codes with "9" as the sixth character), T22.511A*–T22.592S* (Excluding codes with "9" as the sixth character), T22.611A*–T23.792S* (Excluding codes with "9" as the sixth character) | |
| A6507 |
Yes |
Yes | Yes | T24.001A*–T25.792S* (Excluding codes with "9" as the sixth character) | |
| A6508 |
Yes |
Yes | Yes | T24.001A*–T25.792S* (Excluding codes with "9" as the sixth character) | |
| A6509 |
Yes |
No | Yes | T21.00XA*–T21.79XS* | |
| A6510 |
Yes |
No | Yes | T21.00XA*–T22.099S*, T22.10XA*–T22.392S* (Excluding codes with "9" as the sixth character), T22.40XA*–T22.499S*, T22.50XA*–T22.792S* (Excluding codes with "9" as the sixth character) | |
| A6511 |
Yes |
No | Yes | T21.30XA*–T21.39XS*, T21.70XA*–T21.79XS* | |
| A6512 |
Yes |
No | Yes | T30.0, T30.4 | |
| A6513 |
Yes |
No | Yes | T20.00XA*–T20.79XS* (Excluding codes with "9" as the sixth character), T26.01XA*–T26.02XS*, T26.21XA*–T26.22XS*, T26.41XA*–T26.42XS*, T26.51XA*–T26.52XS* | |
| A6530 |
No |
Yes | No | I70.231–I70.249, I70.331–I70.349, I70.431–I70.449, I70.531–I70.549, I70.631–I70.649, I70.731–I70.749, I83.011–I83.029, I83.11–I83.12, I83.211–I83.813, I83.891–I83.893, I83.91–I83.93, I87.001–I87.093 (Excluding codes with "9" as the sixth character), I89.0, L97.111–L97.129, L97.211–L97.229, L97.311–L97.329, L97.411–L97.429, L97.511–L97.529, L97.811–L97.829, L97.911–L97.929, O12.00, O12.20, O26.00, Q82.0 | |
| A6531 |
No |
Yes | No | I70.231–I70.249, I70.331–I70.349, I70.431–I70.449, I70.531–I70.549, I70.631–I70.649, I70.731–I70.749, I83.011–I83.029, I83.11–I83.12, I83.211–I83.813, I83.891–I83.893, I83.91–I83.93, I87.001–I87.093 (Excluding codes with "9" as the sixth character), I89.0, L97.111–L97.129, L97.211–L97.229, L97.311–L97.329, L97.411–L97.429, L97.511–L97.529, L97.811–L97.829, L97.911–L97.929, O12.00, O12.20, O26.00, Q82.0 | |
| A6532 |
No |
Yes | No | I70.231–I70.249, I70.331–I70.349, I70.431–I70.449, I70.531–I70.549, I70.631–I70.649, I70.731–I70.749, I83.011–I83.029, I83.11–I83.12, I83.211–I83.813, I83.891–I83.893, I83.91–I83.93, I87.001–I87.093 (Excluding codes with "9" as the sixth character), I89.0, L97.111–L97.129, L97.211–L97.229, L97.311–L97.329, L97.411–L97.429, L97.511–L97.529, L97.811–L97.829, L97.911–L97.929, O12.00, O12.20, O26.00, Q82.0 | |
| A6533 |
No |
Yes | No | I70.231–I70.249, I70.331–I70.349, I70.431–I70.449, I70.531–I70.549, I70.631–I70.649, I70.731–I70.749, I83.011–I83.029, I83.11–I83.12, I83.211–I83.813, I83.891–I83.893, I83.91–I83.93, I87.001–I87.093 (Excluding codes with "9" as the sixth character), I89.0, L97.111–L97.129, L97.211–L97.229, L97.311–L97.329, L97.411–L97.429, L97.511–L97.529, L97.811–L97.829, L97.911–L97.929, O12.00, O12.20, O26.00, Q82.0 | |
| A6534 |
No |
Yes | No | I70.231–I70.249, I70.331–I70.349, I70.431–I70.449, I70.531–I70.549, I70.631–I70.649, I70.731–I70.749, I83.011–I83.029, I83.11–I83.12, I83.211–I83.813, I83.891–I83.893, I83.91–I83.93, I87.001–I87.093 (Excluding codes with "9" as the sixth character), I89.0, L97.111–L97.129, L97.211–L97.229, L97.311–L97.329, L97.411–L97.429, L97.511–L97.529, L97.811–L97.829, L97.911–L97.929, O12.00, O12.20, O26.00, Q82.0 | |
| A6535 |
No |
Yes | No | I70.231–I70.249, I70.331–I70.349, I70.431–I70.449, I70.531–I70.549, I70.631–I70.649, I70.731–I70.749, I83.011–I83.029, I83.11–I83.12, I83.211–I83.813, I83.891–I83.893, I83.91–I83.93, I87.001–I87.093 (Excluding codes with "9" as the sixth character), I89.0, L97.111–L97.129, L97.211–L97.229, L97.311–L97.329, L97.411–L97.429, L97.511–L97.529, L97.811–L97.829, L97.911–L97.929, O12.00, O12.20, O26.00, Q82.0 | |
| A6536 |
No |
Yes | No | I70.231–I70.249, I70.331–I70.349, I70.431–I70.449, I70.531–I70.549, I70.631–I70.649, I70.731–I70.749, I83.011–I83.029, I83.11–I83.12, I83.211–I83.813, I83.891–I83.893, I83.91–I83.93, I87.001–I87.093 (Excluding codes with "9" as the sixth character), I89.0, L97.111–L97.129, L97.211–L97.229, L97.311–L97.329, L97.411–L97.429, L97.511–L97.529, L97.811–L97.829, L97.911–L97.929, O12.00, O12.20, O26.00, Q82.0 | |
| A6537 |
No |
Yes | No | I70.231–I70.249, I70.331–I70.349, I70.431–I70.449, I70.531–I70.549, I70.631–I70.649, I70.731–I70.749, I83.011–I83.029, I83.11–I83.12, I83.211–I83.813, I83.891–I83.893, I83.91–I83.93, I87.001–I87.093 (Excluding codes with "9" as the sixth character), I89.0, L97.111–L97.129, L97.211–L97.229, L97.311–L97.329, L97.411–L97.429, L97.511–L97.529, L97.811–L97.829, L97.911–L97.929, O12.00, O12.20, O26.00, Q82.0 | |
| A6538 |
No |
Yes | No | I70.231–I70.249, I70.331–I70.349, I70.431–I70.449, I70.531–I70.549, I70.631–I70.649, I70.731–I70.749, I83.011–I83.029, I83.11–I83.12, I83.211–I83.813, I83.891–I83.893, I83.91–I83.93, I87.001–I87.093 (Excluding codes with "9" as the sixth character), I89.0, L97.111–L97.129, L97.211–L97.229, L97.311–L97.329, L97.411–L97.429, L97.511–L97.529, L97.811–L97.829, L97.911–L97.929, O12.00, O12.20, O26.00, Q82.0 | |
| A6539 |
No |
No | No | I83.019, I83.029, I86.1–I86.3, I87.2, I89.0, O12.01–O12.03, O12.21–O12.23, O26.01–O26.03, Q82.0 | |
| A6540 |
No |
No | No | I83.019, I83.029, I86.1–I86.3, I87.2, I89.0, O12.01–O12.03, O12.21–O12.23, O26.01–O26.03, Q82.0 | |
| A6541 |
No |
No | No | I83.019, I83.029, I86.1–I86.3, I87.2, I89.0, O12.01–O12.03, O12.21–O12.23, O26.01–O26.03, Q82.0 | |
| A6545 |
Yes |
Yes | Yes | I83.019, I83.029, I86.1–I86.3, I87.2, I89.0, O12.01–O12.03, O12.21–O12.23, O26.01–O26.03, Q82.0 | |
| A6549 |
Yes |
Yes | Yes | I83.019, I83.029, I86.1–I86.3, I87.2, I89.0, O12.01–O12.03, O12.21–O12.23, O26.01–O26.03, Q82.0 | |
| S8420 |
Yes |
Yes |
Yes |
I97.2 |
|
| S8421 |
No |
Yes |
No |
I97.2 |
|
| S8422 |
Yes |
Yes |
Yes |
I97.2 |
|
| S8423 |
Yes |
Yes |
Yes |
I97.2 |
|
| S8424 |
No |
Yes |
No |
I97.2 |
|
| S8425 |
Yes |
Yes |
Yes |
I97.2 |
|
| S8426 |
Yes |
Yes |
Yes |
I97.2 |
|
| S8427 |
No |
Yes |
No |
I97.2 |
|
| S8428 |
No |
Yes |
No |
I97.2 |
|
| S8429 |
Yes |
Yes |
Yes |
I83.011–I83.029, I83.11, I83.12, I83.211–I83.812, I83.891–I83.893, I83.91–I83.93, I86.1–I86.3, I87.001–I87.093 (Excluding codes with "9" as the sixth character), I87.2, I87.9, I89.0, I97.2, O12.01–O12.03, O12.21–O12.23, O26.01–O26.03, Q82.0 |
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).