01/31/2026 Allen M. Jacobs, DPM
Dispensing Compression Garments for Lymphedema
The recent discussion of the Lymphedema Act and
the ability of the podiatric physician to be
reimbursed for the dispensing of certain products
such as compression garments as an aid for the
management of lymphedema is helpful for
understanding the economic and coding aspects of
lymphedema. However, I believe the clinical issues
discussed in this article require a more detailed
and accurate discussion.
As a student at the PCPM, I was fortunate to have
had the opportunity to study under the late
Anthony Kidawa, DPM, who attempted back in the
1970s to generate an interest in vascular disease
within the curriculum. This included venous,
arterial, and lymphatic disorders. An entire
course in peripheral vascular disease was included
within the curriculum, not only at the direction
of Dr. Kidawa, but supplemented by didactic and
clinical rotations with Andre Korman, MD, Norman
Skeversky, MD, and a vascular surgeon whose first
name escapes me but whose last name was Cohen. We
utilized one of the original textbooks on the
subject, Allen, Barker, and Hines.
As a student, I came to understand that the
evaluation and either treatment or recognition and
referral of patients with peripheral vascular
disease was an important role which we accepted as
podiatric physicians. I have practiced in that
manner for 50 years. I have long called for the
greater involvement of my podiatric colleagues in
the evaluation and local management of edema.
However, it is my general observation that the
subject of PVD (not just PAD) when discussed in
post-graduate educational programs is limited to
arterial disease recognition and referral to
vascular surgeons or interventionalists, or more
recently the ability to garner income by taking
advantage of reimbursements through the Lymphedema
Act or how to bill for CPT 93922 (one level
arterial vascular studies), or strategies for
dealing with DVT recognition and prophylaxis.
There is so much more that we can offer in primary
care podiatry to benefit our patient population.
As PM readers are aware, edema may be and
frequently is a manifestation of a systemic
disorder or generalized fluid or electrolyte
abnormality. The etiology of edema is not as
simplistic as "venous or lymphatic" as implied in
the article. Frequently, edema including
lymphedema is reactive to etiologies causing
increased hydrostatic pressure, reduced osmotic
pressure, sodium retention, or lymphatic or venous
insufficiency. These wide-ranging etiologies
include many common disorders such as CHF, thyroid
disorders, hepatic disorders, complications of
commonly prescribed medications, renal disorders,
malnutrition.
Prior to undertaking strategies to reduce
peripheral edema, the podiatric physician should
look at the medications being taken, and general
health physical health of the patient, A referral
to the primary care physician or appropriate
specialist (eg: nephrology, endocrinology) may be
necessary and in fact life-saving. While we do not
treat these disorders, you can certainly look and
ask appropriate questions. If you determine to
undertake the treatment of edema, you should
document such considerations.
With reference to the diagnosis of lymphedema, the
article refers to the classic teaching of
lymphedema versus venous insufficiency, suggesting
that it is more or less either one or the other.
In fact, this is no longer thought to be the
physiologic reality, and many more patients may
qualify for coverage under the lymphedema act than
suggested in the article. The "new" concept is
that of phlebolympedema. In many patients,
lymphedema is not secondary to disease intrinsic
to the lymphatic system but rather is secondary to
the retention of interstitial fluids from primary
venous insufficiency and the inability of an
otherwise "normal" lymphatic system to remove that
fluid. Simply stated, the normal lymphatic system
is overwhelmed by the generated fluid. It is not
secondary to primary aplasia or dysplasia or
injury or or obstruction of the lymphatics.
Many commonly prescribed drugs such as beta
blockers, cakcium channel blockers, steroids and
hormone therapies, NSAIDs, testosterone, or
medications used to treat neuropathy
(gabapentinoids, TCAs, SNRIs) may cause edema. In
addition to local treatment of the edma, a note to
the primary care physician questioning the
possible medication role in the edema is never
inappropriate and is good medicine.
From a clinical perspective, the distinguishing
features of lymphedema vs. venous insufficiency
are frequently overlapping, and hence the term
phlebolymphedea more appropriate. For example,
stage 1 and stage 2 lymphedema demonstrates a
pitting edema, indistinguishable from the pitting
edema of any etiology including venous
insufficiency. As a result, the diagnosis of
lymphedema is likely more common than considered
in practice, thus qualifying as increased subset
of patients for coverage.
With specific reference to lymphedema, treatment
is more than prescribing compression stockings. I
will frequently prescribe intermittent sequential
lymphedema pumps or similar devices, elevation,
recommend changes in life-style, increased
exercise, and weight loss when appropriate. The
evaluation of response to therapy and assessment
for any adverse sequela qualify for an E/M billing
with appropriate documentation. Similarly response
to compression garments, adherence to treatment
protocols should be documented.
Lymphedema is associated with certain complication
risks beyond the psycho-social. Increased risks of
cellulitis associated with onychomycosis and web
space infections occur with lymphedema. The
patient should be so educated and appropriate
therapy provided, again qualifying for an E/M
billing. Although less common, ulceration and
malignancy such as increased risk for
lymphangiosarcoma call for vigilance, as
lymphangiosarcoma may initially appear as simple
bruising. Other malignancies such as melanoma,
SCC, BCC also occur with increased frequency in
the patient with lymphedema/phlebolymphedema,
hence the indication for biopsy when indicated.
Additional forms of compression or referral to
lymphedema clinics may also be appropriate in
recalcitrant cases.
It has long been my position that the evaluation
and management of edema should be a part of
primary care podiatry practice, an example of
where the so called "medical" aspects of podiatry
may play an essential role in patient health. How
often do you evaluate and treat edema in the
neuropathic diabetic patient, in whom edema and/or
deformities may result in unappreciated shoe
pressure and result in ulceration. What concern do
you express with unilateral edema in the patient
with diabetes, in whom undiagnosed Charcot's joint
disease or stress/avulsion fracture or other
musculoskeletal or metabolic bone disorder is
present?
Consider phlebolymphedema in the patients whom you
evaluate to expand the benefits of the lymphedema
act to our patients. Document appropriately.
Evaluate the potential causes of edema. There is
more to the management of these patients than
dispensing covered products. Good practice
management is important, but even more important
is good medical care.
Allen M. Jacobs, DPM, St. Louis, MO
