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LYMPHEDEMA PUMP EVALUATION FORM - National Rehab

LYMPHEDEMA PUMP EVALUATION FORM - National Rehab 2026

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The document is a Lymphedema Pump Evaluation Form for lower extremities, designed to collect patient information and medical history related to lymphedema treatment. It includes sections for patient details, medical history questions regarding wounds, cancer treatment, previous compression therapy usage, and physical deformities. The form also requires measurements for pump fitting and specifies the type of lymphedema pump being used, along with frequency and duration of use. Instructions for submitting the completed form are provided.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the patient's name, date, height, weight, date of birth, treating physician's name, and contact information in the designated fields.
Indicate whether the condition is bilateral, left, or right by selecting the appropriate checkbox.
Complete the patient medical history section by answering questions regarding open wounds, cancer history, previous compression therapy usage, and lymphedema status. Use checkboxes for 'Yes' or 'No' responses.
Provide detailed measurements for affected areas using a standard measuring tape. Ensure accuracy by measuring circumference and length as straight as possible.
Fill out the lymphedema pump information section by selecting the type of pump used and specifying settings and pressure levels. Indicate frequency and duration of use.
Finally, enter your name and signature along with the date to complete the form before submitting it to MPCS via fax at 1-800-749-0711.

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

How long should each lymphedema pump session be?

Use the pump for 1 hour each day, unless otherwise instructed by your therapist. At the end of day (when the swelling is at its worst) is the best time to do it, unless you are unable to work this time/duration into your schedule.

Does Medicare pay for a lymphedema pump?

Lymphedema pumps are medical devices designed to control and reduce swelling in affected body parts, usually a limb. Medicare reimburses for lymphedema pumps under three different HCPCS codes: E0650, E065 1, and E0652.

What to expect at a lymphedema appointment?

At your first visit a therapist will take your medical history, assess the affected limb, and develop a personalized treatment plan which may include manual lymphatic drainage, compression techniques, exercise recommendations, and skin care education.

What does a lymphedema evaluation consist of?

Imaging. Although lymphedema usually can be identified by history and physical examination, patients often undergo ultrasound, MRI, and/or CT prior to their referral to our center. These tests are not sensitive or specific for lymphedema and only may show skin thickening or subcutaneous edema.

What is lymphedema evaluation?

Lymphoscintigraphy. During this test, the person is injected with a radioactive dye and then scanned by a machine. The resulting images show the dye moving through the lymph vessels, highlighting blockages.

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