Medicare Ostomy Supplies Coverage

he quantity of ostomy supplies needed by a beneficiary is determined primarily by the type of ostomy, its location, its construction, and the condition of the skin surface surrounding the stoma. There will be variation according to individual beneficiary need and their needs may vary over time. The table below lists the maximum number of items/units of service that are usually reasonable and necessary. The actual quantity needed for a particular beneficiary may be more or less than the amount listed depending on the factors that affect the frequency of barrier and pouch change.

 

The explanation for use of a greater quantity of supplies than the amounts listed must be clearly documented in the beneficiary’s medical record. If adequate documentation is not provided when requested, the excess quantities will be denied as not reasonable and necessary.

 

 

USUAL MAXIMUM QUANTITY OF SUPPLIES:

 

Code

# per Month

A4357

2

A4362

20

A4364

4

A4367

1

A4369

2

A4377

10

A4381

10

A4402

4

A4404

10

A4405

4

A4406

4

A4414

20

A4415

20

A4416

60

A4417

60

A4418

60

A4419

60

A4420

60

A4423

60

A4424

20

A4425

20

A4426

20

A4427

20

A4429

20

A4431

20

A4432

20

A4433

20

A4434

20

A4436

1

A4437

1

A4450

40

A4452

40

A5051

60

A5052

60

A5053

60

A5054

60

A5055

31

A5056

40

A5057

40

A5061

20

A5062

20

A5063

20

A5071

20

A5072

20

A5073

20

A5081

31

A5082

1

A5083

150

A5093

10

A5121

20

A5122

20

A5126

20

A5131

1

A6216

60

 

Code

# per 6 Months

A4361

3

A4371

10

A4398

2

A4399

2

A4455

16

A5102

2

A5120

150

 

 

When a liquid barrier is necessary, either liquid or spray (A4369) or individual wipes or swabs (A5120) are appropriate. The use of both is not reasonable and necessary.

 

Beneficiaries with continent stomas may use the following means to prevent/manage drainage: stoma cap (A5055), stoma plug (A5081), stoma absorptive cover (A5083) or gauze pads (A6216). No more than one of these types of supply would be reasonable and necessary on a given day.

 

Beneficiaries with urinary ostomies may use either a bag (A4357) or bottle (A5102) for drainage at night. It is not reasonable and necessary to have both.

 

 

GENERAL

A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving a completed SWO, the claim shall be denied as not reasonable and necessary.

For Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) base items that require a Written Order Prior to Delivery (WOPD), the supplier must have received a signed SWO before the DMEPOS item is delivered to a beneficiary. If a supplier delivers a DMEPOS item without first receiving a WOPD, the claim shall be denied as not reasonable and necessary. Refer to the LCD-related Policy Article, located at the bottom of this policy under the Related Local Coverage Documents section.

For DMEPOS base items that require a WOPD, and also require separately billed associated options, accessories, and/or supplies, the supplier must have received a WOPD which lists the base item and which may list all the associated options, accessories, and/or supplies that are separately billed prior to the delivery of the items. In this scenario, if the supplier separately bills for associated options, accessories, and/or supplies without first receiving a completed and signed WOPD of the base item prior to delivery, the claim(s) shall be denied as not reasonable and necessary.

An item/service is correctly coded when it meets all the coding guidelines listed in CMS HCPCS guidelines, LCDs, LCD-related Policy Articles, or DME MAC articles. Claims that do not meet coding guidelines shall be denied as not reasonable and necessary/incorrectly coded.

Proof of delivery (POD) is a Supplier Standard and DMEPOS suppliers are required to maintain POD documentation in their files. Proof of delivery documentation must be made available to the Medicare contractor upon request. All services that do not have appropriate proof of delivery from the supplier shall be denied as not reasonable and necessary.

 

 

REFILL REQUIREMENTS

 

For DMEPOS items and supplies provided on a recurring basis, billing must be based on prospective, not retrospective use. For DMEPOS products that are supplied as refills to the original order, suppliers must contact the beneficiary prior to dispensing the refill and not automatically ship on a pre-determined basis, even if authorized by the beneficiary. This shall be done to ensure that the refilled item remains reasonable and necessary, existing supplies are approaching exhaustion, and to confirm any changes or modifications to the order. Contact with the beneficiary or designee regarding refills must take place no sooner than 14 calendar days prior to the delivery/shipping date. For delivery of refills, the supplier must deliver the DMEPOS product no sooner than 10 calendar days prior to the end of usage for the current product. This is regardless of which delivery method is utilized.

 

For all DMEPOS items that are provided on a recurring basis, suppliers are required to have contact with the beneficiary or caregiver/designee prior to dispensing a new supply of items. Suppliers must not deliver refills without a refill request from a beneficiary. Items delivered without a valid, documented refill request will be denied as not reasonable and necessary.

 

Suppliers must not dispense a quantity of supplies exceeding a beneficiary's expected utilization. Suppliers must stay attuned to changed or atypical utilization patterns on the part of their clients. Suppliers must verify with the treating practitioners that any changed or atypical utilization is warranted.

 

Regardless of utilization, a supplier must not dispense more than a one (1) -month supply at a time for a beneficiary in a nursing facility and a three (3) -month supply for a beneficiary at home.


HCPCS CODES:

Group 1 Codes

Code

Description

A4331

EXTENSION DRAINAGE TUBING, ANY TYPE, ANY LENGTH, WITH CONNECTOR/ADAPTOR, FOR USE WITH URINARY LEG BAG OR UROSTOMY POUCH, EACH

A4357

BEDSIDE DRAINAGE BAG, DAY OR NIGHT, WITH OR WITHOUT ANTI-REFLUX DEVICE, WITH OR WITHOUT TUBE, EACH

A4361

OSTOMY FACEPLATE, EACH

A4362

SKIN BARRIER; SOLID, 4 X 4 OR EQUIVALENT; EACH

A4363

OSTOMY CLAMP, ANY TYPE, REPLACEMENT ONLY, EACH

A4364

ADHESIVE, LIQUID OR EQUAL, ANY TYPE, PER OZ

A4366

OSTOMY VENT, ANY TYPE, EACH

A4367

OSTOMY BELT, EACH

A4368

OSTOMY FILTER, ANY TYPE, EACH

A4369

OSTOMY SKIN BARRIER, LIQUID (SPRAY, BRUSH, ETC.), PER OZ

A4371

OSTOMY SKIN BARRIER, POWDER, PER OZ

A4372

OSTOMY SKIN BARRIER, SOLID 4 X 4 OR EQUIVALENT, STANDARD WEAR, WITH BUILT-IN CONVEXITY, EACH

A4373

OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE OR ACCORDION), WITH BUILT-IN CONVEXITY, ANY SIZE, EACH

A4375

OSTOMY POUCH, DRAINABLE, WITH FACEPLATE ATTACHED, PLASTIC, EACH

A4376

OSTOMY POUCH, DRAINABLE, WITH FACEPLATE ATTACHED, RUBBER, EACH

A4377

OSTOMY POUCH, DRAINABLE, FOR USE ON FACEPLATE, PLASTIC, EACH

A4378

OSTOMY POUCH, DRAINABLE, FOR USE ON FACEPLATE, RUBBER, EACH

A4379

OSTOMY POUCH, URINARY, WITH FACEPLATE ATTACHED, PLASTIC, EACH

A4380

OSTOMY POUCH, URINARY, WITH FACEPLATE ATTACHED, RUBBER, EACH

A4381

OSTOMY POUCH, URINARY, FOR USE ON FACEPLATE, PLASTIC, EACH

A4382

OSTOMY POUCH, URINARY, FOR USE ON FACEPLATE, HEAVY PLASTIC, EACH

A4383

OSTOMY POUCH, URINARY, FOR USE ON FACEPLATE, RUBBER, EACH

A4384

OSTOMY FACEPLATE EQUIVALENT, SILICONE RING, EACH

A4385

OSTOMY SKIN BARRIER, SOLID 4 X 4 OR EQUIVALENT, EXTENDED WEAR, WITHOUT BUILT-IN CONVEXITY, EACH

A4387

OSTOMY POUCH, CLOSED, WITH BARRIER ATTACHED, WITH BUILT-IN CONVEXITY (1 PIECE), EACH

A4388

OSTOMY POUCH, DRAINABLE, WITH EXTENDED WEAR BARRIER ATTACHED, (1 PIECE), EACH

A4389

OSTOMY POUCH, DRAINABLE, WITH BARRIER ATTACHED, WITH BUILT-IN CONVEXITY (1 PIECE), EACH

A4390

OSTOMY POUCH, DRAINABLE, WITH EXTENDED WEAR BARRIER ATTACHED, WITH BUILT-IN CONVEXITY (1 PIECE), EACH

A4391

OSTOMY POUCH, URINARY, WITH EXTENDED WEAR BARRIER ATTACHED (1 PIECE), EACH

A4392

OSTOMY POUCH, URINARY, WITH STANDARD WEAR BARRIER ATTACHED, WITH BUILT-IN CONVEXITY (1 PIECE), EACH

A4393

OSTOMY POUCH, URINARY, WITH EXTENDED WEAR BARRIER ATTACHED, WITH BUILT-IN CONVEXITY (1 PIECE), EACH

A4394

OSTOMY DEODORANT, WITH OR WITHOUT LUBRICANT, FOR USE IN OSTOMY POUCH, PER FLUID OUNCE

A4395

OSTOMY DEODORANT FOR USE IN OSTOMY POUCH, SOLID, PER TABLET

A4396

OSTOMY BELT WITH PERISTOMAL HERNIA SUPPORT

A4398

OSTOMY IRRIGATION SUPPLY; BAG, EACH

A4399

OSTOMY IRRIGATION SUPPLY; CONE/CATHETER, WITH OR WITHOUT BRUSH

A4402

LUBRICANT, PER OUNCE

A4404

OSTOMY RING, EACH

A4405

OSTOMY SKIN BARRIER, NON-PECTIN BASED, PASTE, PER OUNCE

A4406

OSTOMY SKIN BARRIER, PECTIN-BASED, PASTE, PER OUNCE

A4407

OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE, OR ACCORDION), EXTENDED WEAR, WITH BUILT-IN CONVEXITY, 4 X 4 INCHES OR SMALLER, EACH

A4408

OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE OR ACCORDION), EXTENDED WEAR, WITH BUILT-IN CONVEXITY, LARGER THAN 4 X 4 INCHES, EACH

A4409

OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE OR ACCORDION), EXTENDED WEAR, WITHOUT BUILT-IN CONVEXITY, 4 X 4 INCHES OR SMALLER, EACH

A4410

OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE OR ACCORDION), EXTENDED WEAR, WITHOUT BUILT-IN CONVEXITY, LARGER THAN 4 X 4 INCHES, EACH

A4411

OSTOMY SKIN BARRIER, SOLID 4 X 4 OR EQUIVALENT, EXTENDED WEAR, WITH BUILT-IN CONVEXITY, EACH

A4412

OSTOMY POUCH, DRAINABLE, HIGH OUTPUT, FOR USE ON A BARRIER WITH FLANGE (2 PIECE SYSTEM), WITHOUT FILTER, EACH

A4413

OSTOMY POUCH, DRAINABLE, HIGH OUTPUT, FOR USE ON A BARRIER WITH FLANGE (2 PIECE SYSTEM), WITH FILTER, EACH

A4414

OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE OR ACCORDION), WITHOUT BUILT-IN CONVEXITY, 4 X 4 INCHES OR SMALLER, EACH

A4415

OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE OR ACCORDION), WITHOUT BUILT-IN CONVEXITY, LARGER THAN 4 X 4 INCHES, EACH

A4416

OSTOMY POUCH, CLOSED, WITH BARRIER ATTACHED, WITH FILTER (1 PIECE), EACH

A4417

OSTOMY POUCH, CLOSED, WITH BARRIER ATTACHED, WITH BUILT-IN CONVEXITY, WITH FILTER (1 PIECE), EACH

A4418

OSTOMY POUCH, CLOSED; WITHOUT BARRIER ATTACHED, WITH FILTER (1 PIECE), EACH

A4419

OSTOMY POUCH, CLOSED; FOR USE ON BARRIER WITH NON-LOCKING FLANGE, WITH FILTER (2 PIECE), EACH

A4420

OSTOMY POUCH, CLOSED; FOR USE ON BARRIER WITH LOCKING FLANGE (2 PIECE), EACH

A4421

OSTOMY SUPPLY; MISCELLANEOUS

A4422

OSTOMY ABSORBENT MATERIAL (SHEET/PAD/CRYSTAL PACKET) FOR USE IN OSTOMY POUCH TO THICKEN LIQUID STOMAL OUTPUT, EACH

A4423

OSTOMY POUCH, CLOSED; FOR USE ON BARRIER WITH LOCKING FLANGE, WITH FILTER (2 PIECE), EACH

A4424

OSTOMY POUCH, DRAINABLE, WITH BARRIER ATTACHED, WITH FILTER (1 PIECE), EACH

A4425

OSTOMY POUCH, DRAINABLE; FOR USE ON BARRIER WITH NON-LOCKING FLANGE, WITH FILTER (2 PIECE SYSTEM), EACH

A4426

OSTOMY POUCH, DRAINABLE; FOR USE ON BARRIER WITH LOCKING FLANGE (2 PIECE SYSTEM), EACH

A4427

OSTOMY POUCH, DRAINABLE; FOR USE ON BARRIER WITH LOCKING FLANGE, WITH FILTER (2 PIECE SYSTEM), EACH

A4428

OSTOMY POUCH, URINARY, WITH EXTENDED WEAR BARRIER ATTACHED, WITH FAUCET-TYPE TAP WITH VALVE (1 PIECE), EACH

A4429

OSTOMY POUCH, URINARY, WITH BARRIER ATTACHED, WITH BUILT-IN CONVEXITY, WITH FAUCET-TYPE TAP WITH VALVE (1 PIECE), EACH

A4430

OSTOMY POUCH, URINARY, WITH EXTENDED WEAR BARRIER ATTACHED, WITH BUILT-IN CONVEXITY, WITH FAUCET-TYPE TAP WITH VALVE (1 PIECE), EACH

A4431

OSTOMY POUCH, URINARY; WITH BARRIER ATTACHED, WITH FAUCET-TYPE TAP WITH VALVE (1 PIECE), EACH

A4432

OSTOMY POUCH, URINARY; FOR USE ON BARRIER WITH NON-LOCKING FLANGE, WITH FAUCET-TYPE TAP WITH VALVE (2 PIECE), EACH

A4433

OSTOMY POUCH, URINARY; FOR USE ON BARRIER WITH LOCKING FLANGE (2 PIECE), EACH

A4434

OSTOMY POUCH, URINARY; FOR USE ON BARRIER WITH LOCKING FLANGE, WITH FAUCET-TYPE TAP WITH VALVE (2 PIECE), EACH

A4435

OSTOMY POUCH, DRAINABLE, HIGH OUTPUT, WITH EXTENDED WEAR BARRIER (ONE-PIECE SYSTEM), WITH OR WITHOUT FILTER, EACH

A4436

IRRIGATION SUPPLY; SLEEVE, REUSABLE, PER MONTH

A4437

IRRIGATION SUPPLY; SLEEVE, DISPOSABLE, PER MONTH

A4450

TAPE, NON-WATERPROOF, PER 18 SQUARE INCHES

A4452

TAPE, WATERPROOF, PER 18 SQUARE INCHES

A4455

ADHESIVE REMOVER OR SOLVENT (FOR TAPE, CEMENT OR OTHER ADHESIVE), PER OUNCE

A4456

ADHESIVE REMOVER, WIPES, ANY TYPE, EACH

A5051

OSTOMY POUCH, CLOSED; WITH BARRIER ATTACHED (1 PIECE), EACH

A5052

OSTOMY POUCH, CLOSED; WITHOUT BARRIER ATTACHED (1 PIECE), EACH

A5053

OSTOMY POUCH, CLOSED; FOR USE ON FACEPLATE, EACH

A5054

OSTOMY POUCH, CLOSED; FOR USE ON BARRIER WITH FLANGE (2 PIECE), EACH

A5055

STOMA CAP

A5056

OSTOMY POUCH, DRAINABLE, WITH EXTENDED WEAR BARRIER ATTACHED, WITH FILTER, (1 PIECE), EACH

A5057

OSTOMY POUCH, DRAINABLE, WITH EXTENDED WEAR BARRIER ATTACHED, WITH BUILT IN CONVEXITY, WITH FILTER, (1 PIECE), EACH

A5061

OSTOMY POUCH, DRAINABLE; WITH BARRIER ATTACHED, (1 PIECE), EACH

A5062

OSTOMY POUCH, DRAINABLE; WITHOUT BARRIER ATTACHED (1 PIECE), EACH

A5063

OSTOMY POUCH, DRAINABLE; FOR USE ON BARRIER WITH FLANGE (2 PIECE SYSTEM), EACH

A5071

OSTOMY POUCH, URINARY; WITH BARRIER ATTACHED (1 PIECE), EACH

A5072

OSTOMY POUCH, URINARY; WITHOUT BARRIER ATTACHED (1 PIECE), EACH

A5073

OSTOMY POUCH, URINARY; FOR USE ON BARRIER WITH FLANGE (2 PIECE), EACH

A5081

STOMA PLUG OR SEAL, ANY TYPE

A5082

CONTINENT DEVICE; CATHETER FOR CONTINENT STOMA

A5083

CONTINENT DEVICE, STOMA ABSORPTIVE COVER FOR CONTINENT STOMA

A5093

OSTOMY ACCESSORY; CONVEX INSERT

A5102

BEDSIDE DRAINAGE BOTTLE WITH OR WITHOUT TUBING, RIGID OR EXPANDABLE, EACH

A5120

SKIN BARRIER, WIPES OR SWABS, EACH

A5121

SKIN BARRIER; SOLID, 6 X 6 OR EQUIVALENT, EACH

A5122

SKIN BARRIER; SOLID, 8 X 8 OR EQUIVALENT, EACH

A5126

ADHESIVE OR NON-ADHESIVE; DISK OR FOAM PAD

A5131

APPLIANCE CLEANER, INCONTINENCE AND OSTOMY APPLIANCES, PER 16 OZ.

A6216

GAUZE, NON-IMPREGNATED, NON-STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACH DRESSING

A9270

NON-COVERED ITEM OR SERVICE


The CMS.gov website is an excellent resource for finding out about all of your options.