Ostomy
   For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. For the items addressed in this medical policy, the criteria for "reasonable and necessary" are defined by the following indications and limitations of coverage and/or medical necessity.

For an item to be covered by Medicare, a written signed and dated order must be received by the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving the completed order, the item will be denied as not medically necessary.

The quantity of ostomy supplies needed by a patient 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 patient need and their needs may vary over time. The table below lists the maximum number of items/units of service that are usually medically necessary. The actual quantity needed for a particular patient may be more or less than the amount listed depending on the factors that affect the frequency of barrier and pouch change.

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

USUAL MAXIMUM QUANTITY OF SUPPLIES:

Please remember to include ICD-9 and diagnosis on all orders. We are unable to bill your patients supplies without this information. Below are Medicare's guidelines for Ostomy supplies:

 
Code # per Month
A4357 2
A4362 20
A4364 4
A4367 1
A4369 2
A4377 10
A4381 10
A4397 4
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
A4450 40
A4452 40
A5051 60
A5052 60
A5053 60
A5054 60
A5055 31
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

Provision of ostomy supplies should be limited to a one-month supply for a patient in a nursing facility and a 3-month supply for a patient at home.

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

Patients 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 medically necessary on a given day.

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

HCPCS CODES:
A4331EXTENSION DRAINAGE TUBING, ANY TYPE, ANY LENGTH, WITH CONNECTOR/ADAPTOR, FOR USE WITH URINARY LEG BAG OR UROSTOMY POUCH, EACH
A4357BEDSIDE DRAINAGE BAG, DAY OR NIGHT, WITH OR WITHOUT ANTI-REFLUX DEVICE, WITH OR WITHOUT TUBE, EACH
A4361OSTOMY FACEPLATE, EACH
A4362SKIN BARRIER; SOLID, 4 X 4 OR EQUIVALENT; EACH
A4363OSTOMY CLAMP, ANY TYPE, REPLACEMENT ONLY, EACH
A4364ADHESIVE, LIQUID OR EQUAL, ANY TYPE, PER OZ
A4365ADHESIVE REMOVER WIPES, ANY TYPE, PER 50
A4366OSTOMY VENT, ANY TYPE, EACH
A4367OSTOMY BELT, EACH
A4368OSTOMY FILTER, ANY TYPE, EACH
A4369OSTOMY SKIN BARRIER, LIQUID (SPRAY, BRUSH, ETC), PER OZ
A4371OSTOMY SKIN BARRIER, POWDER, PER OZ
A4372OSTOMY SKIN BARRIER, SOLID 4X4 OR EQUIVALENT, STANDARD WEAR, WITH BUILT-IN CONVEXITY, EACH
A4373OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE OR ACCORDIAN), WITH BUILT-IN CONVEXITY, ANY SIZE, EACH
A4375OSTOMY POUCH, DRAINABLE, WITH FACEPLATE ATTACHED, PLASTIC, EACH
A4376OSTOMY POUCH, DRAINABLE, WITH FACEPLATE ATTACHED, RUBBER, EACH
A4377OSTOMY POUCH, DRAINABLE, FOR USE ON FACEPLATE, PLASTIC, EACH
A4378OSTOMY POUCH, DRAINABLE, FOR USE ON FACEPLATE, RUBBER, EACH
A4379OSTOMY POUCH, URINARY, WITH FACEPLATE ATTACHED, PLASTIC, EACH
A4380OSTOMY POUCH, URINARY, WITH FACEPLATE ATTACHED, RUBBER, EACH
A4381OSTOMY POUCH, URINARY, FOR USE ON FACEPLATE, PLASTIC, EACH
A4382OSTOMY POUCH, URINARY, FOR USE ON FACEPLATE, HEAVY PLASTIC, EACH
A4383OSTOMY POUCH, URINARY, FOR USE ON FACEPLATE, RUBBER, EACH
A4384OSTOMY FACEPLATE EQUIVALENT, SILICONE RING, EACH
A4385OSTOMY SKIN BARRIER, SOLID 4X4 OR EQUIVALENT, EXTENDED WEAR, WITHOUT BUILT-IN CONVEXITY, EACH
A4387OSTOMY POUCH, CLOSED, WITH BARRIER ATTACHED, WITH BUILT-IN CONVEXITY (1 PIECE), EACH
A4388OSTOMY POUCH, DRAINABLE, WITH EXTENDED WEAR BARRIER ATTACHED, (1 PIECE), EACH
A4389OSTOMY POUCH, DRAINABLE, WITH BARRIER ATTACHED, WITH BUILT-IN CONVEXITY (1 PIECE), EACH
A4390OSTOMY POUCH, DRAINABLE, WITH EXTENDED WEAR BARRIER ATTACHED, WITH BUILT-IN CONVEXITY (1 PIECE), EACH
A4391OSTOMY POUCH, URINARY, WITH EXTENDED WEAR BARRIER ATTACHED (1 PIECE), EACH
A4392OSTOMY POUCH, URINARY, WITH STANDARD WEAR BARRIER ATTACHED, WITH BUILT-IN CONVEXITY (1 PIECE), EACH
A4393OSTOMY POUCH, URINARY, WITH EXTENDED WEAR BARRIER ATTACHED, WITH BUILT-IN CONVEXITY (1 PIECE), EACH
A4394OSTOMY DEODORANT, WITH OR WITHOUT LUBRICANT, FOR USE IN OSTOMY POUCH, PER FLUID OUNCE
A4395OSTOMY DEODORANT FOR USE IN OSTOMY POUCH, SOLID, PER TABLET
A4396OSTOMY BELT WITH PERISTOMAL HERNIA SUPPORT
A4397IRRIGATION SUPPLY; SLEEVE, EACH
A4398OSTOMY IRRIGATION SUPPLY; BAG, EACH
A4399OSTOMY IRRIGATION SUPPLY; CONE/CATHETER, INCLUDING BRUSH
A4402LUBRICANT, PER OUNCE
A4404OSTOMY RING, EACH
A4405OSTOMY SKIN BARRIER, NON-PECTIN BASED, PASTE, PER OUNCE
A4406OSTOMY SKIN BARRIER, PECTIN-BASED, PASTE, PER OUNCE
A4407OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE, OR ACCORDION), EXTENDED WEAR, WITH BUILT-IN CONVEXITY, 4 X 4 INCHES OR SMALLER, EACH
A4408OSTOMY SKIN BARRIER, WTIH FLANGE (SOLID, FLEXIBLE OR ACCORDION), EXTENDED WEAR, WITH BUILT-IN CONVEXITY, LARGER THAN 4 X 4 INCHES, EACH
A4409OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE OR ACCORDION), EXTENDED WEAR, WITHOUT BUILT-IN CONVEXITY, 4 X 4 INCHES OR SMALLER, EACH
A4410OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE OR ACCORDION), EXTENDED WEAR, WITHOUT BUILT-IN CONVEXITY, LARGER THAN 4 X 4 INCHES, EACH
A4411OSTOMY SKIN BARRIER, SOLID 4X4 OR EQUIVALENT, EXTENDED WEAR, WITH BUILT-IN CONVEXITY, EACH
A4412OSTOMY POUCH, DRAINABLE, HIGH OUTPUT, FOR USE ON A BARRIER WITH FLANGE (2 PIECE SYSTEM), WITHOUT FILTER, EACH
A4413OSTOMY POUCH, DRAINABLE, HIGH OUTPUT, FOR USE ON A BARRIER WITH FLANGE (2 PIECE SYSTEM), WITH FILTER, EACH
A4414OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE OR ACCORDION), WITHOUT BUILT-IN CONVEXITY, 4 X 4 INCHES OR SMALLER, EACH
A4415OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE OR ACCORDION), WITHOUT BUILT-IN CONVEXITY, LARGER THAN 4X4 INCHES, EACH
A4416OSTOMY POUCH, CLOSED, WITH BARRIER ATTACHED, WITH FILTER (1 PIECE), EACH
A4417OSTOMY POUCH, CLOSED, WITH BARRIER ATTACHED, WITH BUILT-IN CONVEXITY, WITH FILTER (1 PIECE), EACH
A4418OSTOMY POUCH, CLOSED; WITHOUT BARRIER ATTACHED, WITH FILTER (1 PIECE), EACH
A4419OSTOMY POUCH, CLOSED; FOR USE ON BARRIER WITH NON-LOCKING FLANGE, WITH FILTER (2 PIECE), EACH
A4420OSTOMY POUCH, CLOSED; FOR USE ON BARRIER WITH LOCKING FLANGE (2 PIECE), EACH
A4421OSTOMY SUPPLY; MISCELLANEOUS
A4422OSTOMY ABSORBENT MATERIAL (SHEET/PAD/CRYSTAL PACKET) FOR USE IN OSTOMY POUCH TO THICKEN LIQUID STOMAL OUTPUT, EACH
A4423OSTOMY POUCH, CLOSED; FOR USE ON BARRIER WITH LOCKING FLANGE, WITH FILTER (2 PIECE), EACH
A4424OSTOMY POUCH, DRAINABLE, WITH BARRIER ATTACHED, WITH FILTER (1 PIECE), EACH
A4425OSTOMY POUCH, DRAINABLE; FOR USE ON BARRIER WITH NON-LOCKING FLANGE, WITH FILTER (2 PIECE SYSTEM), EACH
A4426OSTOMY POUCH, DRAINABLE; FOR USE ON BARRIER WITH LOCKING FLANGE (2 PIECE SYSTEM), EACH
A4427OSTOMY POUCH, DRAINABLE; FOR USE ON BARRIER WITH LOCKING FLANGE, WITH FILTER (2 PIECE SYSTEM), EACH
A4428OSTOMY POUCH, URINARY, WITH EXTENDED WEAR BARRIER ATTACHED, WITH FAUCET-TYPE TAP WITH VALVE (1 PIECE), EACH
A4429OSTOMY POUCH, URINARY, WITH BARRIER ATTACHED, WITH BUILT-IN CONVEXITY, WITH FAUCET-TYPE TAP WITH VALVE (1 PIECE), EACH
A4430OSTOMY POUCH, URINARY, WITH EXTENDED WEAR BARRIER ATTACHED, WITH BUILT-IN CONVEXITY, WITH FAUCET-TYPE TAP WITH VALVE (1 PIECE), EACH
A4431OSTOMY POUCH, URINARY; WITH BARRIER ATTACHED, WITH FAUCET-TYPE TAP WITH VALVE (1 PIECE), EACH
A4432OSTOMY POUCH, URINARY; FOR USE ON BARRIER WITH NON-LOCKING FLANGE, WITH FAUCET-TYPE TAP WITH VALVE (2 PIECE), EACH
A4433OSTOMY POUCH, URINARY; FOR USE ON BARRIER WITH LOCKING FLANGE (2 PIECE), EACH
A4434OSTOMY POUCH, URINARY; FOR USE ON BARRIER WITH LOCKING FLANGE, WITH FAUCET-TYPE TAP WITH VALVE (2 PIECE), EACH
A4450TAPE, NON-WATERPROOF, PER 18 SQUARE INCHES
A4452TAPE, WATERPROOF, PER 18 SQUARE INCHES
A4455ADHESIVE REMOVER OR SOLVENT (FOR TAPE, CEMENT OR OTHER ADHESIVE), PER OUNCE
A5051OSTOMY POUCH, CLOSED; WITH BARRIER ATTACHED (1 PIECE), EACH
A5052OSTOMY POUCH, CLOSED; WITHOUT BARRIER ATTACHED (1 PIECE), EACH
A5053OSTOMY POUCH, CLOSED; FOR USE ON FACEPLATE, EACH
A5054OSTOMY POUCH, CLOSED; FOR USE ON BARRIER WITH FLANGE (2 PIECE), EACH
A5055STOMA CAP
A5061OSTOMY POUCH, DRAINABLE; WITH BARRIER ATTACHED, (1 PIECE), EACH
A5062OSTOMY POUCH, DRAINABLE; WITHOUT BARRIER ATTACHED (1 PIECE), EACH
A5063OSTOMY POUCH, DRAINABLE; FOR USE ON BARRIER WITH FLANGE (2 PIECE SYSTEM), EACH
A5071OSTOMY POUCH, URINARY; WITH BARRIER ATTACHED (1 PIECE), EACH
A5072OSTOMY POUCH, URINARY; WITHOUT BARRIER ATTACHED (1 PIECE), EACH
A5073OSTOMY POUCH, URINARY; FOR USE ON BARRIER WITH FLANGE (2 PIECE), EACH
A5081CONTINENT DEVICE; PLUG FOR CONTINENT STOMA
A5082CONTINENT DEVICE; CATHETER FOR CONTINENT STOMA
A5083CONTINENT DEVICE, STOMA ABSORPTIVE COVER FOR CONTINENT STOMA
A5093OSTOMY ACCESSORY; CONVEX INSERT
A5102BEDSIDE DRAINAGE BOTTLE WITH OR WITHOUT TUBING, RIGID OR EXPANDABLE, EACH
A5120SKIN BARRIER, WIPES OR SWABS, EACH
A5121SKIN BARRIER; SOLID, 6 X 6 OR EQUIVALENT, EACH
A5122SKIN BARRIER; SOLID, 8 X 8 OR EQUIVALENT, EACH
A5126ADHESIVE OR NON-ADHESIVE; DISK OR FOAM PAD
A5131APPLIANCE CLEANER, INCONTINENCE AND OSTOMY APPLIANCES, PER 16 OZ.
A6216GAUZE, NON-IMPREGNATED, NON-STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACH DRESSING
A9270NON-COVERED ITEM OR SERVICE
 
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