Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Ostomy Supplies
Policy #:MA05.014a

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

The Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition.

MEDICALLY NECESSARY

Ostomy supplies are considered medically necessary and, therefore, covered when all of the following criteria are met:
  • The individual has a surgically created opening (stoma) to divert urine or fecal contents outside of the body.
  • The ostomy supplies replace all or part of an absent body organ or the function of a permanently inoperative or malfunctioning organ.
  • The ostomy supplies are prescribed by an eligible health care provider.
  • The ostomy supplies are supplied by an eligible ancillary provider.

NOT COVERED

A pouch cover is not covered by the Company because it is an item not covered by Medicare. Therefore, it is not eligible for reimbursement consideration.

Refer to Attachment A for a list of ostomy supplies.

The quantity of ostomy supplies needed by an individual 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 need, and individual 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 individual 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 individual’s medical record. If adequate documentation is not provided when requested, the excess quantities will be considered not medically necessary.

USUAL MAXIMUM QUANTITY OF 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
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

COLUMN I/COLUMN II REIMBURSEMENT EDITS

The reimbursement for the item(s) represented by the code(s) in column II are included in the reimbursement for the item represented by the code in column I.


Column I
Column II
A4375
A4361, A4377
A4376
A4361, A4378
A4379
A4361, A4381, A4382
A4380
A4361, A4383
A4416
A4366
A4417
A4366
A4418
A4366
A4419
A4366
A4423
A4366
A4424
A4366
A4425
A4366
A4427
A4366


REQUIRED DOCUMENTATION

The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must be maintained on file to reflect the medical necessity of the care and services provided. These medical records may include but are not limited to: records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports. This policy is consistent with Medicare's documentation requirements, including the following required documentation:

PRESCRIPTION (ORDER) REQUIREMENTS
Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete order for each item billed that is signed and dated by the professional provider who is treating the member. Requesting a provider to sign a retrospective order at the time of an audit or after an audit for submission as an original order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.

PROOF OF DELIVERY
Medical record documentation must include a contemporaneously prepared delivery confirmation or member’s receipt of supplies and equipment. The medical record documentation must include a copy of delivery confirmation if delivered by a commercial carrier and a signed copy of delivery confirmation by member/caregiver if delivered by the DME supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.

CONSUMABLE SUPPLIES
The durable medical equipment (DME) supplier must monitor the quantity of accessories and supplies an individual is actually using. Contacting the individual regarding replenishment of supplies should not be done earlier than approximately seven days prior to the delivery/shipping date. Dated documentation of this contact with the individual is required in the individual’s medical record. Delivery of the supplies should not be done earlier than approximately five days before the individual would exhaust their on-hand supply.

If required documentation is not available on file to support a claim at the time of an audit or record request, the durable medical equipment (DME) supplier may be required to reimburse the Company for overpayments.
Policy Guidelines

This policy is consistent with Medicare's coverage criteria. The Company's reimbursement methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, ostomy supplies are categorized as durable medical equipment (DME) and are covered under the member's medical benefits of the Company's Medicare Advantage products when the medical necessity criteria listed in this policy are met. However, services that are identified as noncovered are not eligible for coverage reimbursement by the Company.

Description

Ostomy is a surgical procedure used to create an exit site for a stoma (surgical opening), which is made in the small intestine, large intestine, or urinary bladder to the outside of the body.

Ostomy supplies are categorized as prosthetic devices and are used by individuals who have a stoma to divert urine, feces, or ileal contents outside of their bodies. Ostomy supplies can also be used to drain an abnormal opening or a malfunctioning organ (e.g., fistula).

Prosthetic devices replace all or part of an absent body organ or the function of a permanently inoperative or malfunctioning body organ.
References

Noridian Health Care Solutions, LLC. Local Coverage Determination (LCD) L33828 Ostomy Supplies. Revised Effective 01/01/2017. Original effective: 10/01/2015. Available at:
https://med.noridianmedicare.com/documents/2230703/7218263/Ostomy+Supplies+LCD+and+PA/cce7f3b5-3e01-4815-866a-ccdc82ae4fb0. Accessed May 20, 2019.

Noridian Health Care Solutions, LLC. Local Coverage Article. Ostomy Supplies - Policy Article (A52487). Revised Effective 01/01/2017. Original effective: 10/01/2015. https://med.noridianmedicare.com/documents/2230703/7218263/Ostomy+Supplies+LCD+and+PA/cce7f3b5-3e01-4815-866a-ccdc82ae4fb0. Accessed May 20, 2019.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

Refer to Attachment A




Revenue Code Number(s)

N/A


Misc Code

HCPCS MODIFIERS:


AU - Item furnished in conjunction with a urological, ostomy or tracheostomy supply




Coding and Billing Requirements

Ostomy clamps (A4363) are used with drainable pouches and are not used with urinary pouches. Ostomy clamps are only eligible for reimbursement when ordered as a replacement. Ostomy clamps billed with ostomy pouches are not eligible for separate reimbursement.

Cross References

Attachment A: Ostomy Supplies
Description: Ostomy Supply Codes







Policy History

MA05.014a
07/03/2019This policy was reviewed and reissued to communicate the Company's continuing position on Ostomy Supplies.
05/23/2018This policy was reviewed and reissued to communicate the Company's continuing position on ostomy supplies.
08/30/2017This policy was reviewed and reissued to communicate the Company's continuing position on ostomy supplies.
08/03/2016This policy was reviewed and reissued to communicate the Company's continuing position for ostomy supplies.
08/14/2015This policy will become effective 08/14/2015

This policy was reviewed and reissued to communicate the Company's continuing position for ostomy supplies.

ICD9 codes have been removed from the policy coding table. HCPCS code A9270 was replaced with A4421.

Revisions from MA05.014
01/01/2015This is a new policy.





Version Effective Date: 08/14/2015
Version Issued Date: 08/14/2015
Version Reissued Date: 07/03/2019