Notification



Notification Issue Date:



Policy Attachment


Attachment to Policy # 05.00.50k


Attachment:A

Policy #:05.00.50k

Description:HCPCS Codes for Ostomy Supplies

Title:Ostomy Supplies


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.



HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS) CODES FOR OSTOMY SUPPLIES

Ostomy Supplies
Procedure Code
Narrative 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, 4x4 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 4x4 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 4x4 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, liquid, per fluid ounce
A4395
Ostomy deodorant for use in ostomy pouch, solid, per tablet
A4396
Ostomy belt with peristomal hernia support
A4397
Irrigation supply; sleeve, each
A4398
Ostomy irrigation supply; bag, each
A4399
Ostomy irrigation supply; cone/catheter, with or without brush
A4400
Ostomy irrigation set
A4402
Lubricant, per ounce
A4404
Ostomy ring, each
A4405
Ostomy skin barrier, non-pectin based, paste, per oz
A4406
Ostomy skin barrier, pectin-based, paste, per oz
A4407
Ostomy skin barrier, with flange (solid, flexible, or accordion), extended wear, with built-in convexity, 4x4 inches or smaller, each
A4408
Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, with built-in convexity, larger than 4x4 in, each
A4409
Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, without built-in convexity, 4x4 in or smaller, each
A4410
Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, without built-in convexity, larger than 4x4 in, each
A4411
Ostomy skin barrier, solid 4x4 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, 4x4 in or smaller, each
A4415
Ostomy skin barrier, with flange (solid, flexible or accordion), without built-in convexity, larger than 4x4 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
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
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, (1piece), 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

Miscellaneous Supplies
Procedure Code
Narrative Description
A4450
Tape, nonwaterproof, per 18 sq in
A4452
Tape, waterproof, per 18 sq in
A4455
Adhesive remover or solvent (for tape, cement or other adhesive), per oz
A4456
Adhesive remover, wipes, any type, each
A5120
Skin barrier, wipes or swabs, each
A5121
Skin barrier; solid, 6x6 or equivalent, each
A5122
Skin barrier; solid, 8x8 or equivalent, each
A5126
Adhesive or non-adhesive; disk or foam pad
A5131
Appliance cleaner, incontinence and ostomy appliances, per 16 oz.
A5200
Percutaneous catheter/tube anchoring device, adhesive skin attachment
A6216
Gauze, nonimpregnated, nonsterile, pad size 16 sq in or less, without adhesive border, each dressing

NON COVERED

THE FOLLOWING CODE IS USED TO REPRESENT OSTOMY POUCH COVERS:
A4421 Ostomy supply; miscellaneous



Version Effective Date: 08/14/2015
Version Issued Date: 08/14/2015
Version Reissued Date: 05/23/2018

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