Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Ostomy Supplies

Policy #:05.00.50k

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


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. 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.

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 Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

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

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

Pouch covers are not covered by the Company because they are not necessary for the proper functioning of the prosthetic device. Therefore, they are not eligible for reimbursement consideration.

Individual benefits for ostomy supplies must be verified, as coverage may vary by product and/or group.

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 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 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 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.
Guidelines

Precertification is not required for the purchase of ostomy supplies; however, a prescription from an eligible health care provider is required.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, ostomy supplies are covered under the medical benefits of most Company products. Individual benefits for ostomy supplies must be verified, as coverage may vary by product and/or group.

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


Company Benefit Contracts.

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 April 6, 2018.

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 April 6, 2018.





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)

See Attachment A for a list of ostomy supplies.


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References

Attachment A: Ostomy Supplies
Description: HCPCS Codes for Ostomy Supplies




Policy History

Revisions from 05.00.50k
05/23/2018This policy was reviewed and reissued to communicate the Company's continuing position on ostomy supplies.

Effective 10/05/2017 this policy has been updated to the new policy template format.
Version Effective Date: 08/14/2015
Version Issued Date: 08/14/2015
Version Reissued Date: 05/23/2018

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.