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Ostomy Supplies
MA05.014d

Policy

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.

Ostomy supplies used for conditions other than for colostomies, ileostomies or urinary ostomies are not covered by the Company because it is an item not covered by Medicare because they are being used for conditions other than a surgically created opening (stoma) to divert fecal or urine contents outside the body​.  Therefore, it is not eligible for reimbursement consideration.


FACE-TO-FACE REQUIREMENTS

As a condition for payment, a professional provider must have a face-to-face encounter with the individual for whom the item is ordered that meets all of the following requirements:

  • The treating professional provider must have an in-person encounter with the individual within the six (6) months prior to the date of the written order prior to delivery.
  • This encounter must document that the individual was evaluated and/or treated for a condition that supports the need for the item(s) of DME ordered.
A new face-to-face encounter is required each time a new
standard written order for one of the specified items is ordered. A new standard written order is required:
  • For all claims for purchases or initial rentals
  • When there is a change in the standard written order for the accessory, supply, drug, etc.
  • If periodic standard written order renewal required per medical policy
  • When an item is replaced
  • When there is a change in the supplier
In this policy the specified item is: 
CodeNarrative
A5121
Skin barrier; solid, 6x6 or equivalent, each​

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.


STANDARD WRITTEN ORDER REQUIREMENTS
Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete standard written 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 standard written order at the time of an audit or after an audit for submission as an original standard written order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.


PROOF OF DELIVERY REQUIREMENTS
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 (WHEN APPLICABLE)
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.


For specified DME items, documentation of a face-to-face encounter between the treating professional provider and the individual meeting the above requirements, including an assessment of the individual's clinical condition supporting the need for the prescribed DME item(s), must be provided to and kept on file by the DME supplier.


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.


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
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

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

BILLING REQUIREMENTS

When codes A4450, A4452, and A5120 are used with ostomy supplies, they must be billed with the AU modifier (Item furnished in conjunction with a urological, ostomy or tracheostomy supply). For this policy, codes A4450, A4452, and A5120 are the only codes for which the AU modifier may be used.

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

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

Centers for Medicare and Medicaid Services (CMS). Federal Register. Medicare Program; End-stage renal disease prospective payment system, payment for renal dialysis services furnished to individuals with acute kidney injury, end-stage renal disease quality incentive program, durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) fee schedule amounts, DMEPOS competitive bidding program (CBP) amendments, standard elements for a DMEPOS order, and master list of DMEPOS items potentially subject to a face-to-face encounter and written order prior to delivery and/or prior authorization requirements for calendar year (CY) 2022; Final Rule. [Federal Register Web site]. 01/01/2022. Available at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/DMEPOS/Downloads/FINAL-RULE-MASTER-LIST-of-DMEPOS-Subject-to-Frequent-Unnecessary-Utilization-2018-03-30.pdf. Accessed Sept​ember 28, 2022.

Noridian Health Care Solutions, LLC. Local Coverage Determination (LCD) L33828 Ostomy Supplies. [Noridian Health Care Solutions Web site]. Original: 10/01/2015. Revised: 01/01/2022. Available at: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=33828. Accessed September 28, 2022.

Noridian Health Care Solutions, LLC. Local Coverage Article. Ostomy Supplies - Policy Article (A52487). [Noridian Health Care Solutions Web site]. Original: 10/01/2015. Revised: 01/01/2022. Available at: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=52487. Accessed September 28, 2022.

Coding

CPT Procedure Code Number(s)
N/A

ICD - 10 Procedure Code Number(s)
N/A

ICD - 10 Diagnosis Code Number(s)
N/A

HCPCS Level II Code Number(s)
Refer to Attachment A.

Revenue Code Number(s)
N/A

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.

Policy History

12/5/2022
12/5/2022
MA05.014
Medical Policy Bulletin
Medicare Advantage
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No