2024 DMEPOS Series #3: Ostomy Supplies

• Standard Written Order (SWO)
• Medical Records
  • Beneficiary must have a surgical created opening (stoma) to divert urine or fecal matter outside the body
  • The location, construction and skin condition surrounding the stoma must be discussed in the medical record
  • Diagnosis must be documented in the medical record as well as submitted on the claim for coverage consideration
  • Diagnosis driven by the type of ostomy the beneficiary has:
    • Colostomy – opening into the colon (large intestine)
    • Ileostomy – opening into abdominal wall (small intestine)
    • Urostomy – opening into abdominal wall that connects to urinary tract
  • Continued medical need can be verified by:
    • Initial medical need being met, the ongoing need for ostomy supplies is assumed to be met.
    • The beneficiary meeting the medical guidelines, no further documentation is required
  • Covered diagnoses can be found in the Local Coverage Determination (LCD) and Policy Article
• Proof of Delivery
• Proof of Refill Request and Affirmative Response
  • Required if delivered or mailed

Other considerations include:

• Ostomy supplies are not separately payable when in a covered home health stay
• Barrier (also known as a Wafer or Faceplate) – protects skin from stoma output and keeps the pouch in place
  • Solid barrier
  • Liquid barrier – liquid OR spray and individual wipes OR swabs may be used but not both
• Pouches – can be one-piece or two-piece
• Tape and adhesive – an AU (Item furnished in conjunction with a urological, ostomy, or tracheostomy supply) modifier code must be billed for tape and adhesive
• If a continent stoma:
  • use only one type of supply per day
  • can be a stoma cap, stoma plug, stoma absorptive cover or gauze pads
• Quantity of supplies needed depends on the type of stoma, condition of skin surface, location, and construction

PAAS Tips:

• If beneficiary resides in a nursing facility, pharmacies are limited to billing a one-month supply
• If beneficiary resides in their home, pharmacies can bill for a 3-month supply and will need a narrative on the claim for the 3-month supply
• Download PAAS’ Proof of Refill Request and Affirmative Response form on the Member Portal where you can document the required information from the beneficiary or their caregiver
• Review documentation checklist for Jurisdiction A and D
• Review documentation checklist for Jurisdiction B and C
• Review the following Newsline articles for additional information:
  • August 2023, Standard Written Order and Medicare Part B Audit Risks – New Guidance
  • February 2024, DMEPOS Updated Refill Request and Affirmative Response Requirements