DMEPOS Mini-Series #2 – Ostomy Supplies

PAAS National® often sees recoupments on ostomy supplies due to unsupported medical records. Insufficient documentation accounted for 86.8% of improper payments for ostomy supplies in 2019, around $65.5 million. Please see the tips provided below to help ensure Medicare B coverage and payment for a beneficiary’s ostomy supplies.

PAAS Tips:

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  • Coverage
    • 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 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
    • Ostomy supplies are not separately payable when in a covered home health stay
  • Continued Medical Need
    • Once the initial medical need has been met, the ongoing need for ostomy supplies is assumed to be met.
    • If the beneficiary continues to meet the medical guidelines, no further documentation is required
  • Coding Guidelines
    • Diagnosis must be documented in the medical record as well as submitted on the claim for coverage consideration
    • 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
  • Covered diagnosis, Healthcare Common Procedure Coding System (HCPCS) codes, modifiers and maximum allowances per month can be found in the LCD and policy articles
  • Quantity of supplies needed depends on the type of stoma, condition of skin surface, location, and construction
  • 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
  • See the June 2022 Newsline article CGS® and Noridian Self-Service Tools and Resources for Durable Medical Equipment, Prosthetics, Orthotics and Supplies for guidance on claim status, eligibility, same or similar items and more
    • Additional Resources
      • Jurisdictions JB and JC Portal – MyCGS
      • Jurisdictions JA and JD Portal

Jennifer Ottman, CPhT
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