2024 DMEPOS Series #3: Ostomy Supplies

Many pharmacies struggle with DMEPOS audits due to the complexity in medical billing and the onerous documentation requirements. Medicare Part B suppliers need to be able to produce all the required documentation if audited, and make sure all documentation meets Medicare Part B standards. This DMEPOS series is intended to help you understand these complexities and gather the needed documents.

In particular, you should be able to show the following if audited on ostomy supplies:

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  • 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:


Jenevra Azzopardi, CPhT