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.
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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
