We published the first version of this article in March 2003, based on material that James Knight distributed at our February 2003 meeting. The Medicare “fees” (allowables) changed in 2004; consequently, a copy of our 2003 article posted on our website was updated to display the 2004 rates. Those rates remained constant until 2009 when they changed again, as I discovered during a recent ostomy supply purchase. Therefore, I downloaded the current Medicare rates to prepare the updated table below. Most of these current rates are 5% higher than those established in 2004.
This table lists the HCPCS Codes and Medicare fees for ostomy products. The “fee” is the amount that Medicare considers the reasonable price for each product. This is how much the dealer gets if accepting assignment. Whether or not the dealer accepts assignment, Medicare (Part B) pays 80% of the “fee.” If the dealer takes assignment, then the patient (and any supplemental insurance) pay the other 20% of the fee. If the dealer doesn’t take assignment, the patient (and supplemental insurance) must make up the entire difference between the amount paid by Medicare and amount charged by the dealer.
These fees are for Oklahoma; some of them differ somewhat in other
states. The fees for some products haven’t been determined and are
listed as zero in the table.
| Code | Fee | Description | ||
|---|---|---|---|---|
| A4455 | $1.28 | Adhesive remover or solvent (for tape, cement or other adhesive), per ounce | ||
| A4456 | $0.26 | Adhesive remover, wipes, any type, each | ||
| A4364 | $3.08 | Adhesive, liquid or equal, any type, per oz | ||
| A5131 | $16.65 | Appliance cleaner, incontinence and ostomy appliances, per 16 oz | ||
| A4357 | $8.66 | Bedside drainage bag, day or night, with or w/o anti-reflux device, with or w/o tube, each | ||
| A5102 | $23.71 | Bedside drainage bottle with or without tubing, rigid or expandable, each | ||
| A5082 | $12.48 | Continent device; catheter for continent stoma | ||
| A5081 | $2.95 | Continent device; plug for continent stoma | ||
| A5126 | $1.18 | Adhesive or non-adhesive; disk or foam pad | ||
| A4331 | $3.34 | Extension drainage tubing, with connector/adaptor, for use with urinary leg bag or urostomy pouch | ||
| A6216 | $0.05 | Gauze, non-impregnated, non-sterile, pad size 16 sq in or less, no adhesive border, each dressing | ||
| A4400 | $51.31 | Ostomy irrigation set | ||
| A4398 | $14.50 | Ostomy irrigation supply; bag, each | ||
| A4399 | $12.87 | Ostomy irrigation supply; cone/catheter, including brush | ||
| A4397 | $4.28 | Irrigation supply; sleeve, each | ||
| A4402 | $1.46 | Lubricant, per ounce | ||
| A4422 | $0.13 | Ostomy absorbent material (sheet/pad/crystal packet) for use in pouch to thicken liquid output, each | ||
| A5093 | $1.92 | Ostomy accessory; convex insert | ||
| A4367 | $7.72 | Ostomy belt, each | ||
| A4396 | $42.50 | Ostomy belt with peristomal hernia support | ||
| A4394 | $2.71 | Ostomy deodorant, with or without lubricant, for use in pouch, per fluid ounce | ||
| A4395 | $0.05 | Ostomy deodorant for use in ostomy pouch, solid, per tablet | ||
| A4361 | $16.40 | Ostomy faceplate, each | ||
| A4384 | $10.10 | Ostomy faceplate equivalent, silicone ring, each | ||
| A4368 | $0.27 | Ostomy filter, any type, each | ||
| A5054 | $1.88 | Ostomy pouch, closed; for use on barrier with flange (2 piece), each | ||
| A4419 | $1.83 | Ostomy pouch, closed; for use on barrier with non-locking flange, with filter (2 piece), each | ||
| A4420 | $0.00 | Ostomy pouch, closed; for use on barrier with locking flange (2 piece), each | ||
| A4423 | $1.95 | Ostomy pouch, closed; for use on barrier with locking flange, with filter (2 piece), each | ||
| A5053 | $1.56 | Ostomy pouch, closed; for use on faceplate, each | ||
| A5051 | $2.17 | Ostomy pouch, closed; with barrier attached (1 piece), each | ||
| A4417 | $3.91 | Ostomy pouch, closed, with barrier attached, with built-in convexity, with filter (1 piece), each | ||
| A4387 | $0.00 | Ostomy pouch, closed, with barrier attached, with built-in convexity (1 piece), each | ||
| A4416 | $2.89 | Ostomy pouch, closed, with barrier attached, with filter (1 piece), each | ||
| A5052 | $1.56 | Ostomy pouch, closed; without barrier attached (1 piece), each | ||
| A4418 | $1.90 | Ostomy pouch, closed; without barrier attached, with filter (1 piece), each | ||
| A5063 | $2.84 | Ostomy pouch, drainable; for use on barrier with flange (2 piece system), each | ||
| A4425 | $3.76 | Ostomy pouch, drainable; for use on barrier with non-locking flange, with filter (2 piece), each | ||
| A4426 | $2.87 | Ostomy pouch, drainable; for use on barrier with locking flange (2 piece), each | ||
| A4427 | $2.92 | Ostomy pouch, drainable; for use on barrier with locking flange, with filter (2 piece), each | ||
| A4413 | $5.78 | Ostomy pouch, drainable, high output, for use on barrier with flange (2 piece), with filter, each | ||
| A4377 | $4.50 | Ostomy pouch, drainable, for use on faceplate, plastic, each | ||
| A4375 | $18.04 | Ostomy pouch, drainable, with faceplate attached, plastic, each | ||
| A4378 | $32.29 | Ostomy pouch, drainable, for use on faceplate, rubber, each | ||
| A4376 | $49.96 | Ostomy pouch, drainable, with faceplate attached, rubber, each | ||
| A5061 | $3.70 | Ostomy pouch, drainable; with barrier attached (1 piece), each | ||
| A4389 | $6.53 | Ostomy pouch, drainable, with barrier attached, with built-in convexity (1 piece), each | ||
| A4424 | $4.99 | Ostomy pouch, drainable, with barrier attached, with filter (1 piece), each | ||
| A4388 | $4.58 | Ostomy pouch, drainable, with extended wear barrier attached (1 piece), each | ||
| A4390 | $10.09 | Ostomy pouch, drainable, with extended wear barrier attached, with built-in convexity (1 piece), each | ||
| A5062 | $2.33 | Ostomy pouch, drainable, without barrier attached (1 piece), each | ||
| A5073 | $3.32 | Ostomy pouch, urinary, for use on barrier with flange (2 piece), each | ||
| A4432 | $3.77 | Ostomy pouch, urinary, for use on barrier with non-locking flange, with faucet-type valve (2 piece), each | ||
| A4433 | $3.51 | Ostomy pouch, urinary, for use on barrier with locking flange (2 piece), each | ||
| A4434 | $3.95 | Ostomy pouch, urinary, for use on barrier with locking flange, with faucet-type valve (2 piece), each | ||
| A4382 | $25.85 | Ostomy pouch, urinary, for use on faceplate, heavy plastic, each | ||
| A4381 | $4.84 | Ostomy pouch, urinary, for use on faceplate, plastic, each | ||
| A4379 | $15.77 | Ostomy pouch, urinary, with faceplate attached, plastic, each | ||
| A4383 | $29.60 | Ostomy pouch, urinary, for use on faceplate, rubber, each | ||
| A4380 | $39.20 | Ostomy pouch, urinary, with faceplate attached, rubber, each | ||
| A5071 | $6.31 | Ostomy pouch, urinary; with barrier attached (1 piece), each | ||
| A4429 | $8.66 | Ostomy pouch, urinary, with barrier attached, with built-in convexity, with faucet-type valve (1 piece), each | ||
| A4431 | $6.53 | Ostomy pouch, urinary; with barrier attached, with faucet-type valve (1 piece), each | ||
| A4391 | $7.42 | Ostomy pouch, urinary, with extended wear barrier attached (1 piece), each | ||
| A4393 | $9.49 | Ostomy pouch, urinary, with extended wear barrier attached, with built-in convexity (1 piece), each | ||
| A4430 | $8.95 | Ostomy pouch, urinary, with extended wear barrier attached, with built-in convexity, with faucet-type valve (1 piece), each | ||
| A4428 | $6.84 | Ostomy pouch, urinary, with extended wear barrier attached, with faucet-type valve (1 piece), each | ||
| A4392 | $8.59 | Ostomy pouch, urinary, with standard wear barrier attached, with built-in convexity (1 piece), each | ||
| A5072 | $3.70 | Ostomy pouch, urinary; without barrier attached (1 piece), each | ||
| A4404 | $1.77 | Ostomy ring, each | ||
| A4421 | Ostomy supply, miscellaneous | |||
| A4405 | $3.57 | Paste, non-pectin based skin barrier, per ounce | ||
| A4406 | $6.03 | Paste, pectin-based skin barrier, per ounce | ||
| A4369 | $2.54 | Skin barrier, liquid (spray, brush, etc), per ounce | ||
| A4371 | $3.83 | Skin barrier, powder, per ounce | ||
| A4372 | $4.39 | Skin barrier, solid, 4x4 or equivalent, standard wear, with built-in convexity, each | ||
| A4385 | $5.36 | Skin barrier, solid, 4x4 or equivalent, extended wear, without built-in convexity, each | ||
| A4362 | $3.09 | Skin barrier, solid, 4x4 or equivalent, each | ||
| A5121 | $7.83 | Skin barrier, solid, 6x6 or equivalent, each | ||
| A5122 | $13.49 | Skin barrier, solid, 8x8 or equivalent, each | ||
| A5120 | $0.25 | Skin barrier, wipes or swabs, each | ||
| A4407 | $9.20 | Skin barrier, with flange (solid, flexible or accordion), extended wear, with built-in convexity, 4x4 or smaller, each | ||
| A4408 | $10.36 | Skin barrier, wtih flange (solid, flexible or accordion), extended wear, with built-in convexity, larger than 4x4, each | ||
| A4409 | $6.53 | Skin barrier, with flange (solid, flexible or accordion), extended wear, without built-in convexity, 4x4 or smaller, each | ||
| A4410 | $9.49 | Skin barrier, with flange (solid, flexible or accordion), extended wear, without built-in convexity, larger than 4x4, each | ||
| A4373 | $6.59 | Skin barrier, with flange (solid, flexible or accordian), with built-in convexity, any size, each | ||
| A4414 | $5.18 | Skin barrier, with flange (solid, flexible or accordion), without built-in convexity, 4x4 or smaller, each | ||
| A4415 | $6.30 | Skin barrier, with flange (solid, flexible or accordion), without built-in convexity, larger than 4x4, each | ||
| A5055 | $1.51 | Stoma cap | ||
| A4450 | $0.09 | Tape, non-waterproof, per 18 square inches | ||
| A4452 | $0.38 | Tape, waterproof, per 18 square inches |
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