See a more recent article with updated rates for 2016.
Editor's note: This material was assembled painstakingly from Medicare publications by James Knight and distributed during his presentation on Feb 15, 1999 to the Stillwater-Ponca City (OK) UOA Chapter. This presentation on Medicare and Insurance issues was given in response to requests by chapter members who were finding it difficult to determine the Medicare limits. This article is, unfortunately, too long for our hard-copy newsletter, but we are publishing it here on our website. The allowables shown here apply specifically to Oklahoma, and may differ somewhat in other states.
Note added Nov 5, 2000: A major Medicare Policy change, effective Oct 1, 2000, has increased many of the allowed usual maximum quantities of supply, and has also relaxed the policy on use of closed pouches. Changes due to this policy shift are marked in red below.
Note added Jan 1, 2001: HCPCS codes marked in green have been updated according to a revision of HCPCS codes, effective Jan 1, 2000.
Ostomy Supplies | ||
| HCPCS Codes: | Description | Allowable |
| A4421 | Miscellaneous, Ostomy Supply | N/A |
| A6216 | Gauze Dressing, Non-sterile, 4x4 or less, without adhesive border, each | 0.05 |
| A6265 | Tape, all types, per 18 square inches | 0.12 |
| A4394 | Deodorant for use in ostomy pouch, liquid, per fluid ounce | 2.46 |
| A4395 | Deodorant for use in ostomy pouch, solid, per tablet | 0.05 |
| A5131 | Cleaner, incontinence and ostomy appliances, per 16 ounces | 15.13 |
| A4402 | Lubricant, per ounce | 1.32 |
| A5093 | Inserts, convex, each | 1.75 |
| A4367 | Belt, each | 7.01 |
| A4368 | Filter, any type, each | 0.25 |
| A4404 | Rings, each | 1.61 |
| A4397 | Irrigation Sleeve, each | 3.88 |
| A4398 | Irrigation Bag, each | 13.17 |
| A4399 | Irrigation Cone/Catheter, Including Brush | 11.70 |
| A4364 | Adhesive; Liquid (Spray, Brush, etc.), cement, powder or Paste; per ounce | 2.80 |
| A5126 | Adhesive; Disc or Foam pad, each | 1.07 |
| A4365 | Adhesive remover wipes, per Box of 50's | 10.80 |
| A4455 | Adhesive remover or solvent (for tape, cement or other adhesive), per ounce | 1.16 |
| A5055 | Stoma Cap, each | 1.37 |
| A4361 | Faceplate, each | 14.89 |
| A4384 | Faceplate equivalent, silicone ring, each | 9.18 |
| A4369 | Skin Barrier; liquid ( spray, brush, etc.) per ounce | 2.30 |
| A4370 | Skin Barrier; paste, per ounce | 3.27 |
| A4371 | Skin Barrier, powder, per ounce | 3.48 |
| A5119 | Skin Barrier; wipes per Box of 50's | 9.81 |
| A4362 | Skin Barrier; solid, 4x4 or equivalent, each | 2.81 |
| A4372 | Skin Barrier, solid, 4x4 or equivalent, standard wear, with built-in convexity, each | 3.98 |
| A4385 | Skin Barrier, solid, 4x4 or equivalent, extended wear, without built-in convexity, each | 4.86 |
| A5121 | Skin Barrier, solid, 6x6 or equivalent, each | 7.12 |
| A5122 | Skin Barrier, solid, 8x8 or equivalent, each | 12.26 |
| A5123 | Skin Barrier, with flange, standard wear without built-in convexity, each | 5.41 |
| A4373 | Skin Barrier, with flange, standard wear, with built-in convexity, each | 5.99 |
| A4386 | Skin Barrier, with flange, extended wear, without built-in convexity, each | 6.41 |
| A4374 | Skin Barrier; with flange, extended wear, with built-in convexity, each | 8.05 |
| A4387 | Pouch, closed, standard wear barrier attached, with built-in convexity (1 pcs), each | 3.83 |
| A5051 | Pouch, closed; standard wear barrier attached ( 1 pcs), each | 2.21 |
| A5052 | Pouch, closed; without Barrier attached ( 1 pcs), each | 1.54 |
| A5053 | Pouch, closed; for use on faceplate, each | 1.41 |
| A5054 | Pouch, closed; for use on barrier with flange (2 pcs), each | 1.37 |
| A5061 | Pouch, drainable, standard wear barrier attached, ( 1 pcs), each | 2.58 |
| A4389 | Pouch, drainable, standard wear barrier attached, with built-in convexity (1 pcs), each | 5.93 |
| A4388 | Pouch, drainable, extended wear barrier attached, without convexity (1 pcs),each | 4.16 |
| A4390 | Pouch, drainable, extended wear barrier attached, with built-in convexity ( 1 pcs),each | 9.17 |
| A5062 | Pouch, drainable; without barrier attached (1 pcs), each | 2.12 |
| A5063 | Pouch, drainable; for use on barrier with flange ( 2 pcs), each | 2.13 |
| A4375 | Pouch, drainable, with faceplate attached, plastic, each | 16.38 |
| A4376 | Pouch, drainable, with faceplate attached, rubber, each | 45.38 |
| A4377 | Pouch, drainable, for use on faceplate, plastic, each | 4.09 |
| A4378 | Pouch, drainable, for use on faceplate, rubber, each | 29.33 |
| A5071 | Pouch, urinary; standard wear barrier attached, ( 1 pcs), each | 4.15 |
| A4392 | Pouch, urinary, standard wear barrier attached, with built-in convexity (1 pcs) | 6.34 |
| A4391 | Pouch, urinary, extended wear barrier attached, without built-in convexity (1 pcs) | 6.74 |
| A4393 | Pouch, urinary, extended wear barrier attached, with built-in convexity (1 pcs) | 8.75 |
| A5072 | Pouch, urinary; without barrier attached (1 Piece), each | 3.36 |
| A5073 | Pouch, urinary; for use on barrier with flange ( 2 Piece), each | 3.02 |
| A4379 | Pouch, urinary, with faceplate attached; plastic, each | 14.33 |
| A4380 | Pouch, urinary, with faceplate attached, rubber, each | 35.60 |
| A4381 | Pouch, urinary, for use on faceplate, plastic, each | 4.40 |
| A4382 | Pouch, urinary, for use on faceplate, heavy plastic, each | 23.48 |
| A4383 | Pouch, urinary, for use on faceplate, rubber, each | 26.89 |
| A4357 | Drainage bag, with or without anti-flux device, each | 7.86 |
| A5102 | Drainage bottle; rigid or expandable, each | 21.53 |
| K0280 | Drainage tubing, with connector/adapter, for urostomy pouch, each | 3.04 |
| A5081 | Continent device; Plug for contient stoma, each | 2.67 |
| A5082 | Continent device; Catheter for continent stoma, each | 11.34 |
Ostomy supplies are covered for use on patients with a surgically created opening (stoma) to divert urine, feces or ileal contents outside the body.
The quantity of ostomy supplies needed by a patient is determined to a
great extent by the type of ostomy, its location, its construction, and
the condition of the skin surface surrounding the stoma. There will be
variation according to individual patient need. The table below lists the
maximum number of items/units of service that are usually medically
necessary. The actual quantity needed by a particular patient may be more
or less than the amount listed depending on the factors that affect the
frequency of barrier and pouch change. The medical necessity for use of a
greater quantity of supplies than the amount listed must be well
documented in the patient's medical record and may be requested by
Medicare and/or Insurances. (Note: The number listed in the table refers to
the number of units of service provided. For example for
A4370, 4 per month represents two
Note: Quantities in red have been revised according to Medicare Policy Change effective Oct 1, 2000 which has increased many of the allowed usual maximum quantities.
There is seldom medical necessity for closed colostomy or ileostomy pouches (A5051-A5054, A4387) rather than drainable pouches (A5061-A5063, A4375-A4378, A4388-A4390). The medical necessity for a closed pouch must be well documented in patient's medical record and may be requested by Medicare and/or Insurances. (These restrictions on use of closed pouches have been rescinded, according to the Medicare Policy Change effective Oct 1, 2000.)
When a liquid barrier is necessary, either liquid or spray (A4369) or individual wipes (A5119) is appropriate. The use of both is not medically necessary.
Patients with continent stomas may use the following means to prevent/manage drainage: stoma cap (A5055), stoma plug (A5081) or gauze pads (A6216). No more than one type of supply would be medically necessary on a given day.
Patients with urinary ostomies may use either a bag (A4357) or bottle (A5102) for drainage at night. It is not medically necessary to have both. When a drainage bag is used with urinary ostomies, more than one per month is rarely medically necessary.
A pouch cover should be coded (A9270 Non-covered item or service). Such items are not covered under Medicare.
Provision of ostomy supplies should be limited to a one month supply for a patient in a nursing facility and a three months supply for a patient at home.
A solid barrier (wafer) is an interface between the patient's skin and the pouching system which is made of a pectin-based or karaya material, has measurable thickness and has an adhesive property. There are distinct codes for barriers with built-in convexity compared to flat barriers. There are also distinct codes for extended wear compared to standard wear barriers.
A barrier with built-in convexity is one in which an outward curve is achieved by plastic embedded in the barrier.
An extended wear barrier is a pectin based barrier with special additives which achieve a stronger adhesive seal, resist breakdown by urine or ileal effluent, and permit longer wear time between changes.
A pouch "with barrier attached" is one in which a solid barrier is part of a one piece pouch system. There are distinct codes for one piece pouches with convex barriers and extended wear barriers.
A pouch "without barrier attached" is a pouch with or without a thin adhesive coating that is applied either directly to the skin or to a separate barrier.
A faceplate is a solid interface between the patient's skin and the pouch. It is usually made of a plastic, rubber or encased metal. It does not have an adhesive property and there is no pectin-based or karaya material that is an integral part of a faceplate. It can be taken off the skin and reattached repeatedly. It is held on by means of a separate adhesive and/or an elastic belt. The clips for attaching the belt are usually a part of the faceplate. There is no coding distinction between flat and convex faceplate.
A pouch "with faceplate attached" or "for use on a faceplate" is generally rubber or heavy plastic. It is drainable, cleanable, and reusable for periods of weeks to months, depending on the products.
