From North Central Oklahoma Ostomy Outlook March 2016 (updated Feb 2017):

Medicare Rates for Ostomy Supplies

Based on information distributed by James Knight at our meetings in Feb 1999 and Feb 2003; updated many times by Bob Baumel, most recently in Feb 2017)

We published the earliest versions of this article in 1999 and 2003, based on information assembled by James Knight, the proprietor of Knight Medical Supply. Since then, we’ve updated this information periodically. The rates have changed as follows during the past few years:
    2013 to 2014: Increased 1.0%
    2014 to 2015: Increased 1.5%
    2015 to 2016: Decreased 0.4%
    2016 to 2017: Increased 0.7%

Note: Ostomy supplies are classified under Medicare as DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies). Many DMEPOS products are subject to a competitive bidding program, which tends to reduce Medicare reimbursement substantially. Ostomy supplies have, so far, been kept out of competitive bidding. See information about competitive bidding on the UOAA site.

The table below 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.

The “Max” column displays the “Usual Maximum Quantity of Supplies” specified by Medicare. These are the quantities that Medicare regards as “usually reasonable and necessary.” For example, the specified numbers of pouches per month are usually 20 for drainable or urinary pouches, and 60 for closed pouches. These aren’t absolute limits, as higher amounts can be covered with adequate medical documentation. In practice, however, when these amounts are exceeded, Medicare often denies coverage first, then requires the patient to provide medical documentation to obtain coverage.

The “Max” quantities aren’t specified for all products; when omitted, the quantities for similar products are usually a good guide. Quantities are normally per month, except when followed by the suffix “/6” indicating a 6-month period. For example, the usual maximum for bedside drainage bottles (A5102) is 2 per 6 months.

Code  Fee  Max  Description
A5126$1.2420Adhesive or non-adhesive; disk or foam pad
A4455$1.3516/6Adhesive remover or solvent (for tape, cement or other adhesive), per ounce
A4456$0.27 Adhesive remover, wipes, any type, each
A4364$3.274Adhesive, liquid or equal, any type, per oz
A5131$17.651Appliance cleaner, incontinence and ostomy appliances, per 16 oz
A4357$9.192Bedside drainage bag, day or night, with or without anti-reflux device, with or without tube, each
A5102$25.132/6Bedside drainage bottle with or without tubing, rigid or expandable, each
A5081$3.1431Stoma plug or seal, any type
A5082$13.241Continent device; catheter for continent stoma
A5083$0.71150Continent device, stoma absorptive cover for continent stoma
A4331$3.54 Extension drainage tubing, any type, any length, with connector/adaptor, for use with urinary leg bag or urostomy pouch, each
A6216$0.0560Gauze, non-impregnated, non-sterile, pad size 16 sq. in. or less, without adhesive border, each dressing
A4400$54.40 Ostomy irrigation set
A4398$15.392/6Ostomy irrigation supply; bag, each
A4399$13.652/6Ostomy irrigation supply; cone/catheter, with or without brush
A4397$4.534Irrigation supply; sleeve, each
A4402$1.554Lubricant, per ounce
A4422$0.13 Ostomy absorbent material (sheet/pad/crystal packet) for use in ostomy pouch to thicken liquid stomal output, each
A5093$2.0410Ostomy accessory; convex insert
A4367$8.191Ostomy belt, each
A4396$45.06 Ostomy belt with peristomal hernia support
A4394$2.88 Ostomy deodorant, with or without lubricant, for use in ostomy pouch, per fluid ounce
A4395$0.05 Ostomy deodorant for use in ostomy pouch, solid, per tablet
A4361$17.383/6Ostomy faceplate, each
A4384$10.70 Ostomy faceplate equivalent, silicone ring, each
A4368$0.28 Ostomy filter, any type, each
A5054$2.0060Ostomy pouch, closed; for use on barrier with flange (2 piece), each
A4419$1.9360Ostomy pouch, closed; for use on barrier with non-locking flange, with filter (2 piece), each
A4420$0.0060Ostomy pouch, closed; for use on barrier with locking flange (2 piece), each
A4423$2.0760Ostomy pouch, closed; for use on barrier with locking flange, with filter (2 piece), each
A5053$1.6460Ostomy pouch, closed; for use on faceplate, each
A5051$2.3060Ostomy pouch, closed; with barrier attached (1 piece), each
A4417$4.1460Ostomy pouch, closed, with barrier attached, with built-in convexity, with filter (1 piece), each
A4387$2.50 Ostomy pouch, closed, with barrier attached, with built-in convexity (1 piece), each
A4416$3.0760Ostomy pouch, closed, with barrier attached, with filter (1 piece), each
A5052$1.6560Ostomy pouch, closed; without barrier attached (1 piece), each
A4418$2.0260Ostomy pouch, closed; without barrier attached, with filter (1 piece), each
A5063$3.0120Ostomy pouch, drainable; for use on barrier with flange (2 piece system), each
A4425$3.9920Ostomy pouch, drainable; for use on barrier with non-locking flange, with filter (2 piece system), each
A4426$3.0420Ostomy pouch, drainable; for use on barrier with locking flange (2 piece system), each
A4427$3.1020Ostomy pouch, drainable; for use on barrier with locking flange, with filter (2 piece system), each
A4413$6.13 Ostomy pouch, drainable, high output, for use on a barrier with flange (2 piece system), with filter, each
A4377$4.7810Ostomy pouch, drainable, for use on faceplate, plastic, each
A4375$19.12 Ostomy pouch, drainable, with faceplate attached, plastic, each
A4378$34.22 Ostomy pouch, drainable, for use on faceplate, rubber, each
A4376$52.98 Ostomy pouch, drainable, with faceplate attached, rubber, each
A5061$3.9320Ostomy pouch, drainable; with barrier attached, (1 piece), each
A4389$6.92 Ostomy pouch, drainable, with barrier attached, with built-in convexity (1 piece), each
A4424$5.3020Ostomy pouch, drainable, with barrier attached, with filter (1 piece), each
A4388$4.86 Ostomy pouch, drainable, with extended wear barrier attached, (1 piece), each
A5056$5.2040Ostomy pouch, drainable, with extended wear barrier attached, with filter, (1 piece), each
A4390$10.69 Ostomy pouch, drainable, with extended wear barrier attached, with built-in convexity (1 piece), each
A5057$10.6940Ostomy pouch, drainable, with extended wear barrier attached, with built in convexity, with filter, (1 piece), each
A5062$2.4820Ostomy pouch, drainable; without barrier attached (1 piece), each
A5073$3.5220Ostomy pouch, urinary; for use on barrier with flange (2 piece), each
A4432$4.0020Ostomy pouch, urinary; for use on barrier with non-locking flange, with faucet-type tap with valve (2 piece), each
A4433$3.7320Ostomy pouch, urinary; for use on barrier with locking flange (2 piece), each
A4434$4.1820Ostomy pouch, urinary; for use on barrier with locking flange, with faucet-type tap with valve (2 piece), each
A4382$27.40 Ostomy pouch, urinary, for use on faceplate, heavy plastic, each
A4381$5.1510Ostomy pouch, urinary, for use on faceplate, plastic, each
A4379$16.72 Ostomy pouch, urinary, with faceplate attached, plastic, each
A4383$31.38 Ostomy pouch, urinary, for use on faceplate, rubber, each
A4380$41.55 Ostomy pouch, urinary, with faceplate attached, rubber, each
A5071$6.6920Ostomy pouch, urinary; with barrier attached (1 piece), each
A4429$9.1820Ostomy pouch, urinary, with barrier attached, with built-in convexity, with faucet-type tap with valve (1 piece), each
A4431$6.9220Ostomy pouch, urinary; with barrier attached, with faucet-type tap with valve (1 piece), each
A4391$7.87 Ostomy pouch, urinary, with extended wear barrier attached (1 piece), each
A4393$10.07 Ostomy pouch, urinary, with extended wear barrier attached, with built-in convexity (1 piece), each
A4430$9.48 Ostomy pouch, urinary, with extended wear barrier attached, with built-in convexity, with faucet-type tap with valve (1 piece), each
A4428$7.25 Ostomy pouch, urinary, with extended wear barrier attached, with faucet-type tap with valve (1 piece), each
A4392$9.10 Ostomy pouch, urinary, with standard wear barrier attached, with built-in convexity (1 piece), each
A5072$3.9320Ostomy pouch, urinary; without barrier attached (1 piece), each
A4404$1.8710Ostomy ring, each
A4405$3.804Ostomy skin barrier, non-pectin based, paste, per ounce
A4406$6.374Ostomy skin barrier, pectin-based, paste, per ounce
A4369$2.702Ostomy skin barrier, liquid (spray, brush, etc), per oz
A4371$4.0610/6Ostomy skin barrier, powder, per oz
A4372$4.67 Ostomy skin barrier, solid 4x4 or equivalent, standard wear, with built-in convexity, each
A4385$5.68 Ostomy skin barrier, solid 4x4 or equivalent, extended wear, without built-in convexity, each
A4411$5.68 Ostomy skin barrier, solid 4x4 or equivalent, extended wear, with built-in convexity, each
A4362$3.2820Skin barrier; solid, 4x4 or equivalent; each
A5121$8.3020Skin barrier; solid, 6x6 or equivalent, each
A5122$14.3020Skin barrier; solid, 8x8 or equivalent, each
A5120$0.26150/6Skin barrier, wipes or swabs, each
A4407$9.75 Ostomy skin barrier, with flange (solid, flexible, or accordion), extended wear, with built-in convexity, 4x4 inches or smaller, each
A4408$10.99 Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, with built-in convexity, larger than 4x4 inches, each
A4409$6.92 Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, without built-in convexity, 4x4 inches or smaller, each
A4410$10.07 Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, without built-in convexity, larger than 4x4 inches, each
A4373$6.98 Ostomy skin barrier, with flange (solid, flexible or accordion), with built-in convexity, any size, each
A4414$5.4820Ostomy skin barrier, with flange (solid, flexible or accordion), without built-in convexity, 4x4 inches or smaller, each
A4415$6.6720Ostomy skin barrier, with flange (solid, flexible or accordion), without built-in convexity, larger than 4x4 inches, each
A5055$1.6031Stoma cap
A4450$0.0940Tape, non-waterproof, per 18 square inches
A4452$0.4040Tape, waterproof, per 18 square inches

Back to North Central Oklahoma Ostomy Newsletter Index
This page last revised 2017-02-22

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