Ostomy supplies cpt code list

HCPCS CODES:

Group 1 Codes:

A4331 EXTENSION DRAINAGE TUBING, ANY TYPE, ANY LENGTH, WITH CONNECTOR/ADAPTOR, FOR USE WITH URINARY LEG BAG OR UROSTOMY POUCH, EACH
A4357 BEDSIDE DRAINAGE BAG, DAY OR NIGHT, WITH OR WITHOUT ANTI-REFLUX DEVICE, WITH OR WITHOUT TUBE, EACH
A4361 OSTOMY FACEPLATE, EACH
A4362 SKIN BARRIER; SOLID, 4 X 4 OR EQUIVALENT; EACH
A4363 OSTOMY CLAMP, ANY TYPE, REPLACEMENT ONLY, EACH
A4364 ADHESIVE, LIQUID OR EQUAL, ANY TYPE, PER OZ
A4366 OSTOMY VENT, ANY TYPE, EACH
A4367 OSTOMY BELT, EACH
A4368 OSTOMY FILTER, ANY TYPE, EACH
A4369 OSTOMY SKIN BARRIER, LIQUID (SPRAY, BRUSH, ETC.), PER OZ
A4371 OSTOMY SKIN BARRIER, POWDER, PER OZ
A4372 OSTOMY SKIN BARRIER, SOLID 4 X 4 OR EQUIVALENT, STANDARD WEAR, WITH BUILT-IN CONVEXITY, EACH
A4373 OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE OR ACCORDION), WITH BUILT-IN CONVEXITY, ANY SIZE, EACH
A4375 OSTOMY POUCH, DRAINABLE, WITH FACEPLATE ATTACHED, PLASTIC, EACH
A4376 OSTOMY POUCH, DRAINABLE, WITH FACEPLATE ATTACHED, RUBBER, EACH
A4377 OSTOMY POUCH, DRAINABLE, FOR USE ON FACEPLATE, PLASTIC, EACH
A4378 OSTOMY POUCH, DRAINABLE, FOR USE ON FACEPLATE, RUBBER, EACH
A4379 OSTOMY POUCH, URINARY, WITH FACEPLATE ATTACHED, PLASTIC, EACH
A4380 OSTOMY POUCH, URINARY, WITH FACEPLATE ATTACHED, RUBBER, EACH
A4381 OSTOMY POUCH, URINARY, FOR USE ON FACEPLATE, PLASTIC, EACH
A4382 OSTOMY POUCH, URINARY, FOR USE ON FACEPLATE, HEAVY PLASTIC, EACH
A4383 OSTOMY POUCH, URINARY, FOR USE ON FACEPLATE, RUBBER, EACH
A4384 OSTOMY FACEPLATE EQUIVALENT, SILICONE RING, EACH
A4385 OSTOMY SKIN BARRIER, SOLID 4 X 4 OR EQUIVALENT, EXTENDED WEAR, WITHOUT BUILT-IN CONVEXITY, EACH
A4387 OSTOMY POUCH, CLOSED, WITH BARRIER ATTACHED, WITH BUILT-IN CONVEXITY (1 PIECE), EACH
A4388 OSTOMY POUCH, DRAINABLE, WITH EXTENDED WEAR BARRIER ATTACHED, (1 PIECE), EACH
A4389 OSTOMY POUCH, DRAINABLE, WITH BARRIER ATTACHED, WITH BUILT-IN CONVEXITY (1 PIECE), EACH
A4390 OSTOMY POUCH, DRAINABLE, WITH EXTENDED WEAR BARRIER ATTACHED, WITH BUILT-IN CONVEXITY (1 PIECE), EACH
A4391 OSTOMY POUCH, URINARY, WITH EXTENDED WEAR BARRIER ATTACHED (1 PIECE), EACH
A4392 OSTOMY POUCH, URINARY, WITH STANDARD WEAR BARRIER ATTACHED, WITH BUILT-IN CONVEXITY (1 PIECE), EACH
A4393 OSTOMY POUCH, URINARY, WITH EXTENDED WEAR BARRIER ATTACHED, WITH BUILT-IN CONVEXITY (1 PIECE), EACH
A4394 OSTOMY DEODORANT, WITH OR WITHOUT LUBRICANT, FOR USE IN OSTOMY POUCH, PER FLUID OUNCE
A4395 OSTOMY DEODORANT FOR USE IN OSTOMY POUCH, SOLID, PER TABLET
A4396 OSTOMY BELT WITH PERISTOMAL HERNIA SUPPORT
A4397 IRRIGATION SUPPLY; SLEEVE, EACH
A4398 OSTOMY IRRIGATION SUPPLY; BAG, EACH
A4399 OSTOMY IRRIGATION SUPPLY; CONE/CATHETER, WITH OR WITHOUT BRUSH
A4402 LUBRICANT, PER OUNCE
A4404 OSTOMY RING, EACH
A4405 OSTOMY SKIN BARRIER, NON-PECTIN BASED, PASTE, PER OUNCE
A4406 OSTOMY SKIN BARRIER, PECTIN-BASED, PASTE, PER OUNCE
A4407 OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE, OR ACCORDION), EXTENDED WEAR, WITH BUILT-IN CONVEXITY, 4 X 4 INCHES OR SMALLER, EACH
A4408 OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE OR ACCORDION), EXTENDED WEAR, WITH BUILT-IN CONVEXITY, LARGER THAN 4 X 4 INCHES, EACH
A4409 OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE OR ACCORDION), EXTENDED WEAR, WITHOUT BUILT-IN CONVEXITY, 4 X 4 INCHES OR SMALLER, EACH
A4410 OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE OR ACCORDION), EXTENDED WEAR, WITHOUT BUILT-IN CONVEXITY, LARGER THAN 4 X 4 INCHES, EACH
A4411 OSTOMY SKIN BARRIER, SOLID 4 X 4 OR EQUIVALENT, EXTENDED WEAR, WITH BUILT-IN CONVEXITY, EACH
A4412 OSTOMY POUCH, DRAINABLE, HIGH OUTPUT, FOR USE ON A BARRIER WITH FLANGE (2 PIECE SYSTEM), WITHOUT FILTER, EACH
A4413 OSTOMY POUCH, DRAINABLE, HIGH OUTPUT, FOR USE ON A BARRIER WITH FLANGE (2 PIECE SYSTEM), WITH FILTER, EACH
A4414 OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE OR ACCORDION), WITHOUT BUILT-IN CONVEXITY, 4 X 4 INCHES OR SMALLER, EACH
A4415 OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE OR ACCORDION), WITHOUT BUILT-IN CONVEXITY, LARGER THAN 4 X 4 INCHES, EACH
A4416 OSTOMY POUCH, CLOSED, WITH BARRIER ATTACHED, WITH FILTER (1 PIECE), EACH
A4417 OSTOMY POUCH, CLOSED, WITH BARRIER ATTACHED, WITH BUILT-IN CONVEXITY, WITH FILTER (1 PIECE), EACH
A4418 OSTOMY POUCH, CLOSED; WITHOUT BARRIER ATTACHED, WITH FILTER (1 PIECE), EACH
A4419 OSTOMY POUCH, CLOSED; FOR USE ON BARRIER WITH NON-LOCKING FLANGE, WITH FILTER (2 PIECE), EACH
A4420 OSTOMY POUCH, CLOSED; FOR USE ON BARRIER WITH LOCKING FLANGE (2 PIECE), EACH
A4421 OSTOMY SUPPLY; MISCELLANEOUS
A4422 OSTOMY ABSORBENT MATERIAL (SHEET/PAD/CRYSTAL PACKET) FOR USE IN OSTOMY POUCH TO THICKEN LIQUID STOMAL OUTPUT, EACH
A4423 OSTOMY POUCH, CLOSED; FOR USE ON BARRIER WITH LOCKING FLANGE, WITH FILTER (2 PIECE), EACH
A4424 OSTOMY POUCH, DRAINABLE, WITH BARRIER ATTACHED, WITH FILTER (1 PIECE), EACH
A4425 OSTOMY POUCH, DRAINABLE; FOR USE ON BARRIER WITH NON-LOCKING FLANGE, WITH FILTER (2 PIECE SYSTEM), EACH
A4426 OSTOMY POUCH, DRAINABLE; FOR USE ON BARRIER WITH LOCKING FLANGE (2 PIECE SYSTEM), EACH
A4427 OSTOMY POUCH, DRAINABLE; FOR USE ON BARRIER WITH LOCKING FLANGE, WITH FILTER (2 PIECE SYSTEM), EACH
A4428 OSTOMY POUCH, URINARY, WITH EXTENDED WEAR BARRIER ATTACHED, WITH FAUCET-TYPE TAP WITH VALVE (1 PIECE), EACH
A4429 OSTOMY POUCH, URINARY, WITH BARRIER ATTACHED, WITH BUILT-IN CONVEXITY, WITH FAUCET-TYPE TAP WITH VALVE (1 PIECE), EACH
A4430 OSTOMY POUCH, URINARY, WITH EXTENDED WEAR BARRIER ATTACHED, WITH BUILT-IN CONVEXITY, WITH FAUCET-TYPE TAP WITH VALVE (1 PIECE), EACH
A4431 OSTOMY POUCH, URINARY; WITH BARRIER ATTACHED, WITH FAUCET-TYPE TAP WITH VALVE (1 PIECE), EACH
A4432 OSTOMY POUCH, URINARY; FOR USE ON BARRIER WITH NON-LOCKING FLANGE, WITH FAUCET-TYPE TAP WITH VALVE (2 PIECE), EACH
A4433 OSTOMY POUCH, URINARY; FOR USE ON BARRIER WITH LOCKING FLANGE (2 PIECE), EACH
A4434 OSTOMY POUCH, URINARY; FOR USE ON BARRIER WITH LOCKING FLANGE, WITH FAUCET-TYPE TAP WITH VALVE (2 PIECE), EACH
A4435 OSTOMY POUCH, DRAINABLE, HIGH OUTPUT, WITH EXTENDED WEAR BARRIER (ONE-PIECE SYSTEM), WITH OR WITHOUT FILTER, EACH
A4450 TAPE, NON-WATERPROOF, PER 18 SQUARE INCHES
A4452 TAPE, WATERPROOF, PER 18 SQUARE INCHES
A4455 ADHESIVE REMOVER OR SOLVENT (FOR TAPE, CEMENT OR OTHER ADHESIVE), PER OUNCE
A4456 ADHESIVE REMOVER, WIPES, ANY TYPE, EACH
A5051 OSTOMY POUCH, CLOSED; WITH BARRIER ATTACHED (1 PIECE), EACH
A5052 OSTOMY POUCH, CLOSED; WITHOUT BARRIER ATTACHED (1 PIECE), EACH
A5053 OSTOMY POUCH, CLOSED; FOR USE ON FACEPLATE, EACH
A5054 OSTOMY POUCH, CLOSED; FOR USE ON BARRIER WITH FLANGE (2 PIECE), EACH
A5055 STOMA CAP
A5056 OSTOMY POUCH, DRAINABLE, WITH EXTENDED WEAR BARRIER ATTACHED, WITH FILTER, (1 PIECE), EACH
A5057 OSTOMY POUCH, DRAINABLE, WITH EXTENDED WEAR BARRIER ATTACHED, WITH BUILT IN CONVEXITY, WITH FILTER, (1 PIECE), EACH
A5061 OSTOMY POUCH, DRAINABLE; WITH BARRIER ATTACHED, (1 PIECE), EACH
A5062 OSTOMY POUCH, DRAINABLE; WITHOUT BARRIER ATTACHED (1 PIECE), EACH
A5063 OSTOMY POUCH, DRAINABLE; FOR USE ON BARRIER WITH FLANGE (2 PIECE SYSTEM), EACH
A5071 OSTOMY POUCH, URINARY; WITH BARRIER ATTACHED (1 PIECE), EACH
A5072 OSTOMY POUCH, URINARY; WITHOUT BARRIER ATTACHED (1 PIECE), EACH
A5073 OSTOMY POUCH, URINARY; FOR USE ON BARRIER WITH FLANGE (2 PIECE), EACH
A5081 STOMA PLUG OR SEAL, ANY TYPE
A5082 CONTINENT DEVICE; CATHETER FOR CONTINENT STOMA
A5083 CONTINENT DEVICE, STOMA ABSORPTIVE COVER FOR CONTINENT STOMA
A5093 OSTOMY ACCESSORY; CONVEX INSERT
A5102 BEDSIDE DRAINAGE BOTTLE WITH OR WITHOUT TUBING, RIGID OR EXPANDABLE, EACH
A5120 SKIN BARRIER, WIPES OR SWABS, EACH
A5121 SKIN BARRIER; SOLID, 6 X 6 OR EQUIVALENT, EACH
A5122 SKIN BARRIER; SOLID, 8 X 8 OR EQUIVALENT, EACH
A5126 ADHESIVE OR NON-ADHESIVE; DISK OR FOAM PAD
A5131 APPLIANCE CLEANER, INCONTINENCE AND OSTOMY APPLIANCES, PER 16 OZ.
A6216 GAUZE, NON-IMPREGNATED, NON-STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACH DRESSING
A9270 NON-COVERED ITEM OR SERVICE


Coverage Guidance
Coverage Indications, Limitations, and/or Medical Necessity

For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. For the items addressed in this local coverage determination, the criteria for "reasonable and necessary", based on Social Security Act §1862(a)(1)(A) provisions, are defined by the following coverage indications, limitations and/or medical necessity.

Medicare does not automatically assume payment for a durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) item that was covered prior to a beneficiary becoming eligible for the Medicare Fee For Service (FFS) program. When a beneficiary receiving a DMEPOS item from another payer (including Medicare Advantage plans) becomes eligible for the Medicare FFS program, Medicare will pay for continued use of the DMEPOS item only if all Medicare coverage, coding and documentation requirements are met. Additional documentation to support that the item is reasonable and necessary, may be required upon request of the DME MAC.

For an item to be covered by Medicare, a detailed written order (DWO) must be received by the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving the completed DWO, the item will be denied as not reasonable and necessary.

Refer to the Nonmedical Necessity Coverage and Payment Rules section of the related Policy Article for information about the statutory coverage requirements for ostomy supplies.

The quantity of ostomy supplies needed by a beneficiary is determined primarily 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 beneficiary need and their needs may vary over time. The table below lists the maximum number of items/units of service that are usually reasonable and necessary. The actual quantity needed for a particular beneficiary may be more or less than the amount listed depending on the factors that affect the frequency of barrier and pouch change.

The explanation for use of a greater quantity of supplies than the amounts listed must be clearly documented in the beneficiary’s medical record. If adequate documentation is not provided when requested, the excess quantities will be denied as not reasonable and necessary.

USUAL MAXIMUM QUANTITY OF SUPPLIES:

Code # per Month
A4357 2
A4362 20
A4364 4
A4367 1
A4369 2
A4377 10
A4381 10
A4397 4
A4402 4
A4404 10
A4405 4
A4406 4
A4414 20
A4415 20
A4416 60
A4417 60
A4418 60
A4419 60
A4420 60
A4423 60
A4424 20
A4425 20
A4426 20
A4427 20
A4429 20
A4431 20
A4432 20
A4433 20
A4434 20
A4450 40
A4452 40
A5051 60
A5052 60
A5053 60
A5054 60
A5055 31
A5056 40
A5057 40
A5061 20
A5062 20
A5063 20
A5071 20
A5072 20
A5073 20
A5081 31
A5082 1
A5083 150
A5093 10
A5121 20
A5122 20
A5126 20
A5131 1
A6216 60

Code # per 6 Months
A4361 3
A4371 10
A4398 2
A4399 2
A4455 16
A5102 2
A5120 150


When a liquid barrier is necessary, either liquid or spray (A4369) or individual wipes or swabs (A5120) are appropriate. The use of both is not reasonable and necessary.

Beneficiaries with continent stomas may use the following means to prevent/manage drainage: stoma cap (A5055), stoma plug (A5081), stoma absorptive cover (A5083) or gauze pads (A6216). No more than one of these types of supply would be reasonable and necessary on a given day.

Beneficiaries with urinary ostomies may use either a bag (A4357) or bottle (A5102) for drainage at night. It is not reasonable and necessary to have both.

REFILL REQUIREMENTS

For DMEPOS items and supplies provided on a recurring basis, billing must be based on prospective, not retrospective use. For DMEPOS products that are supplied as refills to the original order, suppliers must contact the beneficiary prior to dispensing the refill and not automatically ship on a pre-determined basis, even if authorized by the beneficiary. This shall be done to ensure that the refilled item remains reasonable and necessary, existing supplies are approaching exhaustion, and to confirm any changes or modifications to the order. Contact with the beneficiary or designee regarding refills must take place no sooner than 14 calendar days prior to the delivery/shipping date. For delivery of refills, the supplier must deliver the DMEPOS product no sooner than 10 calendar days prior to the end of usage for the current product. This is regardless of which delivery method is utilized. (CMS Program Integrity Manual, Internet-Only Manual, CMS Pub. 100-08, Chapter 5, Section 5.2.6).

For all DMEPOS items that are provided on a recurring basis, suppliers are required to have contact with the beneficiary or caregiver/designee prior to dispensing a new supply of items. Suppliers must not deliver refills without a refill request from a beneficiary. Items delivered without a valid, documented refill request will be denied as not reasonable and necessary.

Suppliers must not dispense a quantity of supplies exceeding a beneficiary's expected utilization. Suppliers must stay attuned to changed or atypical utilization patterns on the part of their clients. Suppliers must verify with the ordering physicians that any changed or atypical utilization is warranted. Regardless of utilization, a supplier must not dispense more than a 1-month supply at a time for a beneficiary in a nursing facility and a 3-month supply for a beneficiary at home.

For information on tracheostomy supplies, see the Tracheostomy Care Supplies policy.


Bill Type Codes:
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
N/A

Revenue Codes:
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

N/A

CPT/HCPCS Codes

Group 1 Paragraph: The appearance of a code in this section does not necessarily indicate coverage.

HCPCS MODIFIERS:

AU - Item furnished in conjunction with a urological, ostomy or tracheostomy supply.
EY - No physician or other licensed health care provider order for this item or service.