Ostomy Supplies

Affected Providers

Treating practitioners and DME suppliers who bill for ostomy supplies.

HCPCS & CPT Codes

Local Coverage Determination (LCD): Ostomy Supplies (L33828) and Article: Ostomy Supplies (A52487) have the current HCPCS and CPT codes.

Background

According to the 2024 Medicare Fee-for-Service Supplemental Improper Payment Data, the improper payment rate for ostomy supplies is 16.2%, with a projected improper payment amount of $34.2 million.

We cover ostomy supplies under the prosthetic device benefit. We outline other policy requirements in LCD L33828 and Article A52487.

Denial Reasons

Insufficient documentation accounted for 66.4% of improper payments for ostomy supplies during the 2024 reporting period, while medical necessity (1.3%), no documentation (0.7%), and other errors (31.6%) also caused improper payments. “Other” errors include duplicate payment, non-covered or unallowable service, or ineligible Medicare patient errors.

Preventing Denials

We cover ostomy supplies for a patient with a surgically created opening (stoma) to divert urine or fecal contents outside the body. Providers use ostomy supplies for colostomies, ileostomies, or urinary ostomies. We deny ostomy supplies as non-covered if providers use them for other conditions.

The type of ostomy primarily decides the patient’s quantity of ostomy supplies. The ostomy type also shows the location, construction, and condition of the skin surface surrounding the stoma. The individual patient’s needs decide the variation of ostomy, and the patient’s needs may vary over time.

The table in LCD L33828 lists the usual greatest number of items or units of service that are usually reasonable and necessary. The actual quantity needed for a particular patient may be more or less than the amount listed, depending on factors affecting the barrier and pouch change frequency.

Clearly document in the patient’s medical record the explanation for using a greater supply quantity than the amounts listed. If you don’t provide adequate documentation when requested, we deny the excess quantities as not reasonable and necessary.

When a liquid barrier is necessary, use either liquid or spray (HCPCS code A4369) or individual wipes or swabs (HCPCS code A5120). Using both isn’t reasonable and necessary.

Patients with continent stomas may use these supplies to prevent or manage drainage: 

• Stoma cap (HCPCS code A5055)
• Stoma plug (HCPCS code A5081)
• Stoma absorptive cover (HCPCS code A5083)
• Gauze pads (HCPCS code A6216) 

No more than 1 of these types of supplies is reasonable and necessary on a given day.

Patients with urinary ostomies may use either a bag (HCPCS code A4357) or a bottle (HCPCS code A5102) for drainage at night. It isn’t reasonable and necessary to use both.

Refill Requirements

For DMEPOS items and supplies provided on a recurring basis, base your billing on prospective, not retrospective use.

Documentation Requirements

To justify payment, you must meet specific requirements when ordering DMEPOS.

Example of Improper Payments Due to Insufficient Documentation for Ostomy Supplies

A supplier bills the claim for HCPCS code A4361 (Ostomy faceplate, each) and submits the following documentation per the review contractor’s request:

• Standard written order with correct HCPCS coding
• Treating practitioner’s medical record that has sufficient medical necessity documentation

What Documentation Was Missing?

There was no proof of delivery in the submitted documentation.

What Happens Next?

The review contractor completes the claim as an insufficient documentation error, and the Medicare Administrative Contractor recoups payment.

Recommendation

To prevent claim denials and improper payments, the certifying physician must collect and submit proper documentation, including proof of delivery, in the treating practitioner’s medical record for DMEPOS.