Ostomy Supplies
Overview
Ostomy supplies are used to manage ostomies by diverting urine or fecal contents outside the body. An ostomy is a surgical procedure to create a stoma in the abdomen to remove waste from the body.
Eligible Providers
The following may provide ostomy supplies:
TPL and Medicare
Providers must meet any provider criteria, including accreditation, for third party insurance or for Medicare to assist members for whom Minnesota Health Care Programs (MHCP) is not the primary payer.
MHCP quantity limits and thresholds apply to all members unless only Medicare coinsurance or deductible is requested.
Refer to the Medicare and Other Insurance section of the MHCP Provider Manual for more information.
Eligible Members
Ostomy supplies are covered for eligible Medical Assistance and MinnesotaCare members to manage care for members with ostomies. Ostomy supplies include pouches, barriers, belts, filters, adhesive remover, accessories, and other items.
Standard wear ostomy products are covered for members who require daily changing. Extended wear ostomy products are covered for members who do not require daily changing.
Covered Services
Codes: A4361-A4364, A4366-A4369, A4371-A4373, A4375-A4385, A4387-A4396, A4398-A4400, A4402, A4404-A4437, A4450, A4452, A5051-A5057, A5061-A5063, A5071-A5073, A5081-A5083, A5093, A5120-A5122, A5126, A5131
MHCP covers the following supplies:
Ostomy supplies are included in the per diem for members living in a nursing facility. Ostomy supplies are not included in the per diem for members living in an intermediate care facility for people with developmental disabilities (ICF/DD). Refer to the Medical Supply Coverage Guide (PDF) for quantity limits and information on which items are included in the long-term care (LTC) per diem.
Barriers
A solid barrier is an interface between the member’s skin and the pouching system. Barriers have measurable thickness and adhesive properties. Barriers may be integrated into a one-piece pouch, manufactured with a flange and be part of a two-piece pouch system, or used independently, usually with a pouch that does not have its own integral skin barrier.
An extended wear barrier is a pectin-based barrier with special additives which achieve a stronger adhesive seal, resist breakdown by urine or bowel discharge, permit longer wear times between changes, and normal wear times for those who cannot achieve them with standard barriers.
Ostomy skin barriers greater than 4x4 inches refer to the size of the skin barriers, not the area of any surrounding tape.
Faceplates
A faceplate is a solid interface between the member’s skin and pouch. It is usually made of plastic, rubber, or encased metal. A faceplate does not have an adhesive property, nor does it have a pectin-based material that is an integral part of the faceplate. It may be removed from the skin and reattached repeatedly. It is secured by a means of a separate adhesive or elastic belt. The clips for attaching the belt are usually a part of the faceplate.
Payment for faceplate components is included in the payment for pouches with faceplates attached. Payment for HCPCS codes listed in column 2 of the Faceplate Components Table are included in payment for any of those in column 1:
Faceplate Components Table
Column 1 | Column 2 |
A4375 | A4361, A4377 |
A4376 | A4361, A4378 |
A4379 | A4361, A4381, A4382 |
A4380 | A4361, A4383 |
A4416 to A4419, A4423 to A4425, A4427 | A4366 |
Pouches
A pouch is an item used for collecting stomal output. Pouches for collecting bowel discharge may be drainable with an opening at the bottom which allows fecal contents to be emptied or closed with a sealed bottom and no outlet. Urinary pouches normally incorporate antireflux devices and a top or spigot to empty the urine contents.
A pouch with a barrier attached is a type of one-piece system in which a solid barrier is part of the pouch.
A pouch without a barrier attached is a pouch with or without an adhesive that is applied directly to the skin or to a separate barrier. This is also a one-piece system.
A pouch that has a flange is part of a two-piece system which enables it to be coupled to a skin barrier with flange.
A pouch with faceplate attached or for use on a faceplate is generally plastic or rubber. It is cleanable, drainable, and reusable for periods of weeks to months, depending on the product.
A high-output pouch (A4412, A4413, A4435) has a capacity of greater than or equal to 0.75 liters, is drainable with a large bore solid spout with cap or plug and is either part of a one-piece (A4435) or two-piece system (A4412, A4413).
Pouches with filters describe pouches that have an opening which allows venting or trapped gas. They typically include materials such as charcoal to deodorize the vented gas. HCPCS code A4368 describes a replacement filter.
HCPCS code A4366 describes a separate ostomy vent that can be added by the member to a pouch to allow the release of gas. An ostomy vent is included in pouches in which a vent with a filter is incorporated in the pouch by the manufacturer. Those products are described by the codes for ostomy pouches with a filter (A4416 to A4419, A4423 to A4425, A4427).
HCPCS code A4422 describes absorbent material that is added to the ostomy pouch may come as sheets, pads, or crystals.
HCPCS code A4429 describes an ostomy pouch with faucet-type tap valve that has a valve for draining urine.
A locking flange is a lever type flange locking mechanism. The mechanism may be incorporated either in the pouch flange or skin barrier flange (two-piece system).
Pastes
A paste is used as a protective layer and sealant beneath ostomy appliances and is applied directly to the skin. HCPCS code A4406 describes a pectin-based paste, while HCPCS code A4405 describes a nonpectin-based paste.
Miscellaneous Ostomy Supplies
Irrigation sleeves allow for the collection and drainage of contents to be directed into a toilet. HCPCS code A4436 describes an ostomy accessory that is secured around the stoma using a belt or by locking onto a faceplate. Reusable irrigation sleeves are typically used for one week. Document medical necessity for the quantity of units dispensed. HCPCS code A4437 describes an ostomy accessory that is applied to the peristomal skin and is discarded after use. Disposable irrigation sleeves are used daily.
Ostomy clamps are used with drainable pouches and are not used with urinary pouches. HCPCS code A4363 describes replacement clamps. MHCP pays for replacement clamps when the original item no longer functions. HCPCS code A4363 is not separately reimbursable on the same date of service of ostomy pouches.
Ostomy filters (A4368) as replacements are covered when the original item no longer functions.
Adhesive tape (A4450, A4452) is only covered for ostomy supplies that do not have adhesive qualities. HCPCS codes A4450 and A4452 must be billed with modifier AU when furnished in conjunction with an ostomy, tracheostomy, or urological supply.
Miscellaneous ostomy supplies (A4421) require authorization if the submitted combined charges are over $400. HCPCS code A4421 should only be used when an ostomy supply is not described by a more specific HCPCS code mentioned in this MHCP Provider Manual section. Documentation must clearly indicate member’s diagnosis, medical necessity, description of the item, and pricing information.
Noncovered Services
MHCP does not cover the following:
Authorization
Authorization is required for the following:
Submit authorization to the Medical Review Agent.
Billing
Providers are responsible to coordinate services. Refer to the Billing Policy Overview section of the MHCP Provider Manual for general billing information.
Bill ostomy supplies using MN–ITS 837P Professional. Refer to the Billing for Durable Medical Equipment, Medical Supplies, Prosthetics, Orthotics, and Augmentative Devices MN–ITS user manual for general billing requirements and guidance when submitting claims.
Documentation must include the following:
Medical necessity is established at the time of initial order. Document the medical necessity of the number of units of ostomy supplies being dispensed. The original documentation must be less than 30 days old. A new order or ongoing supporting documentation explaining a change in required number of units is required only if there is a major change in the member’s condition.
Ostomy supplies are purchase items only. No more than one month’s supply of ostomy supplies may be provided at one time, unless the medical necessity of greater quantities is documented.
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