Ostomy - JA DME

HCPCS A4450, A4452, and A5120 furnished in conjunction with ostomy supplies must be billed with AU modifier. Claims for tape and adhesive (A4450, A4452, A5120) that are billed without an AU modifier or with another modifier indicating coverage under a different policy will be rejected as missing information.

If beneficiary is in a covered 60-day home health care episode, ostomy supplies are not billable to DME MAC. Supplies must be provided by home health agency with payment included in home health prospective payment system (PPS). Utilize the Consolidated Billing/SNF/Home Health/Hospice Lookup for specific HCPCS codes included.

For all DMEPOS items, the initial justification for medical need is established at the time the item(s) is first ordered, therefore, beneficiary medical records demonstrating that the item is reasonable and necessary are created just prior to, or at the time of, the creation of the initial prescription. Once initial medical need is established, ongoing need for ostomy supplies is assumed to be met. There is no requirement for further documentation of continued medical need if the beneficiary continues to meet the Prosthetic Devices benefit.

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 listed in the LCD L33828 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.

The Centers for Medicare & Medicaid Services (CMS) developed Medically Unlikely Edits (MUEs) to reduce the paid claims error rate for Part B claims. An MUE for a HCPCS/CPT code is the maximum units of service a provider would order under most circumstances for a single beneficiary on a single date of service. Not all HCPCS codes have an MUE. The Medically Unlikely Edit (MUE) Lookup Tool on this page, provides guidance for published MUEs for DME HCPCS codes. Although CMS publishes most MUE values on its website, other MUE values are confidential and are for CMS and CMS contractors' use only. The latter group of MUE values is not published.

Codes A4436 (irrigation supply; sleeve, reusable, per month) and A4437 (irrigation supply; sleeve, disposable, per month) are for a month's irrigation sleeve supply allowance. One unit of service is billed regardless of how many sleeves are required. If the beneficiary requires more than the monthly limit of four sleeves, the supplier must deliver the additional sleeves. See MLN Matters MM12521 - Calendar Year 2022 Update for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule for more information.