Article Detail - JD DME

Ostomy supplies are covered under Medicare for beneficiaries with a surgically created opening (stoma) to divert urine or fecal contents outside the body. These supplies are used for colostomies, ileostomies, or urinary ostomies. To ensure coverage, healthcare professionals must provide proper documentation and justification for the medical necessity of these supplies.

Code A4436 (irrigation supply; sleeve, reusable, per month) describes an ostomy accessory that is secured around the stoma using a belt or by locking onto a faceplate that is attached to the peristomal skin. They are typically used for a week or more, cleaned and dried between irrigations, before being discarded.

Code A4437 (irrigation supply; sleeve, disposable, per month) describes an ostomy accessory that is applied directly onto the peristomal skin and is discarded after each irrigation due to inability to re-adhere to the skin surface.

Codes A4436 (irrigation supply; sleeve, reusable, per month) and A4437 (irrigation supply; sleeve, disposable, per month) is a monthly supply allowance for irrigation sleeves. No more than 1 unit of service is billable per thirty (30) days.

Code A4400 (Ostomy irrigation set) is not valid for claim submission. If an irrigation kit is supplied, the individual components should be billed using individual codes, A4398 and A4399.

Ostomy clamps (A4363) are used with drainable pouches and are not used with urinary pouches. Ostomy clamps are only payable when ordered as a replacement. Claims for ostomy clamps billed with ostomy pouches will be denied as not separately payable.

When codes A4450 (non-waterproof tape), A4452 (Waterproof tape), and A5120 (Skin barrier) are used with ostomy supplies, they must be billed with the AU modifier. For this policy, codes A4450, A4452, and A5120 are the only codes for which the AU modifier may be used.

Suppliers should contact the Pricing, Data Analysis, and Coding (PDAC) contractor for guidance on the correct coding of these items. This information can be found in Ostomy Supplies - Policy Article A52487.