Ostomy

Coverage

Documentation

Tips

Topic Details
AU Modifier
  • 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
Consolidated Billing
  • 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
Continued Medical Need
  • 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.

 

Last Updated Thu, 19 May 2022 12:22:33 +0000