Ostomy Supplies Frequently Asked Questions (FAQs) - JD DME

To help our suppliers, Noridian and CGS Provider Outreach and Education worked together to answer your most frequently asked questions.

Q. Are hernia belts (A4396) covered for hernia prevention?
A. The A4396 (hernia belt with peristomal support) could be considered for coverage if the beneficiary has been diagnosed with a peristomal hernia, medical records support the need, and the hernia belt is medically necessary. Hernia belts would not be covered by Medicare as a preventative measure only. Suppliers should get a valid, signed Advance Beneficiary Notice of Noncoverage (ABN) in these situations.

Q. How many ostomy sleeves (A4436 and A4437) can be provided and billed per month?
A. HCPCS A4436 (Irrigation supply; sleeve, reusable, per month) and A4437(Irrigation supply; sleeve; disposable; per month) are billed as one unit of service per month. Medicare pays in advance for the month's supply of irrigation sleeves and suppliers must ensure that the patient has enough sleeves to last for the entire month. If the patient needs more replacement sleeves before the end of the month, the supplier must deliver the additional sleeves to the patient. Refer to CMS MM1251 for additional details on the billing of A4436 and A4437.

Q. How far back should medical records go to show medical necessity or presence of a stoma?
A. The Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) Policy Article states, "Documentation must be maintained in the supplier's files for seven (7) years from DOS. If the Medicare qualifying supplier documentation is older than 7 years, proof of continued medical necessity of the item or necessity of the repair can be used as the supporting Medicare qualifying documentation."

Q. Will surgical dressings be covered for an infection at the stoma site?
A. If complications develop at an established stoma site and the wound(s) require debridement or surgical intervention, dressings could be considered for coverage under the Surgical Dressings benefit.

Q. What medical documentation is necessary to show the initial need for ostomy supplies for a new stoma?
A. The records must show the beneficiary has had a surgically created opening (stoma) to divert urine, or fecal contents outside the body and the beneficiary has a permanent impairment. (Permanence is a condition that is of a long and indefinite duration. This does not require a determination that there is no possibility that the beneficiary's condition may improve sometime in the future.) Some examples of medical records include a hospital discharge summary from the surgery where the stoma was created, follow-up encounters after the surgery, ostomy nurse chart notes, home health visit records, etc. Please see the Ostomy Supplies Policy Article (A52487) for additional information and appropriate diagnosis codes.

Q. How should a supplier bill ostomy supplies for beneficiaries with two ostomies?
A. Per the Ostomy Supplies Local Coverage Determination (L33828), "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." Suppliers should bill appropriate quantities of supplies for each stoma and include a narrative on the claim line(s) (NTE segment, Loop 2400 for electronic claims or Item 19 on the CMS-1500 claim form).

Q. How can a supplier get paid for quantities of ostomy supplies that are above the maximums outlined in the Ostomy Supplies LCD?
A. Suppliers have the option to appeal with additional documentation in the event of a claim denial. The medical records must justify the need for the quantity of ostomy supplies ordered and explain the specific circumstances under which the patient requires a quantity of supplies in excess of the amounts allowed by the Local Coverage Determination. Per the Ostomy Supplies LCD (L33828), "if adequate documentation is not provided when requested, the excess quantities will be denied as not reasonable and necessary."