Sufficient Documentation Essential for Ostomy Pay
Insufficient documentation accounted for nearly 82 percent of improper payments for ostomy supplies in 2018, according to the Centers for Medicare & Medicaid Services (CMS). No documentation and medical necessity also are reasons for ostomy supply pay problems.
Tips to Avoid Pay Problems
CMS recommends the following to providers’ medical coders:
- Medical records must contain adequate, clear documentation that supports the medical necessity of the amount ordered and 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.
- Local Coverage Determination L33828 provides the Healthcare Common Procedure Coding System (HCPCS) codes that are used to bill Ostomy Supplies and the “usual maximum quantity” for
- 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.
- Providers are reminded to clearly document explanations to support the need for a greater quantity of supplies than the amounts.
- Providers are reminded that certain supplies are similar enough in nature and function that they may not be provided/billed in unison:
- When a liquid barrier is necessary, either liquid or spray (A4369) or individual wipes or swabs (A5120) are appropriate. The use of both is not reasonable and necessary.
- Beneficiaries with continent stomas may use the following means to prevent/manage drainage: stoma cap (A5055), stoma plug (A5081), stoma absorptive cover (A5083) or gauze pads (A6216). No more than one of these types of supplies would be reasonable and necessary on a given
- Beneficiaries with urinary ostomies may use either a bag (A4357) or bottle (A5102) for drainage at night. It is not reasonable and necessary to have both.
And the following to providers’ billers:
Ostomy supplies are not separately payable when a beneficiary is in a covered home health episode. The home health agency must provide the ostomy supplies, and payment is included in the home health Medicare payment rate.