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Ostomy Supplies

Section: Orthotic & Prosthetic Devices
Effective Date: July 01, 2018
Revised Date: August 08, 2019
Last Reviewed: July 16, 2019

Description

Ostomy supplies are prosthetic devices used by individuals who have a surgically created opening, or stoma, to divert urine, feces, or ileal contents outside of their bodies.

Tracheostomy care supplies are prosthetic devices used by individuals who have a surgically created opening, or tracheostomy, to assist with breathing when their trachea is impaired.

Prosthetic devices replace all or part of an absent body organ or the function of a permanently inoperative or malfunctioning body organ.

Criteria

Ostomy supplies may be considered medically necessary when ALL of the following are met:

  • The individual has a surgically created opening (stoma) to divert urine or fecal contents outside of the body; and
  • The ostomy supplies replace all or part of an absent body organ or the function of a permanently inoperative or malfunctioning organ.

Tracheostomy supplies may be considered medically necessary when:

  • The tracheostomy supplies are prescribed following an open surgical tracheostomy which has been open or is expected to remain open for at least three (3) months.

Ostomy and tracheostomy supplies not meeting the above criteria are considered not medically necessary.

Dispensing prosthetic devices for post-operative use prior to the procedure is considered not medically necessary.

Procedure Codes

A4331  A4357  A4358  A4361  A4362  A4363  A4364 
A4366  A4367  A4368  A4369  A4371  A4372  A4373 
A4375  A4376  A4377  A4378  A4379  A4380  A4381 
A4382  A4383  A4384  A4385  A4387  A4388  A4389 
A4390  A4391  A4392  A4393  A4394  A4395  A4396 
A4397  A4398  A4399  A4402  A4404  A4405  A4406 
A4407  A4408  A4409  A4410  A4411  A4412  A4413 
A4414  A4415  A4416  A4417  A4418  A4419  A4420 
A4421  A4422  A4423  A4424  A4425  A4426  A4427 
A4428  A4429  A4430  A4431  A4432  A4433  A4434 
A4435  A4450  A4452  A4455  A4456  A4481  A4623 
A4625  A4626  A4629  A5051  A5052  A5053  A5054 
A5055  A5056  A5057  A5061  A5062  A5063  A5071 
A5072  A5073  A5081  A5082  A5083  A5093  A5102 
A5112  A5120  A5121  A5122  A5126  A5131  A6216 
A7501  A7502  A7503  A7504  A7505  A7506  A7507 
A7508  A7509  A7520  A7521  A7522  A7524  A7526 
A7527  L8501  S8189

Quantity Level Limits (QLL)

Quantity level limits (QLL) for ostomy supplies are determined primarily by the type of ostomy, its location, its construction, and the condition of the skin surface surrounding the stoma. 

The table lists the QLL of ostomy supplies that may be considered medically necessary. 

Quantities of ostomy supplies that exceed the QLL listed on the table will be denied as not medically necessary. 

Accessory  Description  Usual Maximum Replacement per month 
A4357  Bedside drainage bag, day or night, with or without anti-reflux device, with or without tube, each  2 every month 
A4362  Skin barrier; solid, 4 x 4 or equivalent; each  20 every month 
A4364  Adhesive, liquid or equal, any type, per oz.  4 every month 
A4367  Ostomy belt, each  1 every month 
A4369  Ostomy skin barrier, liquid (spray, brush, etc.), per oz.  2 every month 
A4377  Ostomy pouch, drainable, for use on faceplate, plastic, each  10 every month 
A4381  Ostomy pouch, urinary, for use on faceplate, plastic, each  10 every month 
A4397  Irrigation supply; sleeve, each  4 every month 
A4402  Lubricant, per ounce  4 every month 
A4404  Ostomy ring, each  10 every month 
A4405  Ostomy skin barrier, non-pectin based, paste, per ounce  4 every month 
A4406  Ostomy skin barrier, pectin-based, paste, per ounce  4 every month 
A4414  Ostomy skin barrier, with flange (solid, flexible or accordion), without built-in convexity, 4 x 4 inches or smaller, each  20 every month 
A4415  Ostomy skin barrier, with flange (solid, flexible or accordion), without built-in convexity, larger than 4<97>4 inches, each  20 every month 
A4416  Ostomy pouch, closed, with barrier attached, with filter (1 piece), each  60 every month 
A4417  Ostomy pouch, closed, with barrier attached, with built-in convexity, with filter (1 piece), each  60 every month 
A4418  Ostomy pouch, closed; without barrier attached, with filter (1 piece), each  60 every month 
A4419  Ostomy pouch, closed; for use on barrier with non-locking flange, with filter (2 piece), each  60 every month 
A4420  Ostomy pouch, closed; for use on barrier with locking flange (2 piece), each  60 every month 
A4423  Ostomy pouch, closed; for use on barrier with locking flange, with filter (2 piece), each  60 every month 
A4424  Ostomy pouch, drainable, with barrier attached, with filter (1 piece), each  20 every month 
A4425  Ostomy pouch, drainable; for use on barrier with non-locking flange, with filter (2 piece system), each  20 every month 
A4426  Ostomy pouch, drainable; for use on barrier with locking flange (2 piece system), each  20 every month 
A4427  Ostomy pouch, drainable; for use on barrier with locking flange, with filter (2 piece system), each  20 every month 
A4429  Ostomy pouch, urinary, with barrier attached, with built-in convexity, with faucet-type tap with valve (1 piece), each  20 every month 
A4431  Ostomy pouch, urinary; with barrier attached, with faucet-type tap with valve (1 piece), each  20 every month 
A4432  Ostomy pouch, urinary; for use on barrier with nonlocking flange, with faucet-type tap with valve (2 piece), each  20 every month 
A4433  Ostomy pouch, urinary; for use on barrier with locking flange (2 piece), each  20 every month 
A4434  Ostomy pouch, urinary; for use on barrier with locking flange, with faucet-type tap with valve (2 piece), each  20 every month 
A4450  Tape, non-waterproof, per 18 square inches  40 every month 
A4452  Tape, waterproof, per 18 square inches  40 every month 
A4456  Skin barrier, wipes or swabs, each  50 every month 
A4481  Tracheostoma filter, any type, any size, each  62 every month 
A4623  Tracheostomy, inner cannula  62 every month 
A4625  Tracheostomy care kit for new tracheostomy  31 every month 
A4626  Tracheostomy cleaning brush, each  2 every month 
A4629  Tracheostomy care kit for established tracheostomy  31 every month 
A5051  Ostomy pouch, closed; with barrier attached (1 piece), each  60 every month 
A5052  Ostomy pouch, closed; without barrier attached (1 piece), each  60 every month 
A5053  Ostomy pouch, closed; for use on faceplate, each  60 every month 
A5054  Ostomy pouch, closed; for use on barrier with flange (2 piece), each  60 every month 
A5055  Stoma cap  31 every month 
A5056  Ostomy pouch, drainable, with extended wear barrier attached, with filter, (1 piece), each  40 every month 
A5057  Ostomy pouch, drainable, with extended wear barrier attached, with built in convexity, with filter, (1 piece), each  40 every month 
A5061  Ostomy pouch, drainable; with barrier attached, (1 piece), each  20 every month 
A5062  Ostomy pouch, drainable; without barrier attached (1 piece), each  20 every month 
A5063  Ostomy pouch, drainable; for use on barrier with flange (2-piece system), each  20 every month 
A5071  Ostomy pouch, urinary; with barrier attached (1 piece), each  20 every month 
A5072  Ostomy pouch, urinary; without barrier attached (1 piece), each  20 every month 
A5073  Ostomy pouch, urinary; for use on barrier with flange (2 piece), each  20 every month 
A5081  Stoma plug or seal, any type  31 every month 
A5082  Continent device; catheter for continent stoma  1 every month 
A5083  Continent device, stoma absorptive cover for continent stoma  150 every month 
A5093  Ostomy accessory; convex insert  10 every month 
A5121  Skin barrier; solid, 6 x 6 or equivalent, each  20 every month 
A5122  Skin barrier; solid, 8 x 8 or equivalent, each  20 every month 
A5126  Adhesive or nonadhesive; disk or foam pad  20 every month 
A5131  Appliance cleaner, incontinence and ostomy appliances, per 16 oz  1 every month 
A6216  Gauze, nonimpregnated, nonsterile, pad size 16 sq in or less, without adhesive border, each dressing  60 every month 
A7501  Tracheostoma valve, including diaphragm, each  1 every month 
A7502  Replacement diaphragm/faceplate for tracheostoma valve, each  1 every month 
A7504  Filter for use in a tracheostoma heat and moisture exchange system, each  62 every month 
A7506  Adhesive disc for use in a heat and moisture exchange system and/or with tracheostoma valve, any type each  62 every month 
A7507  Filter holder and integrated filter without adhesive, for use in a tracheostoma heat and moisture exchange system, each  62 every month 
A7508  Housing and integrated adhesive, for use in a tracheostoma heat and moisture exchange system and/or with a tracheostoma valve, each  62 every month 
A7509  Filter holder and integrated filter housing, and adhesive, for use as a tracheostoma heat and moisture exchange system, each  62 every month 
A7526  Tracheostomy tube collar/holder, each  31 every month 
A7505  Housing, reusable without adhesive, for use in a heat and moisture exchange system and/or with a tracheostoma valve, each  2 every month 
A7520  Tracheostomy/laryngectomy tube, noncuffed, polyvinylchloride (PVC), silicone or equal, each  1 every month 
A7521  Tracheostomy/laryngectomy tube, cuffed, polyvinylchloride (PVC), silicone or equal, each  1 every month 
A7524  Tracheostoma stent/stud/button, each  1 every month 
A7527  Tracheostomy/laryngectomy tube plug/stop, each  2 every month 
A4361  Ostomy faceplate, each  3 per 6 months 
A4371  Ostomy skin barrier, powder, per oz  10 per 6 months 
A4398  Ostomy irrigation supply; bag, each  2 per 6 months 
A4399  Ostomy irrigation supply; cone/catheter, with or without brush  2 per 6 months 
A4455  Adhesive remover or solvent (for tape, cement or other adhesive), per oz  16 per 6 months 
A5102  Bedside drainage bottle with or without tubing, rigid or expandable, each  2 per 6 months 
A5120  Skin barrier, wipes or swabs, each  150 per 6 months 
A7503  Filter holder or filter cap, reusable, for use in a tracheostoma heat and moisture exchange system, each  1 per 6 months 
A7522  Tracheostomy/laryngectomy tube, stainless steel or equal (sterilizable and reusable), each  1 per year

Tracheostomy/laryngectomy tube plug/stop is an alternative to a tracheostomy/ laryngectomy tube. Claims submitted for A7520, A7521 and A7522 in addition to A7527 will be denied as non-covered.

Tracheostomy shower protector, each will be denied as non-covered.

Procedure Codes

A7523    A7527

Diagnosis Codes

J95.00  J95.01  J95.03  J95.04  J95.09  K94.00  K94.03 
K94.10  K94.13  Z43.0  Z43.2  Z43.3  Z43.6  Z93.0 
Z93.2  Z93.3  Z93.6

Links