Ostomy medicare policy

Advances in Skin & Wound Care, Sep/Oct 2002 by Schaum, Kathleen D

Payment Strategies Q: Does Medicare have a medical policy for ostomy supplies similar to the Surgical Dressing Policy? A: Yes. In fact, Medicare's original policy was recently retired and replaced by a new ostomy supply policy, effective for claims with dates of service on or after July 1, 2002.

The new ostomy policy includes the following components:

* Medicare benefits category that covers ostomy supplies

* HCPCS (Health Care Financing Administration Common Procedure Coding System) codes and description of covered ostomy supplies

* definitions of barriers, faceplates, pouches, add-on features to pouches, and pastes

* coverage and payment rules

* coding guidelines

* documentation guidelines.

Q: Many new ostomy supplies are now available from the manufacturers. Does the new policy provide any new HCPCS codes and categories to cover these products?

A: Twenty new K codes, which describe ostomy products that recently came on the market, went into effect on April 1, 2002. The new codes and ceiling rates on the Durable Medical Equipment Regional Carriers' (DMERC) Fee Schedules are listed in Table 1.

Q: Some of the new ostomy codes seem similar to the original ostomy HCPCS codes. Do the new codes replace any of the original codes?

A: Yes, several ostomy codes have been retired: A4370-Paste, A5123-Standard barrier with flange, A4386-Extended wear barrier with flange, A4374-Extended wear barrier with flange with convexity, A5061-One-piece drainable pouch, and A6265-Tape.

Q: Some of the new ostomy codes appear to be additional features of pouches. Can a Medicare Part B supplier bill for those features in addition to billing for the pouch?

A: When supplied with a covered ostomy pouch, HCPCS codes K0574 through K0580 are paid separately and in addition to the ostomy pouch HCPCS codes for which these K codes represent add-on features. In this situation, they should be billed on separate claim lines from the pouch HCPCS code.

Q: Does the ostomy policy require specific information to be included in the physician's order for ostomy supplies? A: The physician's order must specify:

* diagnosis

* type of supplies

* approximate quantity to be used per unit of time

* reason for quantities greater than the usual maximum quantity

* physician signature and date.

Q: How often is a physician's order required for ostomy supplies?

A: Physicians are required to write ostomy supply orders for: * initial ostomy supplies

* change in quantity that will be used per unit of time

* change in type of supplies used.

Q: What documentation should the ostomy supplier/biller keep on file?

A: The ostomy supplier/biller must keep the following information on file:

* order signed and dated by the physician

* ICD-9-CM (International Classification of Diseases, 9th Revision, Clinical Modification) diagnosis describing the type of ostomy

* documentation to support quantity greater than typically allowed by Medicare.

The ostomy supplier/biller must also have access to the patient's medical record and must submit them to the DMERC if and when asked to do so. Noth that the medical record includes records from the:

* physician's office

* hospital

* nursing home

* home health agency

* other professionals

Q: Many durable medical equipment suppliers have stopped accepting Medicare assignment for ostomy supplies. Will these new codes and add-on codes be an incentive for the suppliers to begin accepting Medicare assignment again?

A: This new policy should help motivate ostomy suppliers to accept assignment for a broader spectrum of ostomy supplies. In addition, the new codes and rates should help ostomy patients benefit from newer technology now available. Furthermore, patients will benefit from Nedicare's addition of the new pectin-based skin barrier code and rate. They will no longer be required to pay 100% of the charge for this product, an essential item for many ostomy patients.

Kathleen D. Schaum, MS

Kathleen D, Schaum, MS, is director, Strategic Business Development for Wound Care Strategies, Inc, Harrisburg, PA. Ms Schaum can be reached for questions and consultation by calling 561-964-2470 or through her E-mail address, kdschaum@woundcarestrategies.com. Submit your questions for Payment Strategies by mail to Kathleen D. Schaum, MS, 6491 Rock Creek Drive, Lake Worth, Fl 33467. Information on payment is provided as a service to our readers, but does not guarauntee that payment will be provided, Providers are responsible for case-by-case documentation and qualification for payment.