Ostomy Care Reimbursement

Navigating the healthcare system can be challenging, especially when it comes to understanding insurance coverage and reimbursement for ostomy supplies. This page is designed to help clarify the process, offering guidance on current Medicare ostomy policy and tools and resources available to combat access challenges.

For any questions, please reach out to our Reimbursement and Market Access team at USreimbursement@coloplast.com

Medicare program outline

Medicare is a federal insurance program that covers individuals who are 65 years of age or older, people under age 65 with certain disabilities and people of all ages with end-stage renal disease (permanent kidney failure requiring dialysis or a kidney transplant).

Medicare is an 80/20 plan, meaning Medicare covers 80% and the remaining 20% is the beneficiary’s responsibility.

For any item to be covered by Medicare, it must:

Be eligible for a defined Medicare benefit category,
Be “reasonable and necessary” for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and
Meet all other applicable Medicare statutory and regulatory requirements. For ostomy supplies, determinations other than those based on Social Security Act §1862(a)(1)(A) provisions (i.e. “reasonable and necessary”) are provided in a Policy Article and Local Coverage Determination (LCD).

Part A - Hospital insurance

Hospital stays
Skilled nursing facilities (SNF)
Hospice
Some home health

Part B - Medical insurance

Outpatient care
Physical & occupational therapy
Durable medical equipment (DME) – including medical supplies
Some home health

Part C - Medicare Advantage (Part A (hospital insurance) and Part B (medical insurance) are provided by commercial insurers)

Part D - Prescription drug coverage

Beneficiary pays a monthly premium

Click here for more information about Traditional Medicare or Medicare Advantage

Patient advocacy & combating access challenges

Access challenges in the ostomy care space remain a significant concern for patients, providers, and advocates. Despite medical advancements and improved product designs, several systemic barriers continue to affect the quality and consistency of care including inadequate reimbursement, coverage disparities, and limited advocacy support.

The following resources can aid in combating patient access challenges allowing for more adequate ostomy care.

The Ostomy and Continent Diversion Patient Bill of Rights

The Ostomy and Continent Diversion Patient Bill of Rights was created by a patient organization and advocacy group, United Ostomy Associations of America (UOAA), to address gaps in quality care for individuals with ostomies. It aims to ensure that healthcare facilities and providers deliver patient-centered, high-quality care, including access to specialized support like WOC nurses.

Per the Bill of Rights, patients should expect (not exhaustive):

Pre-operative explanation of the surgical procedure and the rationale for surgery
Opportunities to address emotional and social impact of ostomy surgery
Education at multiple stages of the care continuum on living with an ostomy/continent diversion, including:
- Specialized nurse support – including finding an individualized and reliable fitting pouching system post-discharge
- Information about the impact of surgery on daily activities and lifestyle changes such as clothing choices, exercise, diet and sexuality
- Dietary guidelines and strategies to prevent dehydration given both verbally and in a written format
- Information about the supply ordering process – including resources for obtaining supplies specific to patient circumstances (e.g., uninsured/ underinsured)
- Information about manufacturers’ post-discharge support programs
- Information about organizations that support and advocate for patients living with an ostomy or continent diversion such as United Ostomy Associations of America and their Affiliated Support Groups

Challenges can often arise from uncertainty about what qualifies for coverage, how to document medical necessity, and how to manage situations that fall outside standard quantity limits or typical supply patterns. This section addresses these access obstacles by clarifying common points of confusion, outlining the documentation that supports timely provision of supplies, and equipping suppliers with the knowledge needed to advocate effectively for their patients.

The Noridian Clinician Letter provides targeted guidance to healthcare professionals on Medicare coverage, documentation expectations, and policy updates relevant to DMEPOS services. It is designed to clarify common areas of confusion, promote compliant billing practices, and support clinicians in ensuring beneficiaries receive medically necessary equipment and supplies

The clinician checklist provides a concise, step-by-step guide to ensure all required documentation and medical criteria are met for compliant ordering and coverage of Ostomy Supplies.

Noridian Clinician Checklist: Clinician Checklist for Ostomy Supplies

CGS Clinician Checklist: Ostomy Supplies Documentation Checklist (DME MAC Jurisdictions B & C)

The Ostomy Supplies FAQs offer clear guidance to suppliers on Medicare coverage rules, documentation requirements, and billing expectations for a wide range of ostomy related scenarios, including hernia belts, irrigation sleeves, new stomas, and multiple ostomies. By addressing common points of confusion and outlining when additional justification or appeals are needed, the FAQs help suppliers navigate access challenges and ensure beneficiaries receive medically necessary supplies without unnecessary delays.

Medicare coverage for ostomy supplies

Coverage is defined by Medicare in the Ostomy Supplies – Policy Article and Local Coverage Determination (LCD) for Ostomy Supplies

Coverage criteria for ostomy supplies and accessories are outlined in the Policy Article:

Ostomy supplies are covered for a beneficiary who has a permanent impairment requiring an ostomy. 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. If the medical record, including the judgment of the treating practitioner, indicates the condition is of long and indefinite duration, the test of permanence is considered met.

Ostomy supplies are also covered for beneficiaries with a surgically created stoma for colostomy, ileostomy, or urinary diversion. Use for other conditions is noncovered. These supplies are not separately payable during a covered home health episode; they must be provided by the home health agency and are included in the Medicare payment rate, not billed to the DME MAC.

Coverage guidelines are further outlined in the LCD, which provides monthly quantity limits and requirements for documentation, shipping, delivery and refills.

Reimbursement is based on the Medicare DMEPOS fee schedule.

Ostomy Coverage Details and Number of Supplies Covered

The quantity of ostomy supplies needed by a beneficiary is determined by:

ü The type of ostomy (use for other conditions, including a non-surgically created opening, will be denied as non-covered)

ü Stoma location

ü Stoma construction

ü Skin condition around the stoma

If greater quantity of supplies is needed it must be clearly documented in the medical record.

Medicare: Extended wear vs. standard wear barriers

Standard wear products have a maximum quantity assigned

Extended wear products do not have a maximum quantity assigned

• “An extended wear barrier (e.g., A4409) is a pectin-based barrier with special additives which achieve a stronger adhesive seal, resist breakdown by urine or bowel effluent, permit longer wear times between changes, and normal wear times for those who cannot achieve them with standard barriers”

If a beneficiary resides in a nursing facility the DME provider (durable medical equipment supplier) can ship 1 month of ostomy supplies at a time to the nursing facility.

If a beneficiary resides at home the DME provider (durable medical equipment supplier) can ship 3 months of ostomy supplies at a time to the beneficiary’s home.

The link below details the maximum number of items that are usually medically necessary for some common ostomy products (not exhaustive):

LCD – Ostomy Supplies (L33828) – Centers for Medicare

Number of Supplies Covered

HCPCS	Description	Usual Maximum
A4331*	Extension drainage tubing, any type, any length, with connector/adaptor, for use with urinary leg bag or urostomy pouch, each	Not listed
A4357	Bedside drainage bag, day or night, with or without anti-reflux device, with or without tube, each	2/month
A4361	Ostomy faceplate, each	3/6 month
A4362	Skin barrier; solid, 4 x 4 or equivalent; each	20/month
A4363*	Ostomy clamp, any type, replacement only, each	Not listed
A4367	Ostomy belt, each	1/month
A4368*	Ostomy filter, any type, each	Not listed
A4369	Ostomy skin barrier, liquid (spray, brush, etc.), / oz	2 / mo
A4371	Ostomy skin barrier, powder, / oz	10 / 6 mo
A4373*	Ostomy skin barrier, with flange (solid, flexible or accordion), with built-in convexity, any size, each	Not listed
A4385*	Ostomy skin barrier, solid 4 x 4 or equivalent, extended wear, without built-in convexity, each	Not listed
A4388*	Ostomy pouch, drainable, with extended wear barrier attached, (1 piece), each	Not listed
A4389*	Ostomy pouch, drainable, with barrier attached, with built-in convexity (1 piece), each	Not listed
A4390*	Ostomy pouch, drainable, with extended wear barrier attached, with built-in convexity (1 piece), each	Not listed
A4391*	Ostomy pouch, urinary, with extended wear barrier attached (1 piece), each	Not listed
A4392*	Ostomy pouch, urinary, with standard wear barrier attached, with built-in convexity (1 piece), each	Not listed
A4393*	Ostomy pouch, urinary, with extended wear barrier attached, with built-in convexity (1 piece), each	Not listed
A4394*	Ostomy deodorant, with or without lubricant, for use in ostomy pouch, / fluid ounce	Not listed
A4396*	Ostomy belt with /istomal hernia support	Not listed
A4398	Ostomy irrigation supply; bag, each	2/6 month
A4399	Ostomy irrigation supply; cone/catheter, with or without brush	2/6 month
A4404	Ostomy ring, each	10/month
A4405	Ostomy skin barrier, non-pectin based, paste, / ounce	4/month
A4406	Ostomy skin barrier, pectin-based, paste, / ounce	4/month
A4407*	Ostomy skin barrier, with flange (solid, flexible, or accordion), extended wear, with built-in convexity, 4 x 4 inches or smaller, each	Not listed
A4408*	Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, with built-in convexity, larger than 4 x 4 inches, each	Not listed
A4409*	Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, without built-in convexity, 4 x 4 inches or smaller, each	Not listed
A4410*	Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, without built-in convexity, larger than 4 x 4 inches, each	Not listed
A4411*	Ostomy skin barrier, solid 4 x 4 or equivalent, extended wear, with built-in convexity, each	Not listed
A4413*	Ostomy pouch, drainable, high output, for use on a barrier with flange (2 piece system), with filter, each	Not listed
A4414	Ostomy skin barrier, with flange (solid, flexible or accordion), without built-in convexity, 4 x 4 inches or smaller, each	20/month
A4415	Ostomy skin barrier, with flange (solid, flexible or accordion), without built-in convexity, larger than 4 x 4 inches, each	20/month
A4416	Ostomy pouch, closed, with barrier attached, with filter (1 piece), each	60/month
A4417	Ostomy pouch, closed, with barrier attached, with built-in convexity, with filter (1 piece), each	60/month
A4419	Ostomy pouch, closed; for use on barrier with non-locking flange, with filter (2 piece), each	60/month
A4421	Ostomy supply; miscellaneous	Not listed
A4423	Ostomy pouch, closed; for use on barrier with locking flange, with filter (2 piece), each	60/month
A4424	Ostomy pouch, drainable, with barrier attached, with filter (1 piece), each	20/month
A4425	Ostomy pouch, drainable; for use on barrier with non-locking flange, with filter (2 piece system), each	20/month
A4426	Ostomy pouch, drainable; for use on barrier with locking flange (2 piece system), each	20/month
A4427	Ostomy pouch, drainable; for use on barrier with locking flange, with filter (2 piece system), each	20/month
A4428*	Ostomy pouch, urinary, with extended wear barrier attached, with faucet-type tap with valve (1 piece), each	Not listed
A4429	Ostomy pouch, urinary, with barrier attached, with built-in convexity, with faucet-type tap with valve (1 piece), each	20/month
A4430*	Ostomy pouch, urinary, with extended wear barrier attached, with built-in convexity, with faucet-type tap with valve (1 piece), each	Not listed
A4432	Ostomy pouch, urinary; for use on barrier with non-locking flange, with faucet-type tap with valve (2 piece), each	20/month
A4433	Ostomy pouch, urinary; for use on barrier with locking flange (2 piece), each	20/month
A4434	Ostomy pouch, urinary; for use on barrier with locking flange, with faucet-type tap with valve (2 piece), each	20/month
A4436	Irrigation supply; sleeve, reusable, / month	1/month
A4437	Irrigation supply; sleeve, disposable, / month	1/month
A4455	Adhesive remover or solvent (for tape, cement or other adhesive), / ounce	16/6 month
A4456*	Adhesive remover, wipes, any type, each	Not listed
A5055	Stoma cap	31/month
A5056	Ostomy pouch, drainable, with extended wear barrier attached, with filter, (1 piece), each	40/month
A5057	Ostomy pouch, drainable, with extended wear barrier attached, with built in convexity, with filter, (1 piece), each	40/month
A5061	Ostomy pouch, drainable; with barrier attached, (1 piece), each	20/month
A5063	Ostomy pouch, drainable; for use on barrier with flange (2 piece system), each	20/month
A5071	Ostomy pouch, urinary; with barrier attached (1 piece), each	20/month
A5073	Ostomy pouch, urinary; for use on barrier with flange (2 piece), each	20/month
A5114*	Leg strap; foam or fabric, replacement only, / set	Not listed
A5120	Skin barrier, wipes or swabs, each	150/6 month
A5121	Skin barrier; solid, 6 x 6 or equivalent, each	20/month
A5122	Skin barrier; solid, 8 x 8 or equivalent, each	20/month

*Quantity limits not published

Individual products are submitted by manufacturers for HCPCS code verification to the Medicare Contractor for Pricing, Data Analysis and Coding of HCPCS Level II DMEPOS Codes (PDAC); verified HCPCS codes are posted on the PDAC Product Classification List

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Benefits of the Coloplast® Professional Educational platform

Medicare program outline

Patient advocacy & combating access challenges

The Ostomy and Continent Diversion Patient Bill of Rights

Medicare coverage for ostomy supplies

Ostomy Coverage Details and Number of Supplies Covered