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By Kim Turner RN

As a supplier, have you ever billed a claim to Medicare for ostomy supplies only to receive the denial for exceeds usual maximum quantity? If you answered yes, the information provided below will be helpful.

Most ostomy supply claims are denied for overutilization. The Medicare Ostomy Supplies local coverage determination (LCD) or policy provides a chart that indicates the usual maximum quantity for each supply:   

Code # per Month
A4357 2
A4362 20
A4364 4
A4367 1
A4369 2
A4377 10
A4381 10
A4397 4
A4402 4
A4404 10
A4405 4
A4406 4
A4414 20
A4415 20
A4416 60
A4417 60
A4418 60
A4419 60
A4420 60
A4423 60
A4424 20
A4425 20
A4426 20
A4427 20
A4429 20
A4431 20
A4432 20
A4433 20
A4434 20
A4450 40
A4452 40
A5051 60
A5052 60
A5053 60
A5054 60
A5055 31
A5056 40
A5057 40
A5061 20
A5062 20
A5063 20
A5071 20
A5072 20
A5073 20
A5081 31
A5082 1
A5083 150
A5093 10
A5121 20
A5122 20
A5126 20
A5131 1
A6216 60
Code # per 6 Months
A4361 3
A4371 10
A4398 2
A4399 2
A4455 16
A5102 2
A5120 150

In the event the Medicare beneficiary needs to use more than the usual amounts, the specific medical reason(s) must be clearly documented in the beneficiary's medical record. The documentation is necessary when requesting a redetermination for the initial claim denials and any subsequent appeals.

If the reason(s) in the medical record are not clear and/or not sufficient, or the documentation is not provided, the excess quantities will be denied by Medicare as not reasonable and necessary.

How can we help?

Before billing these HCPCS codes, let our clinical staff prescreen your records to ensure the proper documentation is present that meets coverage criteria. Further, the proactive audit services can review a sample of your claims billed to Medicare and identify areas of weakness needing to be addressed. Proactive audits are completed on a quarterly basis to ensure issues identified are rectified and changes made continue throughout your organization. This proactive approach will allow you to be confident in your claims if you are audited. Contact us today to learn more about the prescreen and proactive audit services.