For the 2018 reporting period, insufficient documentation accounted for 81.6 percent of improper payments for ostomy supplies. Additional types of errors for ostomy supply claims in the 2018 reporting period were no documentation (2.3 percent) and medical necessity (1.9 percent).
Medical records must contain adequate, clear documentation that supports the medical necessity of the amount ordered and billed. 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.
Document if the diversion is an intestinal or urinary ostomy, whether it’s temporary or permanent, and the location— abdominal quadrant, skinfold, umbilicus.
Describe the type of ostomy:
- colostomy (colon)—sigmoid or descending colostomy, transverse colostomy, loop colostomy, ascending colostomy
- ileostomy (small bowel)—ileoanal reservoir (J-pouch), continent ileostomy (Kock pouch)
- urostomy (bladder)—continent urostomy, Indiana pouch, orthotopic neobladder.
Document the presence and location of bowel sounds.
Note the type:
- loop (two openings through one stoma)
- end (one stoma)
- double barrel (two distinct stomas).
Document the overall appearance (shiny, taut, edematous, dry, moist, pale, textured, smooth, and bloody) and the presence of stents, rods, drains (include type and location). Describe the color (red, beefy red, pink, pale pink, purple, blue, black) and shape (round, oval, budded).
Note the height:
- flush—at skin level
- prolapsed—telescoped out from the abdominal surface.
Document the size in millimeters:
- Round stomas are measured by diameter.
- Oval stomas are measured by widest length and width.
Describe the lumen:
- location—straight up, side, level with skin, or centrally located
- number of lumens, stenosis, or stricture.
Note: Document the location of the lumen by using the clock system, with the patient’s head at 12:00. Describe the odor—presence or absence of odor, strong, foul, pungent, fecal, musty, sweet. Note whether the stoma and peristomal skin junction is intact or separated.
- For a fecal stoma, describe the amount, consistency, and overall appearance of effluent— thick, viscous, liquid, pasty, oily, formed, soft, thin, tarry.
- For a urinary diversion, describe urine characteristics, volume, presence of odor (musty, fishy, fecal, acid), color (clear, cloudy, amber, straw, colored, blood-tinged), and presence of substances other than fluid (grit, crystals, mucous strands).
- Describe the characteristics of peristomal skin—color, edema, firmness, intactness, induration, pallor, lesions, texture, scar, incision, rash, staining, moisture.
- Assess a minimum of 2 inches out from around the stoma.
Appliance and accessories
- Document the type of ostomy appliance and accessories. Include the pouching system product, size, and product number. Note the presence of a spout, the convexity, and whether it’s a one-piece or two-piece system,
- Observe and document proper function and adhesion, and complications experienced with appliance systems. Document any modifications to the care plan, implementation of new orders, and referrals.
Other important information
- Document pain—location, causative factors, intensity, quality, duration, alleviating factors, patterns, variations, interventions.
- Note stoma or peristomal skin complications— mucocutaneous separation, stenosis, necrosis, bleeding, dermatitis, folliculitis, peristomal hernia, caput medusae, peristomal hyperplasia, pseudoverrucous lesions, allergic dermatitis, contact dermatitis, pouch leakage, infection.
- Document patient and caregiver education— topics covered, level of understanding, and education materials distributed.
Additional Tips for Medicare Payment:
- Medical records must contain adequate, clear documentation that supports the medical necessity of the amount ordered and 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).
- 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.
- 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.