Product Manual
17
www.hollister.com Hollister Incorporated
Medicare’s Usual Maximum Quantity for Ostomy Supplies
The quantity of ostomy supplies needed by a patient is determined
primarily by the type of ostomy, its location, its construction, and
the condition of the skin surface surrounding the stoma. There will be
variation according to individual patient need and their needs may vary
over time. The table below lists the maximum number of items/units
of service that are usually medically necessary. The actual quantity
needed for a particular patient may be more or less than the amount
listed depending on the factors that affect the frequency of barrier and
pouch change. The medical necessity for use of a greater quantity of
supplies than the amounts listed must be clearly documented in the
patient’s medical record, and must be available upon request. If adequate
documentation is not provided when requested, the excess quantities will
be denied as not medically necessary.
Per LCD for Ostomy Supplies (L11502), NHIC effective 1-1-2011.
New Ostomy Codes added effective 1-1-2012.
Medicare Utilization Chart
HCPCS Long Description Quantity
A4331 Extension drainage tubing, any type, any length, with
✳
connector/adapter, for use with urinary leg bag
or urostomy pouch, each
A4357 Bedside drainage bag, day or night, with or without 2 ea /mo
anti-reux device, with or without tube, each
A4361 Ostomy faceplate, each 3 ea/6 mo
A4362 Skin barrier, solid, 4 x 4 or equivalent, each 20 ea/mo
A4363 Ostomy clamp, any type, replacement only, each
✳
A4364 Adhesive, liquid or equal, any type, per ounce 4 oz/mo
A4366 Ostomy vent, any type, each
✳
A4367 Ostomy belt, each 1 ea/mo
A4368 Ostomy lter, any type, each
✳
A4369 Ostomy skin barrier, liquid (spray, brush, etc.), per ounce 2 oz/mo
A4371 Ostomy skin barrier, powder, per ounce 10 oz/6 mo
A4372 Ostomy skin barrier, solid 4 x 4 or equivalent, standard wear
✳
with built-in convexity, each
A4373 Ostomy skin barrier, with ange (solid, exible, or accordion),
✳
with built-in convexity, any size, each
A4375 Ostomy pouch, drainable, with faceplate attached, plastic, each
✳
A4376 Ostomy pouch, drainable, with faceplate attached, rubber, each
✳
A4377 Ostomy pouch drainable for use on faceplate, 10 ea/mo
plastic, each
A4378 Ostomy pouch, drainable, for use on faceplate, rubber, each
✳
A4379 Ostomy pouch, urinary, with faceplate attached, plastic, each
✳
A4380 Ostomy pouch, urinary, with faceplate attached, rubber, each
✳
A4381 Ostomy pouch, urinary, for use with faceplate, plastic, each 10 ea/mo
A4382 Ostomy pouch, urinary, for use on faceplate,
✳
heavy plastic, each
A4383 Ostomy pouch, urinary, for use on faceplate, rubber, each
✳
A4384 Ostomy faceplate equivalent, silicone ring, each
✳
A4385 Ostomy skin barrier, solid 4 x 4 or equivalent, extended wear,
✳
without built-in convexity, each
A4387 Ostomy pouch, closed, with barrier attached, with built-in
✳
convexity (1 piece), each
A4388 Ostomy pouch, drainable, with extended wear barrier
✳
attached, (1 piece), each
A4389 Ostomy pouch, drainable, with barrier attached, with built-in
✳
convexity (1 piece), each
✳
No established usual maximum, refer to Medicare Utilization Guidelines.