Ostomy pouch, closed, with barrier attached, w/built-in convexity (1 piece), each
A4387
60 per month (180 per 3 mo)
Ostomy pouch, drainable, with extended wear barrier attached, (1 piece), each
A4388
undefined
Ostomy pouch, drainable, with barrier attached, w/built-in convexity (1piece), each
A4389
20 per month (60 per 3 mo)
Ostomy pouch, drainable, with extended wear barrier attached, w/built-in convexity (1 piece), each
A4390
undefined
Ostomy pouch, urinary, with extended wear barrier attached (1 piece), each
A4391
20 per month (60 per 3 mo)
Ostomy pouch, urinary, with standard wear barrier attached, w/built-in convexity (1 piece), each
A4392
20 per month (60 per 3 mo)
Ostomy pouch, urinary, with extended wear barrier attached, w/built-in convexity (1 piece), each
A4393
undefined
Ostomy pouch, closed, with barrier attached, w/filter (1 piece), each
K0581
20 per month (60 per 3 mo)
Ostomy pouch, closed, with barrier attached, w/built-in convexity, w/filter (1 piece), each
K0582
20 per month (60 per 3 mo)
Ostomy pouch, closed, without barrier attached, with filter (1 piece), each
K0583
20 per month (60 per 3 mo)
Ostomy pouch, drainable, with barrier attached, with filter (1 piece), each
K0587
20 per month (60 per 3 mo)
Ostomy pouch, urinary, with extended wear barrier attached, w/faucet-type tap w/valve (1 piece), each
K0591
undefined
Ostomy pouch, urinary, with barrier attached, w/built-in convexity, w/faucet-type tap w/valve (1 piece), each
K0592
20 per month (60 per 3 mo)
Ostomy pouch, urinary, w/extended wear barrier attached,
w/built-in convexity, w/faucet-type tap w/valve (1 piece), each
K0593
undefined
Ostomy pouch, urinary, w/barrier attached, with faucet-type tap w/valve (1 piece), each
K0594
20 per month (60 per 3 mo)
Ostomy pouch, closed, with barrier attached (1 piece), each
A5051
60 per month (180 per 3 mo)
Ostomy pouch, closed, without barrier attached, (1 piece), each
A5052
60 per month (180 per 3 mo)
Ostomy pouch, drainable, without barrier attached (1 piece), each
A5062
20 per month (60 per 3 mo)
Ostomy pouch, urinary, with barrier attached (1 piece), each
A5071
20 per month (60 per 3 mo)
Ostomy pouch, urinary, without barrier attached (1 piece), each
A5072
20 per month (60 per 3 mo)
Two Piece Systems
Ostomy pouch, closed; for use on barrier with flange, each
A5054
60 per month (180 per 3 mo)
Ostomy pouch, drainable; for use on barrier with flange, each
A5063
20 per month (60 per 3 mo)
Ostomy pouch, urinary; for use on barrier with flange, each
A5073
20 per month (60 per 3 mo)
Ostomy pouch, closed; for use on barrier w/flange, w/filter (2 piece), each
K0584
20 per month (60 per 3 mo)
Ostomy pouch, closed; for use on barrier w/locking flange (2 piece), each
K0585
20 per month (60 per 3 mo)
Ostomy pouch, closed; for use on barrier w/locking glange, w/filter (2 piece), each
K0586
20 per month (60 per 3 mo)
Ostomy pouch, drainable; for use on barrier with flange, w/filter (2 piece), each
K0588
20 per month (60 per 3 mo)
Ostomy pouch, drainable; for use on barrier with locking flange (2 piece), each
K0589
20 per month (60 per 3 mo)
Ostomy pouch, drainable; for use on barrier w/locking flange, w/filter (2 piece), each
K0590
20 per month (60 per 3 mo)
Ostomy pouch, urinary; for use on barrier w/flange, w/faucet-type tap w/valve (2 piece), each
K0595
20 per month (60 per 3 mo)
Ostomy pouch, urinary; for use on barrier w/locking flange (2 piece), each
K0596
20 per month (60 per 3 mo)
Ostomy pouch, urinary; for use on barrier w/locking flange w/faucet-type tap w/valve (2 piece), each
K0597
20 per month (60 per 3 mo)
Skin barrier, solid 4x4 or equivalent, w/built in convexity, each
A4372
20 per month (60 per 3 mo)
Skin barrier, w/flange (solid, flexible, or accordian), w/built-in convexity, any size, each
A4373
20 per month (60 per 3 mo)
Skin barrier, w/flange (solid, flexible, or accordian), extended wear, w/built-in convexity, 4x4 inches or smaller, each
A4407
undefined
Skin barrier, w/flange (solid, flexible, or accordian), extended wear, w/built-in convexity, larger than 4x4 inches, each
A4408
undefined
Skin barrier, solid 4x4 or equivalent, extended wear without built in convexity, each
A4385
undefined
Skin barrier, w/flange (solid, flexible, or accordian), extended wear,
without built-in convexity, 4x4 inches or smaller, each
A4409
undefined
Skin barrier, w/flange (solid, flexible, or accordian), extended wear,
without built-in convexity, larger than 4x4 inches, each
A4410
undefined
Skin barrier, w/flange (solid, flexible, or accordian), without built-in convexity, 4x4 inches or smaller, each
A4414
20 per month (60 per 3 mo)
Skin barrier, w/flange (solid, flexible, or accordian), without built-in convexity, larger than 4x4 inches, each
A4415
20 per month (60 per 3 mo)
Skin barrier; solid, 4x4 or equivalent, each
A4362
20 per month (60 per 3 mo)
Skin barrier; solid, 6x6 or equivalent, each
A5121
20 per month (60 per 3 mo)
Skin barrier; solid, 8x8 or equivalent, each
A5122
20 per month (60 per 3 mo)
Non-Adhesive Face Plate Systems
Ostomy pouch, drainable, with faceplate attached, plastic, each
A4375
long term use
Ostomy pouch, drainable, with faceplate attached, plastic, each
A4376
long term use
Ostomy pouch, drainable, for use on faceplate, plastic, each
A4377
10 per month
Ostomy pouch, drainable, for use on faceplate, rubber, each
A4378
long term use
Ostomy pouch, urinary, with faceplate attached, plastic, each
A4379
long term use
Ostomy pouch, urinary, with faceplate attached, rubber, each
A4380
long term use
Ostomy pouch, urinary, for use on faceplate, plastic, each
A4381
10 per month
Ostomy pouch, urinary, for use on faceplate, heavy plastic, each
A4382
long term use
Ostomy faceplate, each
A4361
3 every 6 mo
Ostomy faceplate equivalent, silicone ring, each
A4384
Ostomy pouch, urinary, for use on faceplate, rubber, each
A4383
long term use
Pouch, closed, for use on faceplate, each
A5053
60 per month (180 per 3 mo)
Miscellaneous Skin Supplies
Ostomy skin barrier, liquid (spray, brush, etc.), per ounce (not covered with A5119)
A4369
2 per month
Ostomy skin barrier, non-pectin based, paste, per ounce
A4405
4 per month
Ostomy skin barrier, pectin-based, paste, per ounce
A4406
4 per month
Ostomy skin barrier, powder, per ounce
A4371
10 every 6 months
Skin barrier, wipes, box per 50 (not covered with A4369)
A5119
3 boxes every 6 months
Adhesive, liquid or equal, any type, per ounce
A4364
4 oz per month
Adhesive remover wipes, any type, per 50
A4365
undefined
Adhesive remover or solvent (for tape, cement or other adhesive), per ounce
A4455
16 oz every 6 mo
Adhesive or non-adhesive; disc or foam pad
A5126
20 per month (60 per 3 mo)
Other Miscellaneous Supplies
Ostomy belt, each
A4367
1 per month (3 every 3 mo)
Ostomy belt with peristomal hernia support
A4396
Based on medical necessity
Ostomy filter, any type, each
A4368
Not covered
Ostomy deodorant for use in ostomy pouch, liquid, per fluid ounce
A4394
Based on medical necessity
Ostomy deodorant for use in ostomy pouch, solid, per tablet
A4395
Based on medical necessity
Stoma Cap (not covered with A5081 or A6216)
A5055
31 per month
Continent device; plug for continent stoma (not covered with A5055 or A6216)
A5081
31 per month
Continent device; catheter for continent stoma
A5082
1 per month (3 every 3 mo)
Gauze, non-impregnated, non-sterile, pad size 16 sq. in. or less, without adhesive border,
each dressing (for use with continent stoma) (not covered with A5055 or A5081)
A6216
60 per month (180 every 3 mo)
Appliance cleaner, incontinence and ostomy appliances, per 16oz
A5131
1 per month
Lubricant, per ounce
A4402
4 per month (12 every 3 mo)
Ostomy ring, each
A4404
10 per month (30 every 3 mo)
Ostomy accessory; convex insert
A5093
10 per month (30 every 3 mo)
Tape, non-waterproof, per 18 sq inches (1 billing unit =18 sq inches)
A4450
40 billing units per month
Tape, waterproof, per 18 sq inches (1 billing unit = 18 square inches)
A4452
40 billing units per month
Collection Devices
Bedside drainage bag, day or night, with or without anti-reflux device, with or without tube, each (not with A5102)
A4357
2 per month (6 every 3 mo)
Bedside drainage bottle with or without tubing, rigid or expandable, each (not with A4357)
A5102
2 every 6 months
Extension drainage tubing, any type, any length, with connector/adapter
for use with urinary legbag or urostomy pouch, each
A4331
1 per month (3 every 3 mo)
Irrigation
Irrigation supply; sleeve, each
A4357
2 per month (6 every 3 mo)
Ostomy irrigation supply; bag, each
A5102
2 every 6 months
Ostomy irrigation supply; cone/catheter
A4331
1 per month (3 every 3 mo)
Miscellaneous Codes
Ostomy supply, miscellaneous (requires specific documentation, payment based on medical necessity)
A4421
Non covered item or service (billing for denial)
A9270
Absorbent material (sheet/pad/crystal packet) to thicken liquid stomal output, for use in pouch, each
