Cath Lab Digest

Last year, the Office of Inspector General in the Department of Health and Human Services reported on an investigation into balance billing.¹ Medicare beneficiaries with ostomies were experiencing more of a financial burden for the cost of their supplies than were other Medicare beneficiaries. Also, claims for ostomy supplies had a higher rate of nonassignment than other covered medical supplies.

The Government Affairs Committee of the United Ostomy Association (UOA), chaired by Linda Aukett, has been successful in its ongoing efforts to bring about improvements in Medicare policy for the coverage and payment of ostomy supplies. These changes to Medicare policy may pave the way to solutions for these problems. Twenty new temporary "K" HCPCS codes for ostomy supplies, effective April 1, 2002 (Program Memorandum Intermediaries/Carriers, Transmittal AB-02-001, January 11, 2002), reflect technological advances in ostomy products. These new codes hopefully will help achieve more equitable reimbursement rates for ostomy supplies and decrease the out-of-pocket expenses for Medicare beneficiaries with ostomies. The new HCPCS codes function in three ways:

   1. "Split codes" replace one existing HCPCS code by creating more specific codes and descriptors for certain products.

   2. "Addition to ostomy pouch" codes allow additional and more equitable payment for more advanced features of certain covered products.

   3. "New" product codes acknowledge new categories of ostomy products.

"Split" Codes

"Split" codes recognize, differentiate, and reflect separate reimbursement for larger sizes of skin barriers with flanges, different types of skin barrier pastes, one-piece drainable pouches with different types of skin barriers, and waterproof tape. In most cases, two new HCPCS codes replace each of the seven "retired" HCPCS codes.

-- K0561 - Ostomy skin barrier, non-pectin based, paste, per ounce

-- K0562 - Ostomy skin barrier, pectin-based, paste, per ounce

   -- Retires: A4370 - Ostomy skin barrier, paste, per ounce

-- K0563 - Ostomy skin barrier, with flange (solid, flexible, or accordion), extended wear, with built-in convexity, 4 inches x 4 inches or smaller, each

-- K0564 - Ostomy skin barrier, with flange (solid, flexible, or accordion), with built-in convexity, larger than 4 inches x 4 inches, each

   -- Retires: A4374 - Ostomy skin barrier, with flange (solid, flexible, or accordion), extended-wear, with built-in convexity, any size, each

-- K0565 - Ostomy skin barrier, with flange (solid, flexible, or accordion), extended wear, without built-in convexity, 4 inches x 4 inches or smaller, each

-- K0566 - Ostomy skin barrier, with flange (solid, flexible, or accordion), extended wear, without built-in convexity, larger than 4 inches x 4 inches, each

    -- Retires: A4386 - Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, without built-in convexity, any size, each

-- K0567 - Ostomy pouch, drainable, with karaya based barrier attached, without built-in convexity, (1 piece), each

-- K0568 - Ostomy pouch, drainable, with standard wear barrier attached, without built-in convexity, (1 piece), each

   -- Retires: A5061 - Pouch, drainable; with barrier attached (1 piece)

-- K0570 - Ostomy skin barrier, with flange (solid, flexible, accordion), without built-in convexity, 4 inches x 4 inches or smaller, each

-- K0571 - Ostomy skin barrier, with flange (solid, flexible, accordion), without built-in convexity, larger than 4 inches x 4 inches, each

   -- Retires: A5123 - Skin barrier; with flange (solid, flexible, or accordion), any size, each

-- K0572 - Tape, non-waterproof, per 18 square inches

-- K0573 - Tape, waterproof, per 18 square inches