INSURANCE INFORMATION

Coding and Billing Information for OSTOM – i™ Alert Sensor
Using the CMS-1500 & CMS-1450 (UB-04) Forms

Reimbursement Information

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CMS 1500 02-12 Health Insurance Claim Form

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CMS 1450 UB 04 Health Insurance Claim Form

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A-4421 Ostomy Supply; miscellaneous

Since OSTOM – i™ Alert Sensor does not yet have a permanent HCPCS code assigned, a miscellaneous A-Code such as A-4421 Ostomy Supply; miscellaneous can be used on the:

  • CMS-1500 form if billing in the physician’s office.
  • CMS- 1450(UB-04) if billing under the Hospital OPPS (Outpatient Prospective Payment System.
  • When billing Medicare – Must submit to the appropriate DME Intermediary (Mac):
    • CGS Administrators, LLC
    • National Government Services (NGS), Inc.
    • NHIC
    • Noridian Administrative Services

Indication

For Ostomy/Stoma Patients

Important Information

  • The Ostom-i™ Alert Sensor is a discrete device that alerts patients as to how full their ostomy/stoma bags are so that they can decide if and when to empty them.
  • The Ostom-i™ Alert Sensor clips on to any ostomy bag sending Bluetooth alerts to an “app” on your mobile device (phone or tablet) notifying you that your bag is filling up.
  • The Ostom-i™ Alert Sensor captures guidance information about volume of output over a time period and allows the information to be e-mailed to physicians and other healthcare professionals.
  • Each Ostom-i™ Alert Sensor lasts up to three (3) months.

HOW PROVIDERS MAY BILL FOR:
OSTOM-i™ ALERT SENSOR USING THE CMS-1500 and CMS-1450 (UB-04) FORM

Item 21 or FL (Form Locator) 67 – Diagnosis Code

The ICD-10-CM code(s) are for dates of service commencing on October 1, 2015. ICD-10-CM code(s) should be entered for the use of OSTOM- i™ ALERT SENSOR in Item 21 of the CMS-1500 form for physician offices or FL 67 of the CMS-1450 (UB-04) claim form for the hospital outpatient department.

  • ICD-10-CM code for OSTOM-i™ ALERT SENSOR: 
    • K94.00: Colostomy complication, unspecified
    • K94.03: Colostomy malfunction
    • K94.10: Enterostomy complication, unspecified
    • K94.13: Enterostomy malfunction
    • Z93.2: Ileostomy status, artificial opening status
    • Z93.3: Colostomy status, artificial opening status
    • Z93.6: Other artificial openings of the Urinary Tract status
    • Z43.2: Encounter for attention of ileostomy
    • Z43.3: Encounter for attention of colostomy
    • Z43.6: Encounter for attention to other artificial openings of urinary tract

 

The ICD-9-CM code(s) are for dates of service up to and including September 30, 2015. ICD-9-CM code(s) should be entered for the use of OSTOM- i™ ALERT SENSOR in Box 21 of the CMS-1500 form for physician offices or FL 67 of the CMS-1450 (UB-04) claim form for the hospital outpatient department.

  • ICD-9-CM code for OSTOM-i™ ALERT SENSOR: 
    • 569.60: Colostomy and Enterostomy complication, unspecified
    • 569.62: Mechanical Complication of colostomy and enterostomy (malfunction of colostomy and enterostomy)
    • V44.2: Ileostomy, Artificial opening status
    • V44.3: Colostomy, Artificial opening status
    • V44.6: Status of Other Artificial Opening of Urinary Tract
    • V55.2: Ileostomy, Attention to Artificial Opening
    • V55.3: Colostomy, Attention to Artificial Opening
    • V55.6: Attention to Other Artificial Opening of Urinary Tract

Please note:

  • The following is a required entry for billing CMS (Centers for Medicare and Medicaid Services) and may be required by commercial insurance carriers:
  • For CMS 1500 Claim Form: Box 21, “ICD Ind”, above Box 21 D (indicator) section; this identifies the version of ICD codes being reported. Enter “9” for ICD-9-CM codes and “0” (zero) for ICD-10-CM codes.
  • For CMS 1450 (UB-04) Claim Form: Section 66, Diagnosis and Procedure Code Qualifier (ICD version indicator). Enter “9” to indicate ICD-9-CM codes and “10” to indicate ICD-10-CM codes, when implemented by CMS.

Modifiers:

The modifiers should be entered in line 24D on the CMS-1500 claim form or line FL 44 of the CMS-1450 (UB-04).

  • Level II (HCPCS/National)
    • LT: Left side (used to identify procedures performed on the left side of the body)
    • RT: Right side (used to identify procedures performed on the right side of the body)

Diagnosis code(s) help to support medical necessity.

Item 24D or FL 44 – Product Information

Since Ostom-i™ Alert Sensor does not yet have a permanent HCPCS code assigned, Item 24D of the CMS-1500 form for physician offices and in FL 44 of the CMS-1450 (UB-04) claim form for the hospital outpatient department should indicate;  A-4421, Ostomy Supply, Miscellaneous.

Item 19 or 24A (shaded area) and FL 43- Product Information

In Item 19 or 24A (shaded area) of the CMS-1500 form for physician offices, or FL 43 of the CMS-1450 (UB-04) form for the hospital outpatient department, the full name of the product utilized (i.e., Ostom-i™ Alert Sensor), as well as the Product Code Number U.P.C.

Product Name Product Code Number (U.P.C.)
Ostom-i™ Alert Sensor 866741000101

Item 24F or FL 47 – Product Charge

In Item 24F of the CMS-1500 form for physician offices, or FL 47 of the CMS-1450 (UB-04) form for the hospital outpatient department, insert the charge for 1 unit of the Ostom-i™ Alert Sensor as listed below or your contracted rate.

Product Code Number (UPC) Product Name List Price
866741000101 Ostom-i™ Alert Sensor $100.00 US/unit

Item 24G or FL 46 - Product Quantity

The quantity of product provided should be indicated in Item 24G of the CMS-1500 form for physician offices or FL 46 of the CMS-1450 (UB-04) claim form for the hospital outpatient department. The number of units of the Product Code used should be entered, for example, 1 unit for each Ostom-i™ Alert Sensor.

Please Note: Billable units may vary by payer, so providers should check for appropriate billable units to be used.

Disclaimer: Codes and Billing procedures may vary by payer. Please contact the payer with any questions about payer-specific requirements.  This document has been researched and vetted to the best of our ability.

For Questions regarding this Reimbursement Notice or the usage of Ostom-i™ Alert Sensor, call our U.S. number 1-860-436-5917.