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Statistics
It is difficult to give an accurate
representation of the number of ostomies in
the United States, since ostomies are
included in several different coverage
codes, such as the codes for malignant
neoplasm of the large intestine and rectum,
and codes for diseases of the digestive
system. Best guesses estimate the number of
ostomies in the U.S. at between 500,000 and
800,000 in the year 2000, with an annual
growth rate of about 3%.[4]
Several DRGs could be used to bill for
services provided to inpatients admitted for
treatment of ostomy-related
complications or new surgeries.
Coding systems are not always disease
specific and do not indicate whether a
surgery is temporary or permanent, or
whether the submission is for a patient
previously reported by the same or another
provider, making
it difficult to get accurate numbers.
The average age of a person with a colostomy
is 70.6 years, an ileostomy 67.8 years, and
a urostomy 66.6 years, making all of these
patients Medicare-eligible.
These numbers came from two studies done in
1998.
Using these numbers, the average age of an
American with an ostomy is about 68.3 years;
and, therefore, a Medicare beneficiary.[5][6]
These studies also revealed that there is a
near even distribution between surgery
types; colostomy 36.1%, ileostomy 32.2%, and
urostomy 31.7%. Gender data was not
collected.
Let’s take a look at Medicare coverage for ostomy supplies. They’re are covered under the prosthetic device benefit.
The type of ostomy, its location, its construction, and the condition of
the skin surface surrounding
the stoma determine the quantity of ostomy
supplies needed. There will be variation
according to individual customer need--and those
needs may vary over time.[7]
Physician Order
The ostomy supplier generally takes the responsibility of obtaining the new physician order. An order is required when any of the following occurs:
1. There is an initial claim sent
to Medicare for a new ostomate;
2. There is an increase in the
amount of supplies needed;
3. There is a change in the type of
supplies being billed; or
4. The
beneficiary chooses to alternate between a
drainable and a closed pouch.
Your ostomy handout shows the usual maximum number of pouches or wafers
per month that
Medicare determines to be medically necessary,
as well as the allowable number of other
supplies.
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