Medicare Audit Results: Ostomy
Noridian Ostomy Audit Results: October 2018- December 2018
Ostomy Fail Rate: 37%
Base Benefit Requirement: Ostomy supplies are covered for use on a beneficiary with a surgically created opening (stoma) to divert urine, or fecal contents outside the body. Ostomy supplies are appropriately used for colostomies, ileostomies or urinary ostomies (see covered diagnosis codes below.) Use for other conditions will be denied as noncovered.
Top Denial Reasons
Refill request documentation is incomplete or missing elements.
Suppliers must contact the beneficiary prior to dispensing the refill and not automatically ship on a pre-determined basis, even if authorized by the beneficiary.
Suppliers cannot contact the beneficiary more than 14 days prior to product exhaustion.
Suppliers must have documentation, available upon request, to demonstrate contact with the beneficiary to ensure that the refilled item remains reasonable and necessary, existing supplies are approaching exhaustion, and to confirm any changes/modifications to the order prior to delivery or shipment of the product.
For delivery of refills, the supplier must deliver the DMEPOS product no sooner than 10 calendar days prior to the end of usage for the current product. This is regardless of which delivery method is utilized. DME MACs shall allow for the processing of claims for refills delivered/shipped prior to the beneficiary exhausting his/her supply.
Suppliers must not dispense a quantity of supplies exceeding a beneficiary's expected utilization. Suppliers must stay attuned to changed or atypical utilization patterns on the part of their clients. Suppliers must verify with the prescribing physician that any changed or atypical utilization is warranted.
Refill intervals are noted in the applicable policies. Regardless of utilization, a supplier must adhere to the refill interval(s) noted in the applicable policy.
Items delivered without a valid, documented refill request will be denied as not reasonable and necessary.
For items that the beneficiary obtains in-person at a retail store, the signed delivery slip or a copy of the itemized sales receipt is sufficient documentation of a request for refill.
For items that are delivered to the beneficiary, documentation of a request for refill must be either a written document received from the beneficiary or a contemporaneous written record of a phone conversation/contact between the supplier and beneficiary. The refill request must occur and be documented before shipment. A retrospective attestation statement by the supplier or beneficiary is not sufficient.
The refill record must include:
• Beneficiary's name or authorized representative if different from the beneficiary
• A description of each item that is being requested
• Date of refill request
• For consumable supplies i.e., those that are used up (e.g., ostomy or urological supplies, surgical dressings, etc.) the supplier must assess the quantity of each item that the beneficiary still has remaining to document that the amount remaining will be nearly exhausted on or about the supply anniversary date.
• Detailed Written Order (DWO) is incomplete or missing elements.
• No medical record documentation was received. Refer to Medicare Program Integrity Manual 188.8.131.52.
The patient's medical record is not limited to the physician's office records. It may include hospital, nursing home, or HHA records and records from other health care professionals.
Documentation must be maintained in the supplier's files for seven (7) years from date of service.
• The medical record documentation does not support a covered diagnosis
Ostomy supplies are covered for use on a beneficiary with a surgically created opening (stoma) to divert urine, or fecal contents outside the body.
Ostomy supplies are appropriately used for colostomies, ileostomies or urinary ostomies.
Use for other conditions will be denied as noncovered.