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Ostomy Referral Documentation Guide
A guide to what information may need to be included with a patient referral for ostomy supplies, including Medicare requirements, prescriptions, and more.
Before You Submit an Ostomy Referral
Not sure what's required? Before sending an ostomy referral, check that you’ve included the information our team may need to contact the patient, verify their benefits, and review the prescribed supplies.
- Patient's contact and insurance information
- A complete, signed prescription or Standard Written Order (SWO)
- Recent clinical documentation or supporting notes, when required by the patient's insurance
- Hospital discharge information, when applicable
What Helps Us Process Your Ostomy Referral
Sending complete information up front helps our team review the referral, verify benefits, and confirm the prescribed ostomy supplies with your patient.
If any additional documentation is required by the patient's insurance plan, we’ll work with you to help make the process as smooth as possible.
Here's what to include in your ostomy patient referral.
1. Patient's Contact and Insurance Information
Providing this information helps us contact your patient to review their needs and prescribed supplies and go over the next steps. And having their insurance information up front helps us verify their coverage and determine any additional requirements.
- Patient's full name
- Date of birth
- Address
- Phone number and/or email
- Designated point of contact, if applicable
- Insurance information, including secondary or supplemental policies, if applicable
2. A Prescription or Standard Written Order
A complete prescription or Standard Written Order should be signed and identify the patient, prescriber, ostomy supplies ordered, and quantity needed. Because an ostomy order may include several different products, each item should be listed clearly.
Important Order Information
- Patient's name
- Order date
- Ostomy diagnosis (urostomy, ileostomy, or colostomy)
- Frequency per month & quantity to dispense per month
- Length of need or number of refills, when required by insurance plan
- Patient's date of surgery and date of discharge, if applicable
- Authorized prescriber's name and NPI
- Authorized prescriber's signature, dated
- Facility name, address, and phone number
- Name of person sending referral
Ostomy Supply Details
- Type of ostomy: colostomy, ileostomy, or urostomy
- One-piece or two-piece pouching system
- Drainable, closed-end, or urostomy pouch type
- Flat or convex skin barrier (required with two-piece pouching systems)
- Stoma size or applicable product sizing needs
- Product names and item numbers, if known
- Prescribed accessories, such as barrier rings, paste, adhesive remover, ostomy belt, deodorant, night drainage, or other supplies
List Each Prescribed Ostomy Product Separately
Include the quantity needed, as well as the manufacturer and product number when known. Make sure the order and any supporting notes agree.
3. Supporting Documentation for the Ostomy Referral
Supporting documentation requirements vary based on the patient's insurance, ostomy type, and the supplies or quantities ordered.
Many private or commercial plans may require only a complete prescription or an SWO, while others may request additional documentation, prior authorization, or other information.
Medicaid requirements vary by state and plan.
For Medicare patients, a complete SWO is required, and the medical record must support the patient's ostomy and the medical necessity of the supplies ordered.
What the Documentation Should Support
Ostomy Surgery Type
Document whether the patient has a colostomy, ileostomy, or urostomy.
Surgically Created Opening
The notes should support that the patient has a surgically created opening used to divert urine or fecal contents outside the body.
Ongoing Need
The notes should support a permanent condition that requires an ostomy. Medicare considers a condition of long and indefinite duration to meet the permanence requirement.
Frequency
Document how often pouches, barriers, or accessories are used or changed when that frequency supports the quantity ordered.
Ostomy Characteristics
When relevant to the prescribed products, include information about the type, location, and construction of the ostomy, as well as the condition of the skin around the stoma.
New Ostomy or Recent Hospital Discharge?
If your patient recently had ostomy surgery or is being discharged from the hospital, include the following when available:
- The hospital or facility name
- Discharge date
- Surgery date
- Insurance information
- Any prescribed products or item numbers being used at discharge
We'll review the information provided, confirm coverage requirements, and let you know if anything else is needed before we can provide supplies.
Medicare Ostomy Supply Quantity Guidelines
Medicare establishes usual maximum quantities for many ostomy supplies. The amount a patient may receive depends on the products prescribed, the type of ostomy, and the patient’s individual needs.
Use this chart as a quick reference when completing an ostomy supply order. The quantities shown are not guaranteed coverage amounts. A patient may need more or fewer supplies based on factors that affect how often the pouch or skin barrier must be changed.
Common Ostomy Supplies and Medicare’s Usual Maximum Quantities
Please note: These quantities are not guaranteed coverage amounts. A patient may need more or fewer supplies based on their ostomy type, prescribed products, and factors affecting how often the pouch or skin barrier must be changed.
When the Patient Needs a Higher Quantity
A patient’s actual supply needs may be higher or lower than the quantities shown. If the order exceeds Medicare’s usual maximum for a particular product, include clinical notes that clearly explain why the additional quantity is necessary.
Helpful Documentation to Include
- The specific product requiring a higher quantity
- The HCPCS code, when known
- The monthly quantity prescribed
- How frequently the product is used or changed
- The clinical reason the usual quantity is not sufficient
- Relevant factors affecting pouch or skin barrier change frequency
Medicare requires that the reason for quantities exceeding its usual maximums be clearly documented in the patient’s medical record. When adequate supporting documentation is not provided upon request, Medicare may deny coverage for excess quantities.
Disclaimer: The Medicare requirements summarized here are based on the Ostomy Supplies Local Coverage Determination (LCD L33828) and related Medicare guidance. This information is provided for reference only and is not intended as advice or instruction on how to complete a patient’s detailed written order, medical record, or clinical notes. Coverage and documentation requirements may vary by insurance plan.
Ready to Send in Your Ostomy Referral?
Securely refer your ostomy patients online with E-Script, or download our ostomy referral form, then fax it to (888) 718-0633 or email it to referrals@180medical.com.
Questions About Ostomy Referrals
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