18.2.2.1 Gastrostomy Devices

The CSHCN Services Program may reimburse providers for nonobturated or obturated gastrostomy devices when prescribed by a physician.

Authorization Requirements

Authorization is required. Documentation supporting medical necessity including, but not limited to, the presence of a gastrostomy (diagnosis code V441) must be submitted on the claim.

The following procedure codes must be used to submit claims for gastrostomy devices:

Procedure Codes
B4034	B4035	B4036	B4081	B4082
B4083	B4087	B4088

Procedure code B4035 is limited to a maximum of 31 per month by any provider. Providers may not bill a quantity greater than the number of days in the month for which they are submitting a claim. Claims with a quantity greater than the number of days in that month may be subject to a recoupment.

Procedure codes B4087 and B4088 are limited to two per rolling year.

Refer to:

Section 4.2, “Authorizations,” on page 4‑3 for detailed information about authorization requirements.

Appendix B, ”CSHCN Services Program Prior Authorization Request for Diapers, Pull-ups, Briefs, or Liners” on page B‑23.

Nonobturated Gastrostomy Devices

Nonobturated gastrostomy kits may be reimbursed to physicians, pharmacies, medical suppliers, and home health DME providers. Two devices are considered for reimbursement per year, per client. Additional devices may be considered for reimbursement if the documentation submitted with the claim indicates medical necessity (e.g., failure of the device or infection at the gastrostomy site).

Obturated Gastrostomy Devices

Obturated gastrostomy devices may be reimbursed only to physicians. Two devices may be considered for reimbursement per year, per client.

Refer to:

Section 31.2.20, “Gastrostomy Devices,” on page 31‑69 for information related to gastrostomy tube devices.