Currentpriority healthPolicy No. 150

Bowel Management Device

This policy governs billing, coding, documentation, and reimbursement for bowel management devices (Peristeen trans anal irrigation system) for Priority Health members across commercial, Medicare and Medicaid lines as specified.

Policy Summary

Payerpriority health

PolicyBowel Management Device

Policy CodePolicy No. 150

Change TypeNew policycoding clarification

Effective DateNov 17, 2025

Next Review Date

Key ActionObtain a Pre-Service Organization Determination (PSOD) for Medicare indications that do not meet NCD, LCD, or specific medical policy.

SourceLink

POLICY UPDATE CHANGES

New billing policy for bowel management devices was created.

Coding guidance updated to specify use of HCPCS codes A4459 and A4453 beginning April 1, 2025.

2HCPCS codes specified

3Payer lines referenced

1New policy effective

1Device example

Coverage and Billing Overview

Policy Summary

Payerpriority health

PolicyBowel Management Device

Policy CodePolicy No. 150

Change TypeNew policycoding clarification

Effective DateNov 17, 2025

Next Review Date

Key ActionObtain a Pre-Service Organization Determination (PSOD) for Medicare indications that do not meet NCD, LCD, or specific medical policy.

SourceLink

On This Page

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Coverage overview

Covered when billed in accordance with member benefits, applicable coding, and any authorization requirements; billing rules and place-of-service considerations apply.

ALL of the following

Applies to Commercial, Medicare (follows CMS unless otherwise specified), and Medicaid (follows MDHHS unless otherwise specified).
Coverage considered when services are furnished in the appropriate setting to the patient’s medical needs and condition; place of service must be appropriate to the clinical situation.
Authorization may be required per plan or setting; for Medicare indications that do not meet CMS NCD/LCD or specific medical policy, a Pre-Service Organization Determination (PSOD) may be required.
See Authorization / PSOD requirements
Claims must follow current coding systems (CPT, HCPCS, revenue codes) and be fully documented in the medical record to the highest level of specificity; improper coding or documentation may result in denial, recoupment, or claim rejection.
An authorization is not a guarantee of payment; payment is subject to adherence to billing, coding, and documentation requirements and may be subject to pre- or post-claim review for payment integrity.

HCPCS Codes and Effective Dates

Peristeen bowel management device codesHCPCSCovered

A4459	Peristeen trans anal irrigation system (all-inclusive)
A4453	Refillable rectal catheters

Coding effective dates — A4459 and A4453

Historical guidance (Jan 2015–Mar 2025)Use HCPCS A4459 for Peristeen trans anal irrigation system as an all-inclusive code; individual components should not be billed separately. A4453 used for refillable rectal catheters.

Updated effective coding (Apr 1, 2025 – present)Use HCPCS codes A4459 and A4453 for Peristeen bowel management devices.

Implication for billingDo not bill individual components separately when using A4459 for the period it was designated all-inclusive.

Authorization and Documentation Requirements

Prior Authorization

Pre-Service Organization Determination (PSOD) required for certain Medicare indications

For Medicare indications that do not meet the criteria of an NCD, local LCD, or a specific medical policy, complete a Pre‑Service Organization Determination (PSOD) prior to providing the service. Authorization may also be required depending on the place of service.

Submit PSOD when Medicare indication is not covered by an NCD, LCD, or specific medical policy.
Check whether facility or outpatient setting requires additional authorization per Place of Service guidance.

OpenPayer

Bowel Management Device

Coverage and Billing Overview

HCPCS Codes and Effective Dates

Authorization and Documentation Requirements

Device Definitions