a guide to Reimbursement of Intermittent Catheters 1 Know your options Coloplast Corp. Minneapolis, MN 55411 1.800.533.0464 usmedweb@coloplast.com www.us.coloplast.com is a registered trademark of Coloplast A/S or related companies. 2008-04. All rights reserved. Coloplast Corp., Minneapolis, MN USA. M2116N 04.08 1
Intermittent catheterization is a covered Medicare benefit when basic coverage criteria are met and the individual or caregiver can perform the procedure. This booklet is provided by Coloplast to answer some basic questions about coding and reimbursement of intermittent catheters. Disclaimer: The information in this document is informational only, general in nature, and does not cover all payers rules or policies. This information was obtained from third party sources and is subject to change without notice as a result of changes in reimbursement regulations and payer policies. This document represents no promise or guarantee by Coloplast Corp. regarding coverage or payment for products or procedures by CMS or other payers. Providers are responsible for reporting the codes that most accurately describe the patient s medical condition, procedures performed and products used. Providers should check Medicare bulletins, manuals, program memoranda, and Medicare guidelines to ensure compliance with Medicare requirements. Inquiries should be directed to the appropriate other payer for non-medicare coverage situations. Coverage Criteria Intermittent catheters are considered under Medicare to be a Prosthetic Benefit. That is, they replace all or part of an internal body organ or part of the function of a permanently inoperative or malfunctioning internal body organ. In order to meet the basic coverage criteria an individual must have permanent urinary incontinence or urinary retention. Utilization Guidelines Intermittent catheterization is covered when basic coverage criteria are met and the patient or caregiver can perform the procedure. For each episode of covered catheterization, Medicare will cover: 1 One catheter (A4351, A4352) and an individual packet of lubricant (A4332); or One sterile intermittent catheter kit (A4353) if additional coverage criteria (see below) are met.
Intermittent catheterization using a sterile intermittent catheter kit (A4353) is covered when the patient requires catheterization and the patient meets one of the following criteria (1-5): 1. 2. The patient resides in a nursing facility, The patient is immunosuppressed, for example (not all-inclusive): on a regimen of immunosuppressive drugs post-transplant, on cancer chemotherapy, has AIDS, has a drug-induced state such as chronic oral corticosteroid use 3. The patient has radiologically documented vesico-ureteral reflux while on a program A doctor s order or prescription is required to get 2 of intermittent catheterization, your intermittent catheter supplies and to begin the 3 4. The patient is a spinal cord injured female claims process. This would include the beneficiary s with neurogenic bladder who is pregnant name, detailed description of the item including (for duration of pregnancy only), brand name, approximate quantity used per month, 5. start date of order, signature of treating physician, The patient has had distinct, recurrent urinary and date the order was signed. tract infections, while on a program of sterile intermittent catheterization with A4351/ Additional medical records which support A4352 and sterile lubricant A4332, twice permanent urinary incontinence or urinary retention within the 12-month prior to the initiation or information supporting medical necessity for of sterile intermittent catheter kits. higher utilization than described may also be A patient would be considered to have a urinary necessary. A medical supplies dealer or pharmacy tract infection if they have a urine culture with should be able to assist you in the collection of this greater than 10,000 colony forming units of a information. urinary pathogen AND concurrent presence of one or more of the following signs, symptoms or laboratory findings: Fever (oral temperature greater than 38º C [100.4º F]) Systemic leukocytosis Change in urinary urgency, frequency, or incontinence Appearance of new or increase in autonomic dysreflexia (sweating, bradycardia, blood pressure elevation) Physical signs of prostatitis, epididymitis, orchitis Increased muscle spasms Pyuria (greater than 5 white blood cells [WBCs] per high-powered field) Documentation Requirements
Categories and Healthcare Common Procedure Coding System (HCPCS) Codes Intermittent catheters are classified into generic descriptive categories and are assigned an alphanumeric code. These HCPCS codes are used when billing for your catheter supplies. HCPCS Description A4351 Intermittent urinary catheter; straight tip, with or without coating, each A4352 Intermittent urinary catheter; coude (curved) tip, with or without coating, each A4353 Intermittent urinary catheter, 4 with insertion supplies beneficiaries with extreme utilization requirements 5 A4332 Lubricant, individual sterile will actually need. The typical beneficiary will require packet, for insertion of urinary a much lower amount. The beneficiary s utilization catheter with sterile technique should be determined by the treating physician based upon the patient s medical condition. There The following table represents the usual maximum number of supplies: Code (#/mo) A4332 (200) A4351 (200) A4352 (200) A4353 (200) Frequently Asked Questions: Q: How many intermittent catheters am I allowed each month under current Medicare guidelines? A: As of April 1, 2008, Medicare will allow for the usual maximum of 200 catheters per month or one catheter for each episode of catheterization. Intermittent catheters are a one-time use device that should be discarded after each use. Q: The policy contains a table describing the usual maximum number of supplies. Does this mean that every beneficiary should get 200 per month? A: No. The usual maximum number represents a determination of the number of items that must be sufficient information in the medical record to justify the amount ordered. A beneficiary or caregiver must specifically request refills of urological supplies before they are dispensed. The supplier must not automatically dispense a quantity of supplies on a predetermined regular basis, even if the beneficiary has authorized this in advance. The supplier should check with the patient or caregiver prior to dispensing a new supply of intermittent catheters to determine that previous supplies are nearly exhausted.
Q: My Medicare supplier is working with me since I have a history of urinary tract infections (UTI), I am currently washing and reusing A: Yes, medical documentation is required to support the necessity for a coude tip rather than a straight tip. This should be documented in your catheters (A4351, A4352) - i.e., using clean medical history file with your physician and can technique. I am just waiting for my doctor be descriptive of your inability to successfully pass to send the lab results along with the UTI dates. Sometimes it takes 3 to 4 weeks for the doctors to respond to these requests. Are a straight tip catheter or as the result of urethral strictures. sterile catheter kits (A4353) covered for people The current Medicare guidelines indicate that a in my situation? coude tip is rarely medically necessary in female 6 A: No. If the beneficiary was not using sterile catheter kits (A4353) prior to 4/1/2008, he/she must meet the current criteria in order to be eligible for reimbursement. Beneficiaries who have been reusing intermittent catheters (A4351, A4352) with clean technique at the rate of one catheter per week are eligible to use a sterile catheter (A4351, A4352) and a packet of sterile lubricant (A4332) for each catheterization. The number of items needed must be determined by the treating physician and information in the medical record must justify the need for the number of items prescribed. patients, however, many female patients are unable to pass a straight tip catheter and may find benefit through the use of a coude tip catheter. This experience should be documented in your medical history file. Additionally, some clinicians have determined that using an olive tip coude may be helpful to women in the early learning stages of intermittent self-catheterization. Q: What if I need more supplies than are allowed in the Medicare guidelines? A: If you need more supplies than are currently allowed under Medicare guidelines your physician 7 Q: What if I do not have Medicare coverage but will need to provide a letter explaining the need for private insurance? How will this policy change the additional supplies. Your medical supplier will affect me? keep this letter on file. A: Please call your insurance provider to see if they Also, through the establishment of a history of will follow the Medicare policy. Most insurance symptomatic recurrent urinary tract infections while companies do follow the guidelines set forth by on a program of intermittent catheterization you are CMS (Centers for Medicare and Medicaid services). eligible for a higher quantity of catheters or catheter Q: I have been unable to catheterize using a straight tip catheter and now require a coude tip, is there additional documentation necessary for coverage? kits with insertion supplies. Q: I am currently using straight intermittent catheters but am still having some problems with urinary tract infections. What can I do?
A: You should talk to your physician/clinician and discuss trying a Closed System intermittent catheter. These products are touchless meaning your hands do not have to touch the catheter. These products are reimbursed under an A4353 HCPCS code and require additional documentation. Q: The policy on intermittent catheterization has been revised. The criteria for coverage of sterile kits, A4353, are slightly different from the previous criteria. The previous criteria required two infections while using clean technique. This revision requires two infections while using sterile, single-use catheters (A4351, A4352). Are current A4353 patients that qualified under clean technique grandfathered under this new policy? A: Beneficiaries who were using A4353 sterile A: Yes. A supplier that accepts assignment for 8 catheter kits prior to April 1, 2008 and who met Medicare will collect the 20% co-insurance of the 9 the requirements for A4353 in the previous version Medicare allowable amount for the product you are of the Urological Supplies LCD continue to be purchasing. eligible to receive sterile intermittent catheterization kits. The medical record must contain sufficient information to demonstrate that the applicable coverage criteria were met. Q: I don t have a medical supplier. Can Coloplast help me locate one? will file a claim on your behalf directly with Medicare. You will be responsible for the 20% coinsurance and Medicare will pay its share of the bill directly to the supplier. Using a supplier that accepts assignment may result in a significant out of pocket savings to you. Q: I am having difficulty getting my particular Coloplast brand of catheters. What can I do? A: All brands of intermittent catheters are reimbursed under Medicare at the same $ allowable. If you ever have problems getting our products, please contact the Coloplast Help Line. Q: My supplier bills Medicare for my product do I have to pay anything? A supplier that does not accept assignment may require that you pay most of the entire bill at the time you receive your supplies. However, the supplier is still required to file a Medicare claim on your behalf. Medicare then pays its share of the bill directly to you. A: Yes, the Coloplast Customer Help Line at 800-525-8161 can introduce you to an authorized supplier in your local area or an authorized national supplier who will ship your supplies directly to your home often at no charge to you. Also, we can direct you to a supplier that accepts assignment. A supplier that accepts assignment Q: My supplier is telling me my catheters are not covered and I must pay for them. What can I do? A: Intermittent catheters are a covered benefit under Medicare (see Question1). There are many suppliers that will help you with coverage to reduce your out of pocket expenses.
Q: Where is the best place to get my product if I don t have insurance? A: There are cash based suppliers that offer lower prices for paying cash. They can offer lower prices since they do not have the added administrative expenses that go along with submitting insurance claims. Q: In an audit of a medical supplier, what information must be contained in the medical record to justify payment for both the type and quantity of urological supplies ordered by the treating physician? A: For urological supplies to be covered by Medicare, the patient s medical record must contain sufficient documentation of the patient s medical condition to substantiate the necessity for the A: Yes. A December 13, 2007 informational letter 10 type and quantity of items ordered and for the from the Under Secretary for Health of Department 11 frequency of use or replacement. The information of Veterans Affairs provides new guidance to should include the patient s diagnosis and other clinicians on the re-use of urinary catheters for those pertinent information including, but not limited to, who use intermittent catheterization for bladder duration of the patient s condition, clinical course management. (worsening or improvement), prognosis, nature and VA clinicians under the new recommendations extent of functional limitations, other therapeutic should follow the manufacturer s instructions for interventions and results, past experience catheter use. Catheters identified as single-use with related items, etc. Neither a physician s devices should not be re-used in any setting. Users order nor a supplier-prepared statement nor a should be provided with an adequate number physician attestation by itself provides sufficient of catheters to use a new sterile catheter each documentation of medical necessity, even though catheterization. it is signed by the treating physician. There must be clinical information in the patient s medical record that supports the medical necessity for the item and substantiates the information on a supplier-prepared statement or physician attestation. For intermittent catheterization, in addition to the general information described above, the patient s medical record must contain a statement from the physician specifying how often the patient (or caregiver) performs catheterizations. The patient s medical record is not limited to the physician s office records. It may include hospital, nursing home, or home health agency (HHA) records, and records from other professionals including, but not limited to, nurses, physical or occupational therapists, prosthetists, and orthotists. Q: I heard that the Department of Veterans Affairs recently changed their policy regarding intermittent catheterization and the use of sterile catheters. Is this true?
If you have any questions, call the Coloplast Help Line at 1-800-525-8161. Notes Disclaimer The information in this document is informational only, general in nature, and does not cover all payers rules or policies. This information was obtained from third party sources and is subject to change without notice as a result of changes in reimbursement regulations and payer policies. This document represents no promise or guarantee by Coloplast Corp. regarding coverage or payment for products or procedures by CMS or other payers. Providers are responsible for reporting the codes that most accurately describe the patient s medical condition, procedures performed and products used. Providers should check Medicare bulletins, manuals, program memoranda, and Medicare guidelines to ensure compliance with Medicare requirements. Inquiries should be directed to the appropriate other payer for non-medicare coverage situations.