Documentation for Urological Supplies

March 9th, 2018 - Medicare Learning Network
Categories:   Documentation Guidelines   DME|Supplies|Equipment   Medicare  
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The Medicare Learning Network provides guidance on required documentation for urological supplies.

For DME items, you must meet the following requirements:

  1. Prescription (orders)
  2. Medical Record Information (including continued need/use if applicable)
  3. Correct Coding
  4. Proof of Delivery (Suppliers are required to maintain proof of delivery documentation files)
  5. The supplier must receive a Detailed Written Order before a claim is submitted

You must meet specific criteria for urological supplies to qualify for payment.

  • The patient must have permanent urinary retention or urinary incontinence. This is defined as retention that is not expected to be corrected within 3 months either medically or surgically (this includes supplies billed in a physician’s office). Urological supplies will not be covered in patients with temporary conditions.
  • Medicare will only cover related supplies necessary for proper use if the catheter or external urinary collection device meets the coverage criteria.
  • Medicare covers only one Indwelling Catheter (A4311-A4316, A4338-A4346) per month for routine catheter maintenance. Medicare only covers non-routine catheter changes under medical necessity. Documentation must show medical necessity for the following indications
    • Catheter is accidentally removed
    • Malfunction of catheter
    • Catheter is obstructed
    • History of urinary tract infection or recurring obstruction that requires a schedule change frequency of more than once per month
  • Medicare only covers one Catheter Insertion Tray (A4310-A4316, A4353, and A4354) per episode of insertion.
  • Medicare only covers Intermittent Irrigation of an Indwelling Catheter supplies on a non-routine basis when there is an acute obstruction in the catheter.
  • Medicare covers Continuous Irrigation of Indwelling Catheters when a history of obstruction and patency cannot be maintained with intermittent irrigation and catheter changes.
  • Intermittent catheterization is covered when basic coverage criteria are met and the beneficiary or caregiver can perform the procedure.
    • Additional coverage criteria for sterile intermittent catheter kit includes:
      • Resides in a nursing facility
      • Immunosuppressed
      • Documented vesico-ureteral reflux while on a program of intermittent catheterization
      • Spinal cord injured pregnant female with neurogenic bladder
      • Recurrent UTIs twice within 12 months prior to initiation of sterile intermittent catheter kits
  • Medicare covers External Catheters/Urinary Collection Devices female or male external urinary collection devices as an alternative to an indwelling catheter for patients who have permanent urinary incontinence.
    • Male external catheters should not exceed a quantity of 35/month (A4349)
    • Female external collection devices should not exceed more than one meatal cup (A4327) per week or one pouch (A4328) per day

For a specific list of covered supplies for the above mentioned catheter types, please refer to LCD L33803.

  • Refills. Suppliers must contact the patient prior to dispensing the refill (contact should be no sooner than 14 calendar days prior to the delivery/shipping date). Refills must deliver the DMEPOS product no sooner than 10 calendar days prior to the end of usage of the current product. Suppliers cannot deliver refills without a beneficiary request.

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