Documentation for Urological SuppliesMarch 9th, 2018 - Medicare Learning Network
The Medicare Learning Network provides guidance on required documentation for urological supplies.
For DME items, you must meet the following requirements:
- Prescription (orders)
- Medical Record Information (including continued need/use if applicable)
- Correct Coding
- Proof of Delivery (Suppliers are required to maintain proof of delivery documentation files)
- 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
- 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.
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.
- For additional guidance on Medical Record Documentation Requirements and Medicare Signature Requirements please see Complying With Medical Record Documentation Requirements and Complying with Medicare Signature Requirements.
If you have questions or comments about this article please contact us. Comments that provide additional related information may be added here by our Editors.
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