For your convienence we are providing you an order form that may be completed and faxed to us for your patient's urological supplies.

Urologicals Order Form

Condom Catheter Sizing Guide

Below are Medicare's guidelines regarding urologicals. For intermittent or male external catheters we will need a Letter of Medical Necessity stating the number of times per day the patient performs catheterization to qualify the number of catheters on the order.

GENERAL

The statutory coverage criteria for coverage of urological supplies are specified in the related Policy Article.

The medical necessity for use of a greater quantity of supplies than the amounts specified in the policy must be well documented in the patient's medical record and must be available upon request.

INDWELLING CATHETERS (A4311 - A4316, A4338 - A4346)

No more than one catheter per month is covered for routine catheter maintenance. Non-routine catheter changes are covered when documentation substantiates medical necessity, such as for the following indications:

1) Catheter is accidentally removed (e.g., pulled out by patient)

2) Malfunction of catheter (e.g., balloon does not stay inflated, hole in catheter)

3) Catheter is obstructed by encrustation, mucous plug, or blood clot

4) History of recurrent obstruction or urinary tract infection for which it has been established that an acute event is prevented by a scheduled change frequency of more than once per month

When a specialty indwelling catheter (A4340) or an all silicone catheter (A4344, A4312, or A4315) is used, there must be documentation in the patient's medical record of the medical necessity for that catheter rather than a straight Foley type catheter with coating (such as recurrent encrustation, inability to pass a straight catheter, or sensitivity to latex). In addition, the particular catheter must be necessary for the patient. For example, use of a Coude (curved) tip indwelling catheter (A4340) in female patients is rarely medically necessary. Documentation of medical necessity may be requested. If documentation is requested and does not substantiate medical necessity, payment for A4340 will be based on the least costly medically appropriate alternative (A4338) and payment for A4344, A4312,or A4315 will be based on the least costly medically appropriate alternative (A4338, A4311, or A4314, respectively).


A three way indwelling catheter either alone (A4346) or with other components (A4313 or A4316) will be covered only if continuous catheter irrigation is medically necessary. (Refer to the section "Continuous Irrigation of Indwelling Catheters" for indications for continuous catheter irrigations.) In other situations, payment will be based on the least costly medically appropriate alternative (A4338, A4311, or A4314, respectively).

CATHETER INSERTION TRAY (A4310-A4316, A4353, and A4354)

One insertion tray will be covered per episode of indwelling catheter insertion. More than one tray per episode will be denied as not medically necessary.

One intermittent catheter with insertion supplies (A4353) will be covered per episode of medically necessary sterile intermittent catheterization (see below).

URINARY DRAINAGE COLLECTION SYSTEM (A4314-A4316, A4354, A4357, A4358, A5102, and A5112)

Payment will be made for routine changes of the urinary drainage collection system as noted below. Additional charges will be allowed for medically necessary non-routine changes when the documentation substantiates the medical necessity, (e.g., obstruction, sludging, clotting of blood, or chronic, recurrent urinary tract infection).


Usual Maximum Quantity of Supplies

Code (#/mo.)
A4314 (1)
A4315 (1)
A4316 (1)
A4354 (1)
A4357 (2)
A4358 (2)
A5112 (1)

Code (#/3mo.)
A5102 (1)

Leg bags are indicated for patients who are ambulatory or are chair or wheelchair bound. The use of leg bags for bedridden patients would be denied as not medically necessary.

If there is a catheter change (A4314-A4316, A4354) and an additional drainage bag (A4357) change within a month, the combined utilization for A4314-A4316, A4354, and A4357 should be considered when determining if additional documentation should be submitted with the claim. For example, if 1 unit of A4314 and 1 unit of A4357 are provided, this should be considered as two drainage bags, which is the usual maximum quantity of drainage bags needed for routine changes.

Payment will be made for either a vinyl leg bag (A4358) or a latex leg bag (A5112). The use of both is not medically necessary.

The medical necessity for drainage bags containing gel matrix or other material which are intended to be disposed of on a daily basis has not been established. Payment for this type of bag will be based on the allowance and usual frequency of change for the least costly medically appropriate alternative, code A4357.

INTERMITTENT IRRIGATION OF INDWELLING CATHETERS

Supplies for the intermittent irrigation of an indwelling catheter are covered when they are used on an as needed (non-routine) basis in the presence of acute obstruction of the catheter. Routine intermittent irrigations of a catheter will be denied as not medically necessary. Routine irrigations are defined as those performed at predetermined intervals. In individual cases, a copy of the order for irrigation and documentation in the patient's medical record of the presence of acute catheter obstruction may be requested when irrigation supplies are billed.

Covered supplies for medically necessary non-routine irrigation of a catheter include either an irrigation tray (A4320) or an irrigation syringe (A4322), and sterile water/saline (A4217). When syringes, trays, sterile saline, or water are used for routine irrigation, they will be denied as not medically necessary. Irrigation solutions containing antibiotics and chemotherapeutic agents (A9270) will be denied as noncovered. Irrigating solutions such as acetic acid or hydrogen peroxide, which are used for the treatment or prevention of urinary obstruction (A4321), will be denied as not medically necessary.

CONTINUOUS IRRIGATION OF INDWELLING CATHETERS

Supplies for continuous irrigation of a catheter are covered if there is a history of obstruction of the catheter and the patency of the catheter cannot be maintained by intermittent irrigation in conjunction with medically necessary catheter changes. Continuous irrigation as a primary preventative measure (i.e., no history of obstruction) will be denied as not medically necessary. Documentation must substantiate the medical necessity of catheter irrigation and in particular continuous irrigation as opposed to intermittent irrigation. The records must also indicate the rate of solution administration and the duration of need. This documentation must be available upon request.

Covered supplies for medically necessary continuous bladder irrigation include a 3-way Foley catheter (A4313, A4316, and A4346), irrigation tubing set (A4355), and sterile water/saline (A4217). More than one irrigation tubing set per day for continuous catheter irrigation will be denied as not medically necessary.

Irrigation solutions containing antibiotics and chemotherapeutic agents (A9270) will be denied as noncovered. Payment for irrigating solutions such as acetic acid or hydrogen peroxide will be based on the allowance for sterile water/saline (A4217).

Continuous irrigation is a temporary measure. Continuous irrigation for more than 2 weeks is rarely medically necessary. The patient's medical records should indicate this medical necessity and these medical records must be available upon request.

INTERMITTENT CATHETERIZATION

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:

A. One catheter (A4351, A4352) and an individual packet of lubricant (A4332); or
B. 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. The patient resides in a nursing facility,

2. 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 of intermittent catheterization,

4. The patient is a spinal cord injured female with neurogenic bladder who is pregnant (for duration of pregnancy only),

5. The patient has had distinct, recurrent urinary tract infections, while on a program of sterile intermittent catheterization with A4351/A4352 and sterile lubricant A4332, twice within the 12-month prior to the initiation of sterile intermittent catheter kits

A patient would be considered to have a urinary tract infection if they have a urine culture with greater than 10,000 colony forming units of a 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)

The following table represents the usual maximum number of supplies:

Code (#/mo.)
A4332 (200)
A4351 (200)
A4352 (200)
A4353 (200)

Refer to Coding Guidelines section of the related Policy Article for contents of the kit. The kit code should be used for billing even if the components are packaged separately rather than together as a kit.

Use of a Coude (curved) tip catheter (A4352) in female patients is rarely medically necessary. When a Coude tip catheter is used (either male or female patients), there must be documentation in the patient's medical record of the medical necessity for that catheter rather than a straight tip catheter (A4351). An example would be the inability to catheterize with a straight tip catheter. This documentation must be available upon request. If documentation is requested and does not substantiate medical necessity, payment will be based on the least costly medically appropriate alternative - (A4351).


EXTERNAL CATHETERS/URINARY COLLECTION DEVICES

Male external catheters (condom-type) or female external urinary collection devices are covered for patients who have permanent urinary incontinence when used as an alternative to an indwelling catheter.

The utilization of male external catheters (A4349) generally should not exceed 35 per month. Greater utilization of these devices must be accompanied by documentation of medical necessity.

Male external catheters (condom-type) or female external urinary collection devices will be denied as not medically necessary when ordered for patients who also use an indwelling catheter.

Specialty type male external catheters (A4326) such as those that inflate or that include a faceplate or extended wear catheter systems are covered only when documentation substantiates the medical necessity for such a catheter. Payment will be based on the least costly medically appropriate alternative if documentation does not substantiate medical necessity.

For female external urinary collection devices, more than one meatal cup (A4327) per week or more than one pouch (A4328) per day will be denied as not medically necessary.

MISCELLANEOUS SUPPLIES

Appliance cleaner (A5131) is covered when used to clean the inside of certain urinary collecting appliances (A5102, A5112). More than one unit of service (16 oz.) per month is rarely medically necessary.

One external urethral clamp or compression device (A4356) is covered every 3 months or sooner if the rubber/foam casing deteriorates.

Tape (A4450, A4452) which is used to secure an indwelling catheter to the patient's body is covered. More than 10 units (1 unit = 18 sq. in.; 10 units = 180 sq. in. = 5 yds. of 1 inch tape) per month will be denied as not medically necessary unless the claim is accompanied by documentation justifying a larger quantity in the individual case.

Adhesive catheter anchoring devices (A4333) and catheter leg straps (A4334) for indwelling urethral catheters are covered. More than 3 per week of A4333 or 1 per month of A4334 will be denied as not medically necessary unless the claim is accompanied by documentation justifying a larger quantity in the individual case. A catheter/tube anchoring device (A5200) is covered and separately payable when it is used to anchor a covered suprapubic tube or nephrostomy tube. If code A5200 is used to anchor an indwelling urethral catheter, payment will be based on the allowance for the least costly medically appropriate alternative, A4333. 

HCPCS CODES: