by Medicare Learning Network
March 9th, 2018
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.