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| Article Information |
| Article ID Number back to top |
| A25230 |
| Article Type back to top |
| Article |
| Key Article back to top |
| Yes |
| Article Title back to top |
| Urological Supplies - Policy Article - Effective January 2010 |
| Primary Geographic Jurisdiction back to top |
Connecticut
District of Columbia
Delaware
Massachusetts
Maryland
Maine
New Hampshire
New Jersey
New York - Entire State
Pennsylvania
Rhode Island
Vermont
|
| DME Region Article Covers back to top |
| Jurisdiction A |
| Original Article Effective Date back to top |
| 04/01/2005 |
| Article Revision Effective Date back to top |
| 01/01/2010 |
| Article Text back to top |
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES
GENERAL
Urinary catheters and external urinary collection devices are covered to drain or collect urine for a patient who has permanent urinary incontinence or permanent urinary retention. Permanent urinary retention is defined as retention that is not expected to be medically or surgically corrected in that patient within 3 months.
If the catheter or the external urinary collection device meets the coverage criteria then the related supplies that are necessary for their effective use are also covered. Urological supplies that are used for purposes not related to the covered use of catheters or external urinary collection devices (i.e., drainage and/or collection of urine from the bladder) will be denied as noncovered. Urological supplies billed without a KX modifier (see Documentation section) will be denied as noncovered.
The patient must have a permanent impairment of urination. This does not require a determination that there is no possibility that the patient's condition may improve sometime in the future. If the medical record, including the judgment of the attending physician, indicates the condition is of long and indefinite duration (ordinarily at least 3 months), the test of permanence is considered met. Catheters and related supplies will be denied as noncovered in situations in which it is expected that the condition will be temporary.
The use of a urological supply for the treatment of chronic urinary tract infection or other bladder condition in the absence of permanent urinary incontinence or retention is noncovered. Since the patient's urinary system is functioning, the criteria for coverage under the prosthetic benefit provision are not met.
When urological supplies are furnished in a physician's office, they may be billed only if the patient's condition meets the definition of permanence. (In this situation, the catheters and related supplies are covered under the prosthetic device benefit.) If the patient's condition is expected to be temporary, urological supplies may not be billed. (In this situation, they are considered as supplies provided incident to a physician's service and payment is included in the allowance for the physician services, which are processed by the local carrier.) When billing for urological supplies furnished in a physician's office for a permanent impairment, use the place of service code corresponding to the beneficiary's current place of residence; do not use POS 11, office.
MISCELLANEOUS
Adhesive strips or tape used with male external catheters are included in the allowance for the code and are not separately payable.
Catheter insertion trays (A4310-A4316, A4353 and A4354) that contain component parts of the urinary collection system, (e.g., drainage bags and tubing) are inclusive sets and payment for additional component parts will be allowed only per the stated criteria in each section of the policy.
Irrigation supplies that are used for care of the skin or perineum of incontinent patients are noncovered.
Claims for tape (A4450 or A4452) that are billed without an AU modifier or another modifier indicating coverage under a different policy will be denied as noncovered.
Extension tubing (A4331) will be covered for use with a latex urinary leg bag (A5112). It is included in the allowance for codes A4314, A4315, A4316, A4354, A4357, A4358, and A5105 and should not be separately billed with these codes.
Other supplies used in the management of incontinence, including but not limited to the following items, will be denied as noncovered because they are not prosthetic devices nor are they required for the effective use of a prosthetic device:
- Creams, salves, lotions, barriers (liquid, spray, wipes, powder, paste) or other skin care products (A6250)
- Catheter care kits (A9270)
- Adhesive remover (A4455, A4456) (Coverage remains for use with ostomy supplies.)
- Catheter clamp or plug (A9270)
- Disposable underpads, e.g., Chux (A4554)
- Diapers, or incontinent garments, disposable or reusable (A4520)
- Drainage bag holder or stand (A9270)
- Urinary suspensory without leg bag (A9270)
- Measuring container (A9270)
- Urinary drainage tray (A9270)
- Gauze pads (A6216-A6218) and other dressings (coverage remains under other benefits, e.g. surgical dressings)
- Other incontinence products not directly related to the use of a covered urinary catheter or external urinary collection device (A9270)
- Disposable external urethral clamp or compression device, with pad and/or pouch (A4360)
CODING GUIDELINES
The general term "external urinary collection devices" used in this policy includes male external catheters and female pouches or meatal cups. This term does not include diapers or other types of absorptive pads.
A meatal cup female external urinary collection device (A4327) is a plastic cup, which is held in place around the female urethra by suction or pressure and is connected to a urinary drainage container such as a bag or bottle.
A pouch type female external collection device (A4328) is a plastic pouch which is attached to the periurethral area with adhesive and which can be connected to a urinary drainage container such as a bag or bottle.
A urinary catheter-anchoring device described by code A4333 has an adhesive surface, which attaches to the patient's skin and a mechanism for releasing and re-anchoring the catheter multiple times without changing the anchoring device.
A urinary catheter-anchoring device described by code A4334 is a strap, which goes around a patient's leg and has a mechanism for releasing and re-anchoring the catheter multiple times without changing the anchoring device.
A urinary intermittent catheter with insertion supplies (A4353) is a kit, which includes a catheter, lubricant, gloves, antiseptic solution, applicators, drape, and a tray or bag in a sterile package intended for single use. The collection tray/bag is a separate item included as part of the kit. Materials that serve as packaging for the kit do not meet this requirement.
Therapeutic agent for urinary irrigation (A4321) is defined as a solution containing agents in addition to saline or sterile water (for example acetic acid or hydrogen peroxide) which is used for the treatment or prevention of urinary catheter obstruction.
Code A5105 should be used when billing for a urinary suspensory with leg bag.
A4326 is a male external catheter with an integrated collection chamber that does not require the use of an additional leg bag.
Irrigation solutions containing antibiotics and chemotherapeutic agents should be coded A9270. Irrigating solutions, such as acetic acid or hydrogen peroxide, which is used for the treatment or prevention of urinary obstruction, should be coded A4321.
Adhesive strips or tape used with code A4349 (MALE EXTERNAL CATHETER, WITH OR WITHOUT ADHESIVE, DISPOSABLE,EACH) should not be billed separately.
Adhesive catheter anchoring devices that are used with indwelling urethral catheters are billed using codes A4333 and A4334, respectively. An anchoring device used with a percutaneous catheter/tube (e.g., suprapubic tube, nephrostomy tube) is billed using code A5200.
Replacement leg straps (A5113, A5114) are used with a urinary leg bag (A4358, A5105, or A5112). These codes are not used for a leg strap for an indwelling catheter.
When codes A4217, A4450, and A4452 are used with Urological Supplies, they must be billed with the AU modifier. For this policy, codes A4217, A4450, and A4452 are the only three codes for which the AU modifier may be used.
An external catheter that contains a barrier for attachment should be coded using A4335.
Codes for ostomy barriers (A4369-A4371) should not be used for skin care products used in the management of urinary incontinence.
A percutaneous catheter/tube anchoring device (A5200) is a dressing with adhesive that is designed to be applied directly over the cutaneous opening through which the catheter/tube passes. This dressing has a hole through which the catheter/tube passes and a mechanism for firmly anchoring the catheter/tube to the dressing.
In the following table, the Column I code includes the items identified by the codes in Column II. The Column I code must be used instead of multiple Column II codes when the items are provided at the same time.
| Column I | Column II
| | A4310 | A4332
| | A4311 | A4310, A4332, A4338
| | A4312 | A4310, A4332, A4344
| | A4313 | A4310, A4332, A4346
| | A4314 | A4310, A4311, A4331, A4332, A4338, A4354, A4357
| | A4315 | A4310, A4312, A4331, A4332, A4344, A4354, A4357
| | A4316 | A4310, A4313, A4331, A4332, A4346, A4354, A4357
| | A4353 | A4310, A4332, A4351, A4352
| | A4354 | A4310, A4331, A4332, A4357
| | A4357 | A4331
| | A4358 | A4331, A5113, A5114
| | A5105 | A4331, A4358, A5112, A5113, A5114
| | A5112 | A5113, A5114 |
If a code exists that includes multiple products, that code should be used in lieu of the individual codes.
Suppliers should contact the Pricing, Data Analysis and Coding (PDAC) Contractor for guidance on the correct coding of these items. |
|
| Coding Information |
| No Coding Information has been entered in this section of the article. |
|
| Other Information |
| Revision History Explanation back to top |
Revision Effective Date: 01/01/2010
NONMEDICAL MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Added: A4360 to list of statutorily excluded items.
CODING GUIDELINES:
Replaced: A4365 with A4456
Revision Effective Date: 12/01/2009
CODING GUIDELINES:
Clarified: A4353
Changed: SADMERC to PDAC.
03/01/2008 - In accordance with Section 911 of the Medicare Modernization Act, this policy was transitioned to DME MAC NHIC (16003) Article A25230 from DME PSC TriCenturion (77011) Article A25230.
Revision Effective Date: 01/01/2008
CODING GUIDELINES:
Revised: Guidelines for A5105.
Added: A4326.
Revision Effective Date: 06/01/2007
CODING GUIDELINES:
Updated: Code narrative for A4349.
Removed: Guidelines for A4347, code deleted 12/31/2004.
Removed: A5119, code deleted 12/31/2005.
Removed: A4325 from the bundling table.
06/01/2007 - In accordance with Section 911 of the Medicare Modernization Act of 2003, Virginia and West Virginia were transitioned from DME PSCTriCenturion (77011) to DME PSC TrustSolutions (77012).
Revision Effective Date: 01/01/2007
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Removed: Reference to A4359.
CODING GUIDELINES:
Removed: Reference to A4359.
Added: Instructions for billing urinary suspensories with and without leg bags.
03/01/2006 - In accordance with Section 911 of the Medicare Modernization Act of 2003, this article was transitioned to DME PSC TriCenturion (77011) from DMERC Tricenturion (77011).
Revision Effective Date: 04/01/2005
LMRP converted to LCD and Policy Article.
CODING GUIDELINES:
Added: A4349, A4520
Deleted: A4324, A4325, A4347, A4521-A4538
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| Related Documents back to top |
LCD(s)
L5080 - Urological Supplies
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