LCD: Centers for Medicare & Medicaid Services

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Contractor Information

Contractor Name ^{back to top}
NHIC, Corp.
Contractor Number ^{back to top}
16003
Contractor Type ^{back to top}
DME MAC

LCD Information

LCD ID Number ^{back to top}

L5080

LCD Title ^{back to top}

Urological Supplies

Contractor's Determination Number ^{back to top}

URO

AMA CPT / ADA CDT Copyright Statement ^{back to top}

CPT codes, descriptions and other data only are copyright 2009 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

CMS National Coverage Policy ^{back to top}

None

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

Oversight Region ^{back to top}

Region I

DME Region LCD Covers ^{back to top}

Jurisdiction A

Original Determination Effective Date ^{back to top}

For services performed on or after 10/01/1993

Original Determination Ending Date ^{back to top}

Revision Effective Date ^{back to top}

For services performed on or after 01/01/2010

Revision Ending Date ^{back to top}

Indications and Limitations of Coverage and/or Medical Necessity ^{back to top}

For any item to be covered by Medicare, it must (1) be eligible for a defined Medicare benefit category, (2) be reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member, and (3) meet all other applicable Medicare statutory and regulatory requirements. For the items addressed in this medical policy, the criteria for "reasonable and necessary" are defined by the following indications and limitations of coverage and/or medical necessity.

For an item to be covered by Medicare, a written signed and dated order must be received by the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving the completed order, the item will be denied as not medically necessary.

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:

Catheter is accidentally removed (e.g., pulled out by patient)
Malfunction of catheter (e.g., balloon does not stay inflated, hole in catheter)
Catheter is obstructed by encrustation, mucous plug, or blood clot
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	Number per month
A4314	1
A4315	1
A4316	1
A4354	1
A4357	2
A4358	2
A5112	1

Code	Number per 3 month
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:

One catheter (A4351, A4352) and an individual packet of lubricant (A4332); or
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):

The patient resides in a nursing facility,
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
The patient has radiologically documented vesico-ureteral reflux while on a program of intermittent catheterization,
The patient is a spinal cord injured female with neurogenic bladder who is pregnant (for duration of pregnancy only),
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)

Usual Maximum Quantity of Supplies

Code	Number per Month
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.

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. 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.

There are no indications for which urethral inserts (A4336) have been demonstrated to have any therapeutic effect. Claim lines billed with this code will be denied as not medically necessary.

The supplier must monitor the amount of supplies and accessories a patient is actually using and assure that the patient has nearly exhausted the supply on hand prior to dispensing any additional items. CMS’ Program Integrity Manual (Internet-Only Manual, CMS Pub. 100-8, Chapter 4, section 4.26.1) requires, “Contact with the beneficiary or designee regarding refills should take place no sooner than approximately 7 days prior to the delivery/shipping date. For subsequent deliveries of refills, the supplier should deliver the DMEPOS product no sooner than approximately 5 days prior to the end of usage for the current product.”

Coding Information

Bill Type Codes: ^{back to top}

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

Revenue Codes: ^{back to top}

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

CPT/HCPCS Codes ^{back to top}

The appearance of a code in this section does not necessarily indicate coverage.

HCPCS MODIFIERS:

AU – Item furnished in conjunction with a urological, ostomy, or tracheostomy supply

EY - No physician or other licensed health care provider order for this item or service

GY - Item or service statutorily excluded or does not meet the definition of any Medicare benefit

KX - Requirements specified in the medical policy have been met

HCPCS CODES

A4217	STERILE WATER/SALINE, 500 ML
A4310	INSERTION TRAY WITHOUT DRAINAGE BAG AND WITHOUT CATHETER (ACCESSORIES ONLY)
A4311	INSERTION TRAY WITHOUT DRAINAGE BAG WITH INDWELLING CATHETER, FOLEY TYPE, TWO-WAY LATEX WITH COATING (TEFLON, SILICONE, SILICONE ELASTOMER OR HYDROPHILIC, ETC.)
A4312	INSERTION TRAY WITHOUT DRAINAGE BAG WITH INDWELLING CATHETER, FOLEY TYPE, TWO-WAY, ALL SILICONE
A4313	INSERTION TRAY WITHOUT DRAINAGE BAG WITH INDWELLING CATHETER, FOLEY TYPE, THREE-WAY, FOR CONTINUOUS IRRIGATION
A4314	INSERTION TRAY WITH DRAINAGE BAG WITH INDWELLING CATHETER, FOLEY TYPE, TWO-WAY LATEX WITH COATING (TEFLON, SILICONE, SILICONE ELASTOMER OR HYDROPHILIC, ETC.)
A4315	INSERTION TRAY WITH DRAINAGE BAG WITH INDWELLING CATHETER, FOLEY TYPE, TWO-WAY, ALL SILICONE
A4316	INSERTION TRAY WITH DRAINAGE BAG WITH INDWELLING CATHETER, FOLEY TYPE, THREE-WAY, FOR CONTINUOUS IRRIGATION
A4320	IRRIGATION TRAY WITH BULB OR PISTON SYRINGE, ANY PURPOSE
A4321	THERAPEUTIC AGENT FOR URINARY CATHETER IRRIGATION
A4322	IRRIGATION SYRINGE, BULB OR PISTON, EACH
A4326	MALE EXTERNAL CATHETER WITH INTEGRAL COLLECTION CHAMBER, ANY TYPE, EACH
A4327	FEMALE EXTERNAL URINARY COLLECTION DEVICE; MEATAL CUP, EACH
A4328	FEMALE EXTERNAL URINARY COLLECTION DEVICE; POUCH, EACH
A4331	EXTENSION DRAINAGE TUBING, ANY TYPE, ANY LENGTH, WITH CONNECTOR/ADAPTOR, FOR USE WITH URINARY LEG BAG OR UROSTOMY POUCH, EACH
A4332	LUBRICANT, INDIVIDUAL STERILE PACKET, EACH
A4333	URINARY CATHETER ANCHORING DEVICE, ADHESIVE SKIN ATTACHMENT, EACH
A4334	URINARY CATHETER ANCHORING DEVICE, LEG STRAP, EACH
A4335	INCONTINENCE SUPPLY; MISCELLANEOUS
A4336	INCONTINENCE SUPPLY, URETHRAL INSERT, ANY TYPE, EACH
A4338	INDWELLING CATHETER; FOLEY TYPE, TWO-WAY LATEX WITH COATING (TEFLON, SILICONE, SILICONE ELASTOMER, OR HYDROPHILIC, ETC.), EACH
A4340	INDWELLING CATHETER; SPECIALTY TYPE, EG; COUDE, MUSHROOM, WING, ETC.), EACH
A4344	INDWELLING CATHETER, FOLEY TYPE, TWO-WAY, ALL SILICONE, EACH
A4346	INDWELLING CATHETER; FOLEY TYPE, THREE WAY FOR CONTINUOUS IRRIGATION, EACH
A4349	MALE EXTERNAL CATHETER, WITH OR WITHOUT ADHESIVE, DISPOSABLE, EACH
A4351	INTERMITTENT URINARY CATHETER; STRAIGHT TIP, WITH OR WITHOUT COATING (TEFLON, SILICONE, SILICONE ELASTOMER, OR HYDROPHILIC, ETC.), EACH
A4352	INTERMITTENT URINARY CATHETER; COUDE (CURVED) TIP, WITH OR WITHOUT COATING (TEFLON, SILICONE, SILICONE ELASTOMERIC, OR HYDROPHILIC, ETC.), EACH
A4353	INTERMITTENT URINARY CATHETER, WITH INSERTION SUPPLIES
A4354	INSERTION TRAY WITH DRAINAGE BAG BUT WITHOUT CATHETER
A4355	IRRIGATION TUBING SET FOR CONTINUOUS BLADDER IRRIGATION THROUGH A THREE-WAY INDWELLING FOLEY CATHETER, EACH
A4356	EXTERNAL URETHRAL CLAMP OR COMPRESSION DEVICE (NOT TO BE USED FOR CATHETER CLAMP), EACH
A4357	BEDSIDE DRAINAGE BAG, DAY OR NIGHT, WITH OR WITHOUT ANTI-REFLUX DEVICE, WITH OR WITHOUT TUBE, EACH
A4358	URINARY DRAINAGE BAG, LEG OR ABDOMEN, VINYL, WITH OR WITHOUT TUBE, WITH STRAPS, EACH
A4360	DISPOSABLE EXTERNAL URETHRAL CLAMP OR COMPRESSION DEVICE, WITH PAD AND/OR POUCH, EACH
A4402	LUBRICANT, PER OUNCE
A4450	TAPE, NON-WATERPROOF, PER 18 SQUARE INCHES
A4452	TAPE, WATERPROOF, PER 18 SQUARE INCHES
A4455	ADHESIVE REMOVER OR SOLVENT (FOR TAPE, CEMENT OR OTHER ADHESIVE), PER OUNCE
A4456	ADHESIVE REMOVER, WIPES, ANY TYPE, EACH
A4520	INCONTINENCE GARMENT, ANY TYPE, (E.G. BRIEF, DIAPER), EACH
A4554	DISPOSABLE UNDERPADS, ALL SIZES
A5102	BEDSIDE DRAINAGE BOTTLE WITH OR WITHOUT TUBING, RIGID OR EXPANDABLE, EACH
A5105	URINARY SUSPENSORY WITH LEG BAG, WITH OR WITHOUT TUBE, EACH
A5112	URINARY LEG BAG; LATEX
A5113	LEG STRAP; LATEX, REPLACEMENT ONLY, PER SET
A5114	LEG STRAP; FOAM OR FABRIC, REPLACEMENT ONLY, PER SET
A5131	APPLIANCE CLEANER, INCONTINENCE AND OSTOMY APPLIANCES, PER 16 OZ.
A5200	PERCUTANEOUS CATHETER/TUBE ANCHORING DEVICE, ADHESIVE SKIN ATTACHMENT
A9270	NON-COVERED ITEM OR SERVICE

ICD-9 Codes that Support Medical Necessity ^{back to top}

Not specified.

Diagnoses that Support Medical Necessity ^{back to top}

Not specified.

ICD-9 Codes that DO NOT Support Medical Necessity ^{back to top}

Not specified.

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation ^{back to top}

Diagnoses that DO NOT Support Medical Necessity ^{back to top}

Not specified.

General Information

Documentation Requirements ^{back to top}

Section 1833(e) of the Social Security Act precludes payment to any provider of services unless "there has been furnished such information as may be necessary in order to determine the amounts due such provider." It is expected that the patient's medical records will reflect the need for the care provided. The patient's medical records include the physician's office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be available upon request.

An order for each item billed must be signed and dated by the treating physician, kept on file by the supplier, and made available upon request. Items billed before a signed and dated order has been received by the supplier must be submitted with an EY modifier added to each affected HCPCS code.

The order must include the type of supplies ordered and the approximate quantity to be used per unit of time.

KX and GY MODIFIERS:

Suppliers must add a KX modifier to a code only if the order indicates the patient has permanent urinary incontinence or urinary retention, and if the item is a catheter, an external urinary collection device, or a supply used with one of these items.

If all the criteria in the related Policy Article are not met, the GY modifier must be added to the code.

Claims lines billed without a KX or GY modifier will be rejected as missing information.

Refer to the Supplier Manual for more information on documentation requirements.

Appendices ^{back to top}

Utilization Guidelines ^{back to top}

Refer to Indications and Limitations of Coverage and/or Medical Necessity.

Sources of Information and Basis for Decision ^{back to top}

Reserved for future use

Advisory Committee Meeting Notes ^{back to top}

Start Date of Comment Period ^{back to top}

04/30/1993

End Date of Comment Period ^{back to top}

06/14/1993

Start Date of Notice Period ^{back to top}

08/01/1993

Revision History Number ^{back to top}

URO013

Revision History Explanation ^{back to top}

Revision Effective Date: 01/01/2010
INDICATIONS AND LIMITATIONS OF COVERAGE:
Added: Coverage statement for urethral inserts.
Added: Statement about checking before refilling orders
HCPCS CODES AND MODIFIERS:
Added: A4336, A4360, A4456

Revision Effective Date: 12/01/2009
INDICATIONS AND LIMITATIONS OF COVERAGE:
Revised: Additional quantity denial statements for tape, anchoring devices and leg-bag straps.
HCPCS CODES and MODIFIERS:
Revised: KX modifier.
DOCUMENTATION REQUIREMENTS:
Added: Instructions for the use of the GY modifier.
Removed: Instructions for additional quantities.

Revision Effective Date: 04/01/2008
INDICATIONS AND LIMITATIONS OF COVERAGE:
Revised: Indications for intermittent catheterization.
HCPCS CODES AND MODIFIERS:
Revised: A5105 (Effective 01/01/2008)
APPENDICES:
Removed: Definitions.

03/01/2008 - In accordance with Section 911 of the Medicare Modernization Act, this policy was transitioned to DME MAC NHIC (16003) LCD L5080 from DME PSC TriCenturion (77011) LCD L5080.

06/01/2007 - In accordance with Section 911 of the Medicare Modernization Act of 2003, Virginia and West Virginia were transitioned from DME PSC TriCenturion (77011) to DME PSC TrustSolutions (77012).

Revision Effective Date: 01/01/2007
INDICATIONS AND LIMITATIONS OF COVERAGE:
Removed: References to DMERC.
Removed: Reference to A4348.
HCPCS CODES AND MODIFIERS:
Revised: A4326, A5105
Deleted: A4348, A4359
DOCUMENTATION:
Removed: References to DMERC.

03/01/2006 - In accordance with Section 911 of the Medicare Modernization Act of 2003, this policy was transitioned to DME PSC TriCenturion (77011) from DMERC Tricenturion (77011).

Revision Effective Date: 01/01/2006
DOCUMENTATION REQUIREMENTS:
Revised: Requirements for high utilization.

Revision Effective Date: 04/01/2005
LMRP converted to LCD and Policy Article.
HCPCS CODES AND MODIFIERS:
Deleted: A4324, A4325, A4347, A4521-A4538
Added: A4349, A4520
Revised: A4332
INDICATIONS AND LIMITATIONS OF COVERAGE:
Added: References to new codes and removed deleted codes.

Revision Effective Date: 04/01/2004
HCPCS CODES AND MODIFIERS:
Added: A4217
Deleted: A4319, A4323
INDICATIONS AND LIMITATIONS OF COVERAGE:
Added: References to new code and removed deleted codes.
CODING GUIDELINES:
Added: A4217 to codes requiring AU modifier.

Revision Effective Date: 04/01/2003
HCPCS CODES AND MODIFIERS:
Added: AU, EY modifiers, A4450, A4452, A4521-A4538
Deleted: K0572, K0573, A4360
INDICATIONS AND LIMITATIONS OF COVERAGE:
Added: Standard language concerning coverage of items without an order and use of the AU modifier.
CODING GUIDELINES:
Added: coding definitions from “LMRP Description” section.
DOCUMENTATION REQUIREMENTS:
Added: Standard language concerning use of EY modifier for items without an order.

The revision dates listed below are the dates the revisions were published and not necessarily the effective dates for the revisions.

04/01/2002 - Added HCPCS codes A4319, A4324, A4325,
A4331-A4333, A4348, A4360, K0572, K0573. Deleted from policy HCPCS codes A4329, A4359, A4554, A5149, A6265, K0280, K0281, K0407-K0409, K0411. Added use of GY modifier for non-covered conditions. Replaced ZX with KX modifier.

04/01/2000 - In the Winter 1999 Region D Supplier Manual update, verbiage was inadvertently omitted from the Urological Supplies regional medical review policy (RMRP) revision. The verbiage below was present in previous versions of the policy but was absent in the latest revision published. Coverage and Payment Rules for indwelling catheters (IX-37), indications #3 and #4 for non-routine changes should read:

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 at intervals of less than one per month

The revision also reflects updates to the Coding Guidelines (IX - 37.5) which clarify the previously published payment policy for HCPCS code A5200 (Percutaneous catheter/tube anchoring device, adhesive skin attachment). (See Winter 1998 DMERC Dialogue, page 12.)

01/01/2000 – Added HCPCS codes A5200 and A6265. Added reasonable and necessary language in Coverage and Payment Rules section. Added language for A4340 in Coverage and Payment Rules section.

03/01/1998 – Deleted certain HCPCS K and XX codes.

04/01/1996 – Updated utilization table.

07/01/1995 – Added HCPCS codes. Renamed policy from Incontinence Appliances and Care Supplies to Urological Supplies. Entire policy revised.

02/01/1994 – Deleted codes K0137-K0139.

12/01/1993 – Added codes XX004 and XX005.

11/15/2009 - CPT/HCPCS code A4365 was deleted from group 1

Reason for Change ^{back to top}

Last Reviewed On Date ^{back to top}

Medicare Coverage Database

LCD for Urological Supplies (L5080)