Urological Supplies

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What's Changed?

We updated the improper payment rate and denial reasons for the 2024 reporting period.

Affected Providers

Treating practitioners and DME suppliers who bill for urological supplies.

HCPCS & CPT Codes

Local Coverage Determination (LCD): Urological Supplies (L33803) has the current HCPCS and CPT codes.

Background

According to the 2024 Medicare Fee-for-Service Supplemental Improper Payment Data, the improper payment rate for urological supplies is 45.2%, with a projected improper payment amount of $257.8 million.

We cover urological supplies under the prosthetic benefit. We outline other policy requirements in LCD L33803.

Denial Reasons

No documentation accounted for 80.2% of improper payments for urological supplies during the 2024 reporting period, while insufficient documentation (16%), medical necessity (0.4%), incorrect coding (0.2%), and other errors (3.2%) also caused improper payments. “Other” errors include duplicate payment, non-covered or unallowable service, or ineligible Medicare patient errors.

Preventing Denials

The patient’s medical records must support the medical necessity for the urological supplies and must be available, if asked, for us to consider them reasonable and necessary.

Indwelling Catheters

We cover only 1 indwelling catheter (HCPCS codes A4311 – A4316, A4338, A4340, A4344, and A4346) per month for routine catheter maintenance. We cover non-routine catheter changes when documentation supports medical necessity, like these indications:

The catheter is accidentally removed (for example, pulled out by patient)
Catheter malfunction (for example, balloon doesn’t stay inflated; hole in catheter)
Encrustation, a mucous plug, or a blood clot obstructs catheter
History of recurrent obstruction or urinary tract infection when it has been shown that a scheduled change frequency of more than once per month prevents an acute event

NOTE:
Using a Coude (curved) tip indwelling catheter (A4340) in a female patient is rarely reasonable and necessary. If requested documentation doesn’t prove medical necessity, we deny payment for A4340, A4344, A4312, or A4315 as not reasonable and necessary.

We cover:

One catheter insertion tray (HCPCS codes A4310–A4316, A4353, and A4354) per episode of indwelling catheter insertion
Supplies for intermittent irrigation of indwelling catheter on a non-routine basis when there’s an acute obstruction in the catheter
Supplies for continuous irrigation of indwelling catheters when there’s a history of catheter obstruction, and intermittent irrigation and catheter changes can’t maintain the catheter’s patency

NOTE:
Continuous irrigation is a temporary measure. Continuous irrigation for more than 2 weeks is rarely reasonable and necessary. The patient’s medical records should show the medical necessity and must be available upon request.

Intermittent Catheterization

We cover intermittent catheterization when the patient meets basic coverage criteria, and the patient or caregiver can do the procedure.

For each episode of intermittent catheterization, we cover 1 of these:

One catheter (HCPCS code A4351 or A4352) and an individual packet of lubricant (HCPCS code A4332)
A sterile intermittent catheter kit (HCPCS code A4353) when the patient meets 1 of these criteria:
- Lives in nursing facility
- Is immunosuppressed
- Has radiologically documented vesico-ureteral reflux while on an intermittent catheterization program
- Is a spinal cord injured pregnant female with a neurogenic bladder (for duration of pregnancy only)
- Has had distinct, recurrent urinary tract infections, while on a program of sterile intermittent catheterization with A4351 or A4352 and sterile lubricant A4332, twice within the 12 months before initiating sterile intermittent catheter kits

NOTE:
Using a Coude (curved) tip catheter in female patients is rarely reasonable and necessary. When we provide a Coude tip catheter, you must document in the patient’s medical record the medical necessity for the catheter. The inability to catheterize with a straight tip catheter is 1 example for using a Coude tip catheter. Make documentation available upon request; if it doesn’t support medical necessity, we deny the claims as not reasonable and necessary.

NOTE:

Using a Coude (curved) tip catheter in female patients is rarely reasonable and necessary. When we provide a Coude tip catheter, you must document in the patient’s medical record the medical necessity for the catheter. The inability to catheterize with a straight tip catheter is 1 example for using a Coude tip catheter. Make documentation available upon request; if it doesn’t support medical necessity, we deny the claims as not reasonable and necessary.

External Catheters or Urinary Collection Devices

We cover external catheters or urinary collection devices (female or male) as an alternative to an indwelling catheter for patients who have permanent urinary incontinence.

Male external catheter (HCPCS code A4349) quantities generally shouldn’t exceed 35 per month
Female external collection devices shouldn’t exceed more than 1 meatal cup (HCPCS code A4327) per week or 1 pouch (HCPCS code A4328) per day

NOTE:
LCD L33803 has a specific list of covered supplies for the above-mentioned catheter types.

Refill Requirements

For DMEPOS items and supplies provided on a recurring basis, base your billing on prospective, not retrospective use.