Clinicians! Are You Ordering Urological Supplies for Your Patients? - JD DME

Urological supplies are covered as part of the Prosthetic Device benefit as outlined in the Social Security Act § 1861(s)(8). Prosthetic devices (other than dental) which replace all or part of an internal body organ (including contiguous tissue) or replace all or part of the function of a permanently inoperative or malfunctioning internal body organ are covered when furnished on a physician’s order.

Urinary catheters and external urinary collection devices are covered to drain or collect urine for a beneficiary who has permanent urinary incontinence or permanent urinary retention. 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, the test of permanence is considered met. Catheters and related supplies will be denied as non-covered in situations in which it is expected that the condition will be temporary.

Indwelling catheters are those that remain in place, and Medicare will pay for one catheter per month, barring a few exceptions (e.g., catheter is accidentally removed, there is a malfunction with the catheter, or there is a catheter obstruction). Medicare will also pay for related catheter supplies appropriate for use with indwelling catheters.

The Urological Supplies LCD also details coverage criteria for external catheters/urinary collection devices as alternatives for indwelling catheters.

Intermittent catheters are those that are changed with each episode, and the beneficiary or caregiver can perform the procedure of changing the catheter. There are three types of intermittent catheters:

1. Straight tip catheter 
2. Coude (curved) tip catheter 
3. Catheter with insertion supplies (please note this particular catheter, also referred to as a "sterile kit," has additional coverage criteria such as recurrent urinary tract infections, immunosuppressed, or residing in a skilled nursing facility). The preceding are examples only and not a full list of applicable conditions where this type of intermittent catheter may be medically necessary.

Medicare will cover up to 200 intermittent catheters per month as long as the medical record supports the need for the quantity ordered by the treating practitioner.

Medicare will also consider coverage of external catheter systems if the need is substantiated by information in the beneficiary’s medical records. This includes male and female external catheter systems and the inFlow device. Specific coverage criteria can be found in the LCD and related Policy Article.

A standard written order (SWO) must be in the DME supplier’s possession before they can submit claims to the Medicare program. A valid standard written order contains the following elements:

• Beneficiary's name or Medicare Beneficiary Identifier (MBI)
• Order date
• General description of the item
  • The description can be either a general description (e.g., catheter), a HCPCS code, a HCPCS code narrative, or a brand name/model number.
  • For equipment - In addition to the description of the base item, the SWO may include all concurrently ordered options, accessories, or additional features that are separately billed or require an upgraded code (list each separately).
  • For supplies - In addition to the description of the base item, the DMEPOS order/prescription may include all concurrently ordered supplies that are separately billed (list each separately).
• Quantity to be dispensed, if applicable
• Treating practitioner name or NPI
• Treating practitioner's signature

The DME supplier will likely send you a SWO for the urological supplies, which has been prepared for your review and signature. Please review and sign that SWO in a timely manner so the DME supplier can file claims to the Medicare program.

Following these coverage guidelines will help your patients and the Medicare program by verifying there is medical documentation to support the provision of urological supplies. Your assistance will allow Medicare to pay claims appropriately and ensure that your patient receives the DMEPOS items you have prescribed.

The LCD and Policy Article for urological supplies are located on the DME MAC websites.