Article Detail - JD DME

To help our suppliers, Noridian and CGS Provider Outreach and Education worked together to answer the most frequently asked questions on Urological Supplies. These FAQs are found on the Urological Supplies page.

Q1: A patient requests 230 intermittent catheters per month, but the usual maximum quantity in the Urological Supplies Policy Article is 200. How should I handle the 30 additional catheters?
A1: You should bill upgrade modifiers on the claim if you expect the beneficiary to pay for any quantity above the maximum as outlined in the LCD. If there is medical justification for the additional quantity, you can file an appeal for denied claims.

Q2: Is the A4353 (sterile catheterization kits) covered for a high-level spinal cord injury patient immunocompromised beneficiary?
A2: Yes, a spinal cord injury could meet LCD coverage criteria if the beneficiary is immunosuppressed and the condition is supported by the beneficiary’s medical record.

Q3: If a beneficiary new to Medicare was using the A4353, do they have to go back to intermittent urinary catheters (A4351 or A4352) and have two urinary tract infections (UTIs) in a year to continue coverage of the A4353?
A3: No, they don’t need to switch. However, the beneficiary’s medical record must show they had UTIs in the past or that one of the other LCD coverage criteria is met.

Q4: Is the diagnosis of neurogenic bladder enough or does the practitioner need to specify permanent urinary retention or incontinence?
A4: The beneficiary’s medical record must show permanent urinary retention or permanent urinary incontinence and meet the LCD requirements for urological supplies.

Q5: For intermittent catheters, does the frequency of use need to be documented in the medical records even if indicated on the standard written order (SWO)?
A5: Additional elements included on the SWO, such as frequency of use, must be corroborated by the information in the medical record but not necessarily redocumented in the medical records.

Q6: Do I need a refill request if the patient picks up the catheter at the local store?
A6: Per the Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426), for items that the beneficiary obtains in-person at a retail store, the signed delivery slip or a copy of the itemized sales receipt is sufficient documentation of a request for refill.

Q7: Are urological supplies separately payable for beneficiaries enrolled in a home health episode?
A7: No, urological supplies fall within the consolidated billing requirements and should be provided by the home health agency. View the Home Health Consolidated Billing Master Code List for  HCPCS that shouldn’t be billed to the DME MACs during a 60-day home health episode.

Q8: If a beneficiary can’t use an indwelling catheter due to issues and they switched to intermittent straight tip catheters, is that justification for providing over 200 each month?
A8: Medical documentation must show both the need to switch to intermittent catheters and the necessity for more than the usual maximum quantity. If you expect the beneficiary to pay for quantities above the maximum, bill upgrade modifiers on the claim. If the beneficiary doesn't qualify, obtain a valid Advance Beneficiary Notice (ABN) to transfer financial responsibility to the beneficiary for the extra catheters. If there is medical justification for the additional quantity, you can file an appeal for denied claims.

Q9: Is there a medical justification for providing both sterile catheterization kits (A4353) and straight tip intermittent catheters (A4351) at the same time?
A9: No, Medicare guidelines and clinical standards don’t support providing both sterile catheterization kits (A4353) and straight tip catheters (A4351) at the same time. Patients who qualify for sterile catheterization kits should use them exclusively rather than in combination with regular catheters. Sterile catheterization kits provide a higher level of protection against infection for high-risk patients.

Q10: Can a beneficiary use a Coude tip intermittent catheter (A4352) to stretch a stricture and then void on their own for the rest of week? Can I bill both a Coude and a straight tip (A4351) to Medicare in these situations?
A10: No, urinary catheters and external urinary collection devices are covered to drain or collect urine for a beneficiary with permanent urinary incontinence or retention. The beneficiary must have a permanent impairment of urination.

Q11: Does Medicare provide coverage for the PureWick female catheter system?
A11: The DME MACs manually process claims for the PureWick and associated supplies or accessories. Coverage is considered on a claim-by-claim basis. If a claim is denied, appeal rights are available. Review the PureWick Urine Collection System – Coding and Billing Instructions - Revised article.

Q12: When should I bill with the AU modifier?
A12: The AU modifier should be used with sterile water or saline, and tape codes when used with urological supplies. If these codes are billed without an AU modifier or the appropriate modifier under another LCD (e.g., AW or AV), the claim will be rejected as missing information.

Q13: For shipping, what information do I need as proof of delivery? What date of service do I use?
A13: For items shipped to the beneficiary, the proof of delivery should include the delivery service’s package identification number, supplier invoice number, or alternative method that links the supplier’s delivery documents with the delivery service’s records. The date of service can be either the date the label was created, the date the item(s) were shipped, or the date the beneficiary received the item. For more information, see the Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) Policy Article.

Q14: For a Coude tip catheter (A4352) justification, is "due to benign prostatic hyperplasia (BPH), a non-cancerous enlargement of the prostate gland," sufficient?
A14: A diagnosis alone is not enough. When a Coude tip catheter is used, there must be documentation in the medical record of the medical necessity for that catheter. For example, the beneficiary can’t be catheterized with a straight-tip catheter.

Q15: Does the urine culture need to state, "greater than 10,000 pathogenic bacteria," or can it just state the specific bacteria?
A15: The urine culture should state the specific bacterial count. Per Local Coverage Determination (LCD) L33803, "A beneficiary 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."