Urological Supplies

Coverage

Documentation

Reviews/Audits

  • Medical Review - View notifications/findings of pre/post claim reviews completed by Noridian Medical Review

Bundling

Per the bundling table listed in Policy Article A52521:

  • When the bundled code listed in Column I is billed, the codes in column II are not separately payable.
  • When the codes in Column II are provided at the same time, it must be billed with the bundled code listed in Column I.
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
A4354 A4310, A4331, A4332, A4357
A4357 A4331
A4358 A4331, A5113, A5114
A5105 A4331, A4358, A5112, A5113, A5114
A5112 A5513, A5114

Tips

Topic Details
Continued Medical Need For all DMEPOS items, the initial justification for medical need is established at the time the item(s) is first ordered, therefore, beneficiary medical records demonstrating that the item is reasonable and necessary are created just prior to, or at the time of, the creation of the initial prescription. Once initial medical need is established, ongoing need for urological supplies is assumed to be met. There is no requirement for further documentation of continued medical need if the beneficiary continues to meet the Prosthetic Devices benefit.
Coverage Criteria for Intermittent Urinary Catheters A4353 - Immunosuppressed Beneficiaries Meeting Criteria 2

Immunosuppressed criteria for the A4353 (intermittent urinary catheter, with insertion supplies) are covered when a beneficiary requires catheterization and the beneficiary is immunosuppressed, for example below (not an all-inclusive list).

  • On a regimen of immunosuppressive drugs post-transplant,
  • On cancer chemotherapy,
  • Has AIDS,
  • Has a drug-induced state such as chronic oral corticosteroid use.
  • Immunosuppressed spinal cord injury patients will be considered for coverage when conducting medical reviews.

Please note that the above list indicates that it is not an all-inclusive list. For all conditions, the practitioner is required to clearly document the condition causing the immunosuppression within the beneficiary’s medical records to qualify for criteria 2. These practitioner records must meet the medical necessity based on the coverage criteria listed within the Local Coverage Determination (LCD) L33803

Beneficiary Entering Medicare FFS Using Sterile Intermittent Catheters (A4353) Suppliers must obtain documentation supporting the claim that the beneficiary has been using the A4353 prior to becoming Medicare eligible. The beneficiary would not have to go back and retrial the other catheters.

Noridian understands that beneficiaries entering Medicare who are currently on sterile intermittent catheters (A4353) must continue to utilize these catheters. Medicare will not require beneficiaries entering Medicare to go back and trial the A4351 or A4352 and wait for two urinary tract infections (UTIs) within 12 months.

Documentation needed to continue the A4353 would need to be submitted if a claim denial occurs. A redetermination may need to be submitted. Supporting medical records documenting the previous UTIs would be the best documentation to support the use of A4353. If this documentation is not available, provide the most current medical necessity documentation to support the medical need of A4353. As a reminder, Medicare will not request medical records that are more than 7 years. More information on Beneficiaries Entering Medicare can be found on our website.
Last Updated Jun 19 , 2024

Related Articles

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Articles Source Posted
Urological Supplies and Continuing Medical Need 05/09/2024
Targeted Probe and Education (TPE) Pre-Payment Reviews 04/24/2024
LCD and Policy Article Revisions Summary for December 14, 2023 12/14/2023
Urological Supplies Clinician Letter Available to Suppliers 11/22/2023
Coverage Criteria for Intermittent Urinary Catheters A4353 - Immunosuppressed Beneficiaries Meeting Criteria 2 10/31/2023