O'NEIL TOUCHLESS STERILE INTERMITTENT URINARY CATHETERs


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Medicare/Medicaid Cover


Basic Medicare Coverage Criteria

The patient must have permanent urinary incontinence or urinary retention, and the patient or caregiver must be able to perform the procedure. 

Catheter Prescription for Medicare

Medicare and most insurers require that a catheter prescription contain the following elements:

  • patient’s name
  • description of the item ordered
  • quantities per month
  • the date order was signed
  • start date of order (only if different than date order was signed)

Quantities of Catheters Covered

Medicare programs allow 200 intermittent catheters per month without additional medical documentation. 

Medicaid programs typically allow 120 intermittent catheters per month without additional medical documentation.  Note: Benefits vary by state Medicaid plan. 

Other insurance coverage varies by plan, and benefits must be verified at the time of intake. 

Why the Centers for Medicare and Medicaid Services covers a new catheter each time 

Reason #1: Washing and reusing catheters increases the likelihood of bacteria remaining in the catheter to be reinserted into the urinary tract, thereby causing infection. UTI’s are one of the most frequent and significant complications for intermittent catheter users.  Symptoms of infection include: burning sensation with urination, having the urge to urinate more frequently, opaque or bloody urine, nausea and fever.   

Reason #2:  The benefits of hydrophilic-coated catheters are only available for a single use.  This is because the hydrophilic coating is removed when washed, and the catheter requires manual lubrication for reuse.  Clinical studies have documented that single-use hydrophilic-coated catheters significantly reduce the incidence of urinary tract infections, as well as urethral damage and trauma, and withdrawal friction, while simultaneously increasing user preference and patient satisfaction, as compared to uncoated catheters with lubrication. 

Reason #3:  The cost of treating urinary tract infections in catheter users (an estimated $3.5 billion so far) is much higher than the cost of providing single use intermittent catheters.  Based on these research findings, the Department of Veterans Affairs (VA) and the Centers for Medicare and Medicaid Services (CMS) have eliminated mandatory reuse practices, and now allow for sterile single use catheters for each catheterization.

Reason #4: Intermittent catheters were never made or approved by the FDA for repeated use.  They are Single Use Devices (SUDs), and when used repeatedly pose significant risk for infection or product failure, endangering patient health and safety.

Reason #5:  Why struggle and fuss with washing, and drying catheters?   Individuals with neurogenic bladder and their caregivers should have the quality, freedom and convenience of sterile single use intermittent catheters.  Single use intermittent catheters represent the best practices in medicine our healthcare system has to offer. 

Reason #6:  Individuals who experience infections even with sterile single use catheters should increase their efforts to avoid infection by using catheter kits.  They should not give up their efforts to avoid urinary tract infections, and go back to washing and reusing catheters.  Medicare provides catheter kits for individuals who experience two distinct documented urinary tract infections in a twelve month period while using sterile intermittent catheters.  Catheter kits are sterile insertion supplies containing gloves, antiseptic wipe, drapes, and lubricant.  Closed system catheter kits additionally contain a drainage bag. 

Additional preventative measure include: thoroughly washing your hands with soap and water before and after each catheterization, ensuring the bladder is completely empty at each catheterization, catheterizing at least 6 times a day, ensuring adequate water and Vitamin C intake, and dietary improvement. 

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:

  1. One catheter (A4351, A4352) and an individual packet of lubricant (A4332); or
  2. 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):

  1. The patient resides in a nursing facility,
  2. 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
  3. The patient has radiologically documented vesico-ureteral reflux while on a program of intermittent catheterization,
  4. The patient is a spinal cord injured female with neurogenic bladder who is pregnant (for duration of pregnancy only),
  5. 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).


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