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Medicare coverage of urological supplies Indwelling catheters, including latex, silicone, 2-way and 3-way catheters may be covered up to 1 per month. Additional/non-routine catheter changes may be covered only if medically necessary due to accidental removal, malfunction, obstruction, history of urinary tract infection or recurring obstruction that requires more frequent changes. For disposable male/external catheters medical necessity determines coverage as an alternative to indwelling catheters with permanent urinary incontinence. Up to 35 per month may be covered for male external catheters while female external collection devices may be covered up to one metal cup per week or one pouch per day. Medical necessity determines coverage of bedside and leg drainage bags. Leg bags may be covered for ambulatory, wheelchair-bound, or chair-bound patients and are not considered medically necessary for bedbound beneficiaries. Medicare covers up to 2 per month, which may be a combination of 1 bedside and 1 leg bag. Irrigation trays and syringe are covered according to medical necessity. Medicare may cover up to 1 per month (one per episode of insertion). Special care should be taken to assure that coding is correct and that codes that includes several components are not billed separately as an “a la carte” item. Sterile water/saline is covered only for intermittent irrigation of indwelling catheters. Medicare provides for up to 500 ml per month. It also provides for non-routine irrigation when there is an acute obstruction of catheter. Continuous irrigation of indwelling catheters with a history of obstruction and patency cannot be maintained with intermittent irrigation and catheter changes. Tape coverage includes both waterproof and non-waterproof tape. Medicare covers up to 10 per month. Gauze, skin barriers, sealants, ointments and gloves are not generally covered. Refills may be covered through the supplier. Delivery/shipping of the new supplies should be no sooner than 10 calendar days prior to the end of usage for their current products. Note that refill deliveries are not covered without a beneficiary request.
Reasons for denial Improper payment for urological supplies as found in a targeted probe and educated review from April through June 2019 was 37%. Top reasons for the denial of claims included the following:
Tips for improving documentation and reimbursement Following checklists and guides for appropriate documentation will accomplish many things, including assuring accurate communications, quality of care, transition of care when needed, and successful submissions for coverage. Documentation checklists provided by local coverage determination jurisdictions are helpful for Medicare submissions. Private insurance should be checked for coverage as policies vary widely. The supplier should have a standard written order on file that includes the beneficiary’s name, a description of item, their physician’s name, the start date of order, a valid written order, beneficiary authorization, proof of delivery, and documentation supporting medical necessity (permanent/>3 months of urinary impairment). Specific documentation for special items and quantities above normal monthly allowances should be included. And, to prevent wasted time and labor, check to be sure that items included in “kits” (that may include multiple or duplicate supplies) are not also submitted for coverage separately. Because a common reason for non-coverage is the lack of a response to questions or requests posed for coverage, getting it right the first time can save time and a lot of frustration on the part of health care providers, suppliers, and beneficiaries.
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