DMEPOS Mini-Series #4 – Urological Supplies: Intermittent Catheters
If you are a Medicare Part B supplier, then you are aware that billing Medicare B is quite different than billing other payors, and consequently, can be incredibly challenging for pharmacies. Being able to produce all the required documentation upon an audit, and making sure that the documentation meets Medicare Part B requirements, is a daunting task.
Medicare performs post-payment medical reviews on intermittent catheters due to having a high, sustained error rate. The top errors are:
- invalid orders or missing documentation to support the item is reasonable and necessary
- no clinical documentation received
- invalid proof of delivery
- NPI on claim is not the ordering physician
Follow the tips below to be prepared in case of an intermittent urinary catheter audit.
PAAS Tips:
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- Required Documentation for all DMEPOS items – See our April 2021 Newsline for more details
- Standard Written Order
- Proof of refill request
- Proof of delivery
- Medical Records
- Coverage Criteria for Intermittent Catheterization
- Beneficiary must have permanent urinary incontinence or retention
- “Permanent” is defined as a long and indefinite duration of at least three months
- The impairment is not expected to be surgically or medically corrected within three months
- The beneficiary or caregiver can perform the procedure
- For each episode, Medicare will cover:
- One catheter: A4351 (straight tip catheter) or A4352 (coude or curved tip catheter) and an individual pack of sterile lubricant A4332 OR
- One sterile intermittent catheter kit: A4353
- Must meet one of the following:
- Nursing facility resident
- Immunosuppressed
- Radiologically documented reflux
- Pregnant female with spinal cord injury with neurogenic bladder (for duration of pregnancy only)
- Had at least 2 urinary tract infections (UTIs) within 12 months while on sterile intermittent catheterization using A4351/A4352 and sterile lubricant A4332
- Maximum quantity of intermittent catheterization supplies per month is two hundred for codes A4332, A4351, A4352 and A4353
- Medical necessity of coude (curved-tip) catheters must be supported by documentation in the medical record – use of a coude tip catheter in female beneficiaries is rarely reasonable and necessary
- Urological supplies are an exception to requiring proof of continued need. Once the initial medical need is established, ongoing need for urological supplies is assumed due the permanent condition
- Must meet one of the following:
- Please reference the following helpful links when billing intermittent catheters
- Urological Supplies LCD and Policy Article
- Documentation Checklist for Urological Supplies: Intermittent Catheters
Analyst at PAAS National®
I began working at an independent pharmacy in high school and really enjoyed being in the health care field. I provided clinical support to improve patient care and adherence to their medications. I have played a vital role in the pharmacy industry full-time for 23 years.
I have a Bachelor of Science degree from the University of Wisconsin-River Falls and have been a Certified Pharmacy Technician since 2001. Prior to joining the PAAS team, I was a floating technician, 3rd party district chargeback specialist, and district pharmacy training coordinator. Formerly, I was also an instructor for pharmacy technician certification classes.
PAAS’ personal, one-on-one connection will help your pharmacy become more successful in dealing with tiresome PBM audits. It is a pleasure knowing that my colleagues and I can help member pharmacies.
I have a Bachelor of Science degree from the University of Wisconsin-River Falls and have been a Certified Pharmacy Technician since 2001. Prior to joining the PAAS team, I was a floating technician, 3rd party district chargeback specialist, and district pharmacy training coordinator. Formerly, I was also an instructor for pharmacy technician certification classes.
PAAS’ personal, one-on-one connection will help your pharmacy become more successful in dealing with tiresome PBM audits. It is a pleasure knowing that my colleagues and I can help member pharmacies.
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