Medicare Urological Utilization Guidelines

Intermittent Catheters

General Description

HCPCS

Medicare Quantity Guidelines

Intermittent urinary catheter, straight tip

A4351

200 per month

Intermittent urinary catheter, coude (curved) tip

A4352

200 per month. Additional documentation is always required to justify medical necessity of coude tip. Coude justifications include: urethral strictures or other inability to pass a straight tip catheter.

Intermittent urinary catheter, with insertion supplies

A4353

See Guidelines below.

 

A4353 Guidelines

Medicare also covers Closed-System Intermittent Catheters and Intermittent Catheters with Insertion Kits if the beneficiary has permanent urinary incontinence and has at least one of the following criteria documented in their medical record:

 

1.       Patient resides in nursing home

2.       Patient is immune-suppressed

3.       Patient has radiologically documentation ureteral vesico-uteral reflux

4.       Patient is a spinal cord injured pregnant female

5.       Patient has had at least 2 distinct urinary tract infections within a 12 month period while on sterile intermittent catheterization program.

 

Urinary Tract Infection (UTI) Documentation Requirements

Medicare requires urine culture with greater that 10,000 colony forming units of a urinary pathogen and one or more of the following: 

1.       Fever (measured orally) greater than 100.4 F

2.       Pyuria; white blood cell count greater 5 per high power field (HPF)

3.       Change in urinary urgency, frequency, or incontinence

4.       Appearance of dysreflexia or increase in existing dysreflexia (sweating, slow heart rate, elevated blood pressure)

5.       Physical signs of prostatitis, epididymitis, orchitis

6.       Systemic leukocytosis

7.       Increased muscle spasms

 

Condom Catheters

General Description

HCPCS

Medicare Quantity Guidelines

Male external catheter, with or without adhesive, disposable

A4349

35 per month

 

Guidelines for additional quantities

If approved for sterile technique of intermittent catheterization or skin breakdown history.

Foley Catheters

General Description

HCPCS

Medicare Quantity Guidelines

Indwelling catheter, Foley type, 2-way with coating

A4338

1 per month

Indwelling catheter, specialty type, eg; coude, mushroom, wing, etc

A4340

1 per month

Indwelling catheter, Foley type, 2-way all silicone

A4344

1 per month

Insertion tray without drainage bag without catheter (accessories only)

A4310

1 per month

Insertion tray without drainage bad with indwelling catheter, Foley type, 2-way with latex with coating

A4311

1 per month

Insertion tray without drainage bag with indwelling catheter, Foley type, 2-way all silicone

A4312

1 per month

Insertion tray with drainage bag with indwelling catheter, Foley type, 2-way latex with coating

A4314

1 per month

Insertion tray with drainage bag with indwelling catheter, Foley type, 2-way all silicone

A4315

1 per month

 

Guidelines for additional quantities

Non-routine indwelling catheter changes are covered if one of the following are documented; catheter accidentally removed, catheter malfunction, obstruction of catheter, documented history of recurrent obstruction or urinary tract infection proven to be preventable when catheter is changed more than once a month.

 

 

Irrigation Supplies

General Description

HCPCS

Medicare Quantity Guidelines

Irrigation tray with bulb or piston syringe, any purpose

A4320

1 as needed for irrigation, not routinely

Irrigation syringe, bulb or piston

A4322

1 as needed for irrigation, not routinely

Collection Devices       

General Description

HCPCS

Medicare Quantity Guidelines

Bedside drainage bag, with or without anti-reflux device, with or without tube

A4357

2 per month

Urinary drainage bag, leg or abdomen, vinyl, with or without tube, with straps

A4358

2 per month

Bedside drainage bottle with or without tubing, rigid or expandable

A5102

1 every 3 months

Urinary leg bag, latex

A5112

1 per month

Miscellaneous Items              

General Description

HCPCS

Medicare Quantity Guidelines

Lubricant, individual sterile packer, for insertion or urinary catheter

A4332

1 packet per episode of intermittent catheterization

Extension drainage tubing, any type, any length, with connector/adaptor, for use with urinary leg bag or urostomy pouch

A4358

2 per month

 

Note: Monthly allowable amounts do not represent a benefit limit. The actual quantity needed by a particular customer may be more or less than the amount listed, depending on the individual customer’s medical condition as prescribed by their physician. Customers ordering over the allowable amount must have appropriate medial justification.