New Medicare Regs involving urinary catheters

[LindaAukett UOAA Advocacy]

Medicare has anounced to the supplier community some changes in the way urinary catheters will be reimbursed. This might be of interest to some of you who are using catheters with a urinary diversion AND are relying on Medicare for your supplies.
Please bear in mind that it is written as a Q&A between Medicare and suppliers.

For Immediate Release
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April 25, 2008

Urological Supplies - Policy Changes FAQ

The March 2008 revision of the Urological Supplies LCD removed references to "Clean Intermittent Catheterization" and removed the requirement for re-use of intermittent catheters with that technique. This FAQ addresses some issues associated with the policy revision.

Q1. The policy on intermittent catheterization has been revised. The criteria for coverage of sterile kits, A4353, are slightly different from the previous criteria. The previous criteria required two infections while using "clean technique". This revision requires two infections while using sterile, single-use catheters (A4351, A4352). Are current A4353 patients that qualified under clean technique grandfathered under this new policy?

A1. Beneficiaries who were using A4353 sterile catheter kits prior to April 1, 2008 and who met the requirements for A4353 in the previous version of the Urological Supplies LCD continue to be eligible to receive sterile intermittent catheterization kits. The medical record must contain sufficient information to demonstrate that the applicable coverage criteria were met.

Q2. We are working with patients, who have a history of urinary tract infections (UTI), but are currently washing and reusing their catheters (A4351, A4352) - i.e., they are using clean technique. We are just waiting for their doctors to send the lab results along with the UTI dates. Sometimes it takes 3 to 4 weeks for the doctors to respond to our requests. Are sterile catheter kits (A4353) covered for these patients?

A2. No. If the beneficiary was not using sterile catheter kits (A4353) prior to 4/1/2008, he/she must meet the current criteria in order to be eligible for reimbursement. Beneficiaries who have been reusing intermittent catheters (A4351, A4352) with clean technique at the rate of one catheter per week are eligible to use a sterile catheter (A4351, A4352) and a packet of sterile lubricant (A4332) for each catheterization. The number of items needed must be determined by the treating physician and information in the medical record must justify the need for the number of items prescribed.

Q3. The policy contains a table describing the usual maximum number of supplies. Does this mean that every beneficiary should get 200 per month?

A3. No. The usual maximum number represents a determination of the number of items that beneficiaries with extreme utilization requirements will actually need. The typical beneficiary will require a much lower amount. The beneficiary's utilization should be determined by the treating physician based upon the patient's medical condition. There must be sufficient information in the medical record to justify the amount ordered. A beneficiary or their caregiver must specifically request refills of urological supplies before they are dispensed. The supplier must not automatically dispense a quantity of supplies on a predetermined regular basis, even if the beneficiary has "authorized" this in advance. The supplier should check with the patient or caregiver prior to dispensing a new supply of intermittent catheters to determine that previous supplies are nearly exhausted.

Q4. In an audit, what information must be contained in the medical record to justify payment for both the type and quantity of urological supplies ordered by the treating physician?

A4. For urological supplies to be covered by Medicare, the patient's medical record must contain sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement. The information should include the patient's diagnosis and other pertinent information including, but not limited to, duration of the patient's condition, clinical course (worsening or improvement), prognosis, nature and extent of functional limitations, other therapeutic interventions and results, past experience with related items, etc. Neither a physician's order nor a supplier-prepared statement nor a physician attestation by itself provides sufficient documentation of medical necessity, even though it is signed by the treating physician. There must be clinical information in the patient's medical record that supports the medical necessity for the item and substantiates the information on a supplier-prepared statement or physician attestation.
For intermittent catheterization, in addition to the general information described above, the patient's medical record must contain a statement from the physician specifying how often the patient (or caregiver) performs catheterizations. The patient's medical record is not limited to the physician's office records. It may include hospital, nursing home, or home health agency (HHA) records, and records from other professionals including, but not limited to, nurses, physical or occupational therapists, prosthetists, and orthotists.

[Carl W]

First, let me say that I've been called "cheap" and "too frugile". I have no medical insurance, and have to supply myself with my caths. It's no big deal though. I'm using the clear plastic 14 fr caths, since they are stiffer, and work better for me. But, there is another advantage to using the clear ones. You can tell when they are clean, and have no mucus in them.
My procedure is to use the cath, rinse it out when I'm done with it, and put it away. When I'm ready to drain my Indiana Pouch again, of course, you have to wash your hands well with a disinfectant liquid soap. I use dial, either the think orange pump kind, or the foaming type that's become so popular. While I'm washing my hands (with almost no water added), I coil my cath up in my hand, and wash it at the same time. I make certain that the soap gets into the cath. When I'm rinsing my hands, I also rinse out the cath, and make certain all the soap is off the outside of the cath as well. Then, I just insert the cath, (I don't use anything as a lube except the water). and drain as usual. I've been doing this for a year now, after having gone through the boiling routine, and finding it was just too much trouble. I haven't had one infection doing it that way. I can also be sure that it's really clean, and hasn't laid around too long collecting whatever is in the air. This also works well when I'm out somewhere, since almost all places have good soap in their restrooms now. And, I've long ago gotten over any embarasement if someone sees me in public with a cath. Hell, I'll never see them again, so why worry! LOL