Medicare Guidelines for Catheters

medicare guidelines for catheters

**UPDATED: October 3, 2017
Medicare has specific guidelines for covering urological supplies such as intermittent catheters, which are in place to protect you, your doctor’s office, and the supplier. This ensures that everyone follows the proper standards. As a fully ACHC-accredited supplier, 180 Medical follows all insurance guidelines, and we thought it might be helpful for you to know more about what the Medicare guidelines are for catheter coverage.

PDF: Documentation Requirements for Catheters

Medicare will cover intermittent catheters for one-time, sterile-use catheterization for up to 200 straight catheters and an individual packet of lubricant per month (every 30 days), based upon need. This, however, does require proper documentation in the prescribing doctor’s notes to match the plan of care/prescription. These notes are typically referred to as PDF, and it stands for what must be included: the permanence of the condition, the diagnosis, and the frequency of cathing per day or per week, etc.

Permanence
Note stating that the condition for using catheters is a permanent condition. If the medical record indicates the condition is of long-term and indefinite duration (at least 3 months), the test of permanence is considered met.

Diagnosis
Approved ICD-10 diagnosis codes:

  1. Retention of Urine R33.9
  2. Incomplete Bladder Emptying R39.14
  3. Other Specified Retention of Urine R33.8
  4. Urinary Incontinence R32
  5. Urge Incontinence N39.41

Frequencydoctors notes for medicare
There must be information
listing the number of times the patient is cathing per day/week/month, and this
must match the frequency listed on the plan of care. The plan of care must match the doctor’s notes as to
number of catheters needed, frequency, diagnosis, and duration.

Any additional notes in the records (Progress Notes) relating to the following information are helpful:

  1. Duration of the patient’s condition
  2. Clinical course
  3. Prognosis
  4. Nature and extent of functional limitations
  5. Other therapeutic interventions and results
  6. Past experience with related items
  7. Anything else that might provide information on a patient’s use of catheters

Coudé Catheter Justification

The prescribing doctor must make notate in the progress notes, along with the PDF (as discussed above), stating why a straight catheter is not sufficient for use and justification as to why a patient requires the use of a coudé tip catheter for catheterization.

Justification for Advanced Products

advanced product example closed system cathetersIn order for Medicare to cover advanced products such as closed system catheters or hydrophilic catheters with insertion supply kits, for example, additional documentation is required as well.

You must have had two UTIs (Urinary Tract Infections) documented at your doctor’s office while you were practicing sterile use of intermittent catheters and sterile lubrication packets within a twelve-month period of one another, and there must be documented concurrent symptoms at the time each UTI was documented.

Examples of Accepted & Documented Concurrent Symptoms:

  • Fever greater than 100.4 F
  • Systemic leukocytosis (abnormal increase in the number of circulating white
    blood cells in the CBC/complete blood count)
  • Change in urgency, frequency, or incontinence
  • Sweating, bradycardia, blood pressure elevation
  • Prostatitis, epididymitis, orchitis
  • Increased muscle spasms
  • Documented pyuria (greater than 5 white blood cells (WBCs) in Urine

There are a few exceptions to this guideline requiring proof of UTIs, if:

  • Patient resides in a nursing home/facility as their primary residence
  • Documented chronic use of immunosuppressant drugs post-transplant
  • Documented chemotherapy
  • Documented
    HIV or AIDS
  • Documented drug-induced state, such as chronic oral corticosteroid use
  • Documented radiologically vesico-urethral reflux while on sterile intermittent catheters
  • Documented spinal cord-injured, pregnant female with neurogenic bladder (covered for
    duration of pregnancy only)

Have more questions about how your insurance will cover your intermittent catheter products and related urological supplies? Our friendly, trained customer specialists are happy to help you, so feel free to contact us during our regular business hours.

For more information, visit the Medicare website.

Call Toll-Free (877) 688-2729

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