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Advanced Catheter Requirements With Medicare

by billf July 12 2016 08:04
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My name is Bill, and I have worked for 180 Medical for over 10 years. About 28 years ago, I was involved in a motocross accident that rendered me quadriplegic. You can learn more about my story here. Over the years since then, I've been able to help and counsel others who are also dealing with life after a spinal cord injury. I am happiest when I am helping others, and these days, I spend a lot of time just talking to our customers on the phone who are new to catheterizing. 

One thing that I often talk to people about are recurring urinary tract infections (also known more commonly as UTIs). It's an unfortunate truth that self-catheterization can carry a risk of getting UTIs, even for people practicing sterile use. One upside to this is that there are advanced products which may help reduce the risk of UTIs, such as closed system catheters.

Many people who are insured by Medicare or an insurance plan that follows Medicare's guidelines may not have that as an immediate option, but if you continue to get infections while cathing with a standard straight intermittent catheter and lubrication packets while on sterile use, you do have an option to get Medicare to cover an advanced product for your needs, such as closed system catheters or hydrophilic catheters with insertion supplies

If you have been practicing sterile use with a new catheter and a new lubrication packet each time you self-catheterize, and you have experienced at least two UTIs within the last 12 months, you could possibly qualify. But it's important to have proof in the form of documentation which includes a urine culture and any corresponding symptoms that you might have experienced while you had the UTI. Let's go into these two things a little more in detail.

Cultures

The first step to take is to go to the doctor whenever you feel like you have a urinary tract infection. You will need to be able to provide them with a urine specimen so that they can do a formal culture test to determine if it is indeed a UTI. 

If it's a positive culture report, documentation must show that the urine culture has greater than 10,000 CFU (colony forming units), which is a way to show that the bacteria is present and growing at high colony counts. This counts as positive proof of a urinary tract infection.

Concurrent Symptoms

The second piece of information needed is any documentation proving that you experienced a symptom at the same time as your culture was taken. It is important that you mention to your doctor if you have one of these symptoms, and that they are documented in the progress notes.

Qualifying concurrent symptoms are listed below:
  • A fever greater than 100.4ºF or 38ºC
  • A change in urgency, increased frequency of catheterization, or incontinence
  • Increased muscle spasms
  • Systemic leukocytosis, which is an abnormal increase in the number of circulating white blood cells in the complete blood count (CBC). This can be determined through a urinalysis, which is often taken along with a culture.
  • Autonomic dysreflexia: sweating, blood pressure elevation, abnormally slow heart rate
  • Prostatitis: acute or chronic inflammation of the prostate gland
  • Epididymitis: discomfort or pain of the epididymis
  • Orchitis: inflammation of one or both of the testes, characterized by swelling and pain

Other Requirements to Be Eligible

In order to qualify and begin receiving the advanced catheter products with Medicare, you had to have been already practicing sterile use during the times you had the infections documented, while using one standard catheters along with one lubrication packet per each time you self-catheterize. 

The following practices would unfortunately make you ineligible for advanced catheters:

  • If you don't practice sterile use (using a new catheter and a new lubrication packet each time you catheterize).
  • If you use lubrication packets more than once (not considered sterile use)
  • If you use a tube of lubricant instead of a new, sterile lubrication packet each time.
Having this information before going to see your doctor should give you a leg-up in the process of getting qualified for advanced catheters that could help further reduce incidences of UTIs, if you are insured by Medicare or another insurance plan that follows Medicare requirements. 

If you have more questions about how you can qualify, please contact one of our friendly, trained specialists for more information.

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