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Urological and Bowel Supplies

Revised: 04-04-2018

  • Overview
  • Eligible Providers
  • TPL and Medicare
  • Eligible Recipients
  • Covered Services
  • Indwelling Catheters or Insertion Trays
  • Intermittent Catheterization
  • Drainage Collection Devices
  • Irrigation Supplies
  • Anal Irrigation System and Accessory Unit
  • Authorization
  • Excess Quantities of Intermittent Catheters
  • Excess Quantities of Drainage Collection Devices
  • Billing
  • Overview

    Catheters and related supplies are used to drain urine from the bladder or promote evacuation of the contents of the colon when a member is unable to completely empty the bladder by voiding or unable to control their bowel movements.

    Eligible Providers

    The following providers may provide catheters and related supplies:

  • • Federally qualified health center
  • • Home health agencies
  • • Indian Health Services
  • • Medical suppliers
  • • Pharmacies
  • • Rural health clinic
  • TPL and Medicare

    Providers must meet any provider criteria, including accreditation, for third-party insurance or for Medicare in order to assist members for whom MHCP is not the primary payer.

    MHCP quantity limits and thresholds apply to all members unless only Medicare coinsurance or deductible is requested.

    Eligible Recipients

    Catheters and related supplies are covered for eligible MHCP recipients unable to completely empty their bladder by voiding or unable to control their bowel movements.

    Covered Services

  • • A4310 - A4316 & A4354 (insertion trays for indwelling catheters)
  • • A4338 - A4346 (indwelling catheters without insertion trays)
  • • A4351 - A4353 (intermittent catheters)
  • • A4357 - A4358, A5102 & A5112 (drainage collection systems)
  • • A4320 - A4334, A4349, A4355 – A4356 (related supplies)
  • • A4335 (Miscellaneous incontinence supplies)
  • • A4459 (anal irrigation system)
  • • A9999 (accessory unit for anal irrigation system)
  • Indwelling Catheters or Insertion Trays

    Most members can be served with one indwelling catheter per month. A second catheter may be required if the catheter is accidentally removed, malfunctions, or becomes obstructed or if the person has a medical history that requires the catheter to be replaced more than once per month. One insertion tray is covered per episode of indwelling catheter insertion. An insertion tray is not covered for use with an intermittent catheter. In rare situations, a person may require daily changes of indwelling catheters. Documentation must support the quantity dispensed.

    Documentation of medical necessity (such as recurrent encrustation, inability to pass a straight catheter, or sensitivity to latex) is required for a specialty indwelling catheter (A4340) or a silicone catheter (A4312, A4315, A4344).

    Intermittent Catheterization

    Most members can be served with 150 - 180 intermittent catheters per month. Up to 300 intermittent catheters without insertion supplies may be required if the person has a medical history that requires more than six episodes of catheterization daily. MHCP does not encourage the reuse of intermittent catheters. Reuse of intermittent catheters can cause infection. Intermittent catheters with sterile insertion supplies are covered if the person has a medical history that requires sterile, rather than clean, catheterization and documentation of medical necessity for sterile catheterization is maintained in the medical supplier’s files. The member’s living arrangement alone does not support the need for sterile catheterization. More than 200 intermittent catheters with insertion supplies per month require authorization. Documentation must support the quantity dispensed. See Authorization subsection for thresholds.

    Drainage Collection Devices

    Most members can be served with one to two drainage bags or bottles per month. Additional drainage bags or bottles may be required if the person has a medical history that requires the bag to be replaced more frequently.

    Exception: Due to the CMS-required Medically Unlikely Edits (MUEs), A5102 is limited to one per month. Documentation must support the quantity dispensed. See Authorization subsection for thresholds.

    Irrigation Supplies

    Most members who require intermittent irrigation can be served with one irrigation tray or syringe per week. Up to 31 irrigation syringes or trays may be required if the person has a medical condition that requires daily irrigation with a new syringe. Documentation must support the quantity dispensed. Supplies for intermittent irrigation of an indwelling catheter include either an irrigation tray or an irrigation syringe, and sterile water or saline.

    Most members who require continuous irrigation can be served with one irrigation tubing set per day for up to two weeks. Up to 31 continuous days may be required if the person has persistent obstructions. Supplies for continuous irrigation include a three-way Foley catheter, irrigation tubing set and sterile water or saline.

    Authorization thresholds for urological supplies

    HCPCS code(s)

    Code category

    Monthly threshold

    A4353

    Intermittent catheters with insertion supplies

    200 units per month

    A4357, A4358, A5112

    Drainage collection devices

    10 units in any combination per month

    Anal Irrigation System and Accessory Unit

    Anal irrigation is used for fecal incontinence, chronic constipation, or time-consuming bowel management procedures when other conservative bowel management alternatives have been tried and failed.

    The member must meet the following criteria:

  • • Has one of the following:
  • • Fecal incontinence
  • • Chronic constipation
  • • Bowel management methods or combination of methods requiring more than 30 minutes a day
  • • The following first-line bowel management methods have been prescribed and demonstrated failure:
  • • Dietary modification
  • • Medication
  • • Enema bag
  • • Physical therapies (pelvic floor stimulation, biofeedback, electrical stimulation)
  • Most members can be served with one accessory unit per month and two anal irrigation systems per year. One accessory unit is included with code A4459. Up to 22 accessory units (not including the two included with code A4459) and four anal irrigation systems per year may be required if the person requires daily catheter use.

    Authorization

    Authorization is required for quantities of intermittent catheters with insertion supplies, or drainage collection systems exceeding limits.

    Authorization is always required for code A4459 and accessory units under code A9999. Include documentation of demonstrated failure and length of trial for first-line bowel management methods. For requests of more than 10 accessory units, include documentation supporting the need for daily catheter use

    Submit authorization requests and required documentation to the authorization medical review agent.

    Excess Quantities of Intermittent Catheters

  • • Authorization is required for billing more than 200 intermittent catheters with insertion supplies per month.
  • • Documentation must include an order from the physician stating how often the person must be catheterized and the medical justification for exceeding 200 catheters per month. Document why clean catheterization techniques are not appropriate for the person.
  • Excess Quantities of Drainage Collection Devices

  • • Authorization is required for billing more than 10 drainage bags or bottles per month.
  • • Documentation must include an order from the physician stating how often the collection bag or bottle must be changed and the medical justification for replacing the bag or bottle more than twice per week.
  • Billing

  • • Bill services approved through the authorization process on a separate claim from services not requiring authorization Example: submit one claim (no authorization required) for the number of units up to the authorization threshold. Submit another claim with the prior authorization number for the additional quantity dispensed over the threshold.
  • • Bill A4459 and A9999 with the NU modifier and the long description for auto pricing.
  • • If the member has Medicare, MHCP will pay the deductible or coinsurance on any units for which Medicare has made payment. Any units that Medicare denies payment for must meet MHCP quantity and authorization requirements. Authorization can be requested retroactively
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