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Minnesota Department of Human Services Provider Manual
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Urological Supplies

Revised: 09-14-2012

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

    Catheters and related urological supplies are used to drain urine from the bladder when a recipient is unable to completely empty the bladder by voiding.

    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 recipients for whom MHCP is not the primary payer.

    MHCP quantity limits and thresholds apply to all recipients unless only Medicare co-insurance or deductible is requested.

    Eligible Recipients

    Catheters and related urological supplies are covered for eligible MHCP recipients unable to completely empty their bladder by voiding.

    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)
  • Indwelling Catheters/Insertion Trays

    Most recipients 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 recipient 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, recipients may require daily changes of indwelling catheters. Documentation must support the quantity dispensed.

    Intermittent Catheterization

    Most recipients can be served with 150 - 180 intermittent catheters per month. Up to 300 intermittent catheters without insertion supplies may be required if the recipient has a medical history that requires more than six episodes of catheterization daily. MHCP does not encourage the re-use of intermittent catheters. Re-use of intermittent catheters can cause infection. Intermittent catheters with sterile insertion supplies are covered if the recipient 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 recipient’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 section for thresholds.

    Drainage Collection Devices

    Most recipients can be served with one to two drainage bags/bottles per month. Additional drainage bags/bottles may be required if the recipient 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 section for thresholds.

    Irrigation Supplies

    Most recipients who require intermittent irrigation can be served with one irrigation tray/syringe per week. Up to 31 irrigation syringes/trays may be required if the recipient 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/saline.

    Most recipients who require continuous irrigation can be served with one irrigation tubing set per day for up to 2 weeks. Up to 31 continuous days may be required if the recipient has persistent obstructions. Supplies for continuous irrigation include a 3-way Foley catheter, irrigation tubing set and sterile water/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

    Authorization

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

    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 recipient must be catheterized and the medical justification for exceeding 200 catheters per month. Document why clean catheterization techniques are not appropriate for the recipient.
  • Excess Quantities of Drainage Collection Devices

  • • Authorization is required for billing more than 10 drainage bags / bottles per month.
  • • Documentation must include an order from the physician stating how often the collection bag/bottle must be changed and the medical justification for replacing the bag/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.
  • • If the recipient has Medicare, MHCP will pay the deductible/co-insurance 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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