Urological and Bowel Supplies
Overview
Catheters and related supplies are used to drain urine from the bladder or promote emptying 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:
TPL and Medicare
Providers must meet any provider criteria, including accreditation, for third-party insurance or for Medicare to assist members for whom Minnesota Health Care Programs (MHCP) is not the primary payer.
MHCP quantity limits and thresholds apply to all members unless only Medicare coinsurance or deductible is requested.
Eligible Members
Urological and bowel supplies are covered for members with Medical Assistance or MinnesotaCare who are unable to completely empty their bladder by voiding or unable to control their bowel movements.
Covered Services
Codes: A4310-A4316, A4320-A4322, A4326-A4328, A4330-A4338, A4340, A4344, A4346, A4349, A4351-A4358, A4453, A4459, A5102, A5112
Indwelling Catheters or Insertion Trays
Most members can be served with one indwelling catheter per month. A second catheter may be allowed 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 to 180 intermittent catheters per month. Up to 300 intermittent catheters without insertion supplies may be allowed 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 300 intermittent catheters with insertion supplies per month require authorization. Documentation must support the quantity dispensed. Review the 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 allowed if the person has a medical history that requires the bag to be replaced more frequently.
Due to the Centers for Medicare & Medicaid Services’ (CMS) Medically Unlikely Edits (MUEs), HCPCS code A5102 is limited to one per month. Documentation must support the quantity dispensed. Review the 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 62 irrigation syringes or trays may be allowed per month if the person has a medical condition that requires more than daily irrigation with new syringes. 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 allowed 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 | 300 units per month |
A4357, A4358, A5112 | Drainage collection devices | 10 units in any combination per month |
A4320, A4322 | Irrigation supplies | 62 units per month |
Anal Irrigation System and Catheter (A4459 and A4453)
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.
Anal irrigation systems and catheters are covered with authorization if the following criteria are met:
For HCPCS code AA459, one unit is one kit and MHCP covers up to four units per year if medically necessary due to daily irrigation.
For HCPCS code A4453, one unit is one catheter. MHCP covers up to 31 units per month.
Authorization
Authorization is required for the following:
Submit authorization requests and required documentation to the Medical Review Agent.
Review the following categories of urological and bowel supplies for information on specific documentation required for each type of item.
Anal Irrigation Systems (A4459) and Catheters (A4453)
Documentation must demonstrate failure and length of trial for first-line bowel management methods and covered indications listed under Covered Services.
Intermittent Catheters (A4353)
Documentation must include an order from the physician stating how often the person must be catheterized and the medical justification for exceeding 300 catheters per month. Document must explain why clean catheterization techniques are not appropriate for the person.
Drainage Collection Devices (A4357, A4358, A5112)
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
Providers are responsible to coordinate services. Refer to the Billing Policy Overview section of Provider Basics for general billing information.
Bill urological and bowel supplies using MN–ITS 837P. Refer to the Billing for Durable Medical Equipment, Medical Supplies, Prosthetics and Orthotics, and Augmentative Devices MN–ITS user manual for claim instructions.
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