Urological Supplies - Policy Article

NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. Information provided in this policy article relates to determinations other than those based on Social Security Act §1862(a)(1)(A) provisions (i.e. “reasonable and necessary”). Urological supplies are covered under the Prosthetic Device benefit (Social Security Act § 1861(s)(8)). In order for a beneficiary’s equipment to be eligible for reimbursement the reasonable and necessary (R&N) requirements set out in the related Local Coverage Determination must be met. In addition, there are specific statutory payment policy requirements, discussed below, that also must be met. REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO Final Rule 1713 (84 Fed. Reg Vol 217) Final Rule 1713 (84 Fed. Reg Vol 217) requires a face-to-face encounter and a Written Order Prior to Delivery (WOPD) for specified HCPCS codes. CMS and the DME MACs provide a list of the specified codes, which is periodically updated. The required Face-to-Face Encounter and Written Order Prior to Delivery List is available here . Claims for the specified items subject to Final Rule 1713 (84 Fed. Reg Vol 217) that do not meet the face-to-face encounter and WOPD requirements specified in the LCD-related Standard Documentation Requirements Article (A55426) will be denied as not reasonable and necessary. If a supplier delivers an item prior to receipt of a WOPD, it will be denied as not reasonable and necessary. If the WOPD is not obtained prior to delivery, payment will not be made for that item even if a WOPD is subsequently obtained by the supplier. If a similar item is subsequently provided by an unrelated supplier who has obtained a WOPD prior to delivery, it will be eligible for coverage. GENERAL Urinary catheters and external urinary collection devices are covered to drain or collect urine for a beneficiary who has permanent urinary incontinence or permanent urinary retention. The beneficiary must have a permanent impairment of urination. This does not require a determination that there is no possibility that the beneficiary's condition may improve sometime in the future. If the medical record, including the judgment of the treating practitioner, indicates the condition is of long and indefinite duration, the test of permanence is considered met. If the catheter or the external urinary collection device meets the coverage criteria then the related supplies that are necessary for their effective use are also covered. Urological supplies that are used for purposes not related to the covered use of catheters or external urinary collection devices (i.e., drainage and/or collection of urine from the bladder) will be denied as non-covered. The use of a urological supply for the treatment of chronic urinary tract infection or other bladder condition in the absence of permanent urinary incontinence or retention is non-covered. Since the beneficiary's urinary system is functioning, the criteria for coverage under the prosthetic benefit provision are not met. When inserting an inFlow device or using urological supplies in a treating practitioner’s office as part of a professional service that is billed to Medicare, the supplies are considered incident to the professional services of the health care practitioner and are not separately payable. Claims for these devices must not be submitted. Claims for the professional service, which includes the device, must be submitted to the A/B MAC. If additional inFlow devices or urological supplies are sent home with the beneficiary, claims for these devices may be billed to the DME MAC only if the beneficiary's condition meets the definition of permanence as defined in the Prosthetic Device benefit. In this situation, use the place of service corresponding to the beneficiary's residence; Place of Service Office (POS) 11 must not be used. If the beneficiary's condition is expected to be temporary, urological supplies may not be billed. In this situation, they are considered as supplies provided incident to a treating practitioner's service and payment is included in the allowance for the treating practitioner services, which are processed by the A/B MAC. POLICY SPECIFIC DOCUMENTATION REQUIREMENTS In addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD. Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS discussed below. When the prescribing practitioner is also the supplier, and is permitted to furnish specific items of DMEPOS, a separate order is not required; however, the medical record must still contain all of the required order elements. For intermittent catheterization using a sterile intermittent catheter kit (A4297, A4353), documentation in the medical records of a diagnosis of spinal cord injury (SCI) is sufficient to establish the beneficiary is immunocompromised. CONTINUED MEDICAL NEED For all DMEPOS items, the initial justification for medical need is established at the time the item(s) is first ordered, therefore, beneficiary medical records demonstrating that the item is reasonable and necessary are created just prior to, or at the time of, the creation of the initial prescription. Once initial medical need is established, unless continued coverage requirements are specified in the LCD, ongoing need for urological supplies is assumed to drain or collect urine for a beneficiary who has permanent urinary incontinence or permanent urinary retention. There is no requirement for further documentation of continued medical need as long as the beneficiary continues to meet the Prosthetic Devices benefit. MODIFIERS AU MODIFIER: When codes A4217, A4450, and A4452 are used with Urological Supplies, they must be billed with the AU modifier. For this policy, codes A4217, A4450, and A4452 are the only three codes for which the AU modifier may be used. Claim lines for codes A4217, A4450 and A4452 billed for urological supplies without an AU modifier will be rejected as missing information. KX, GA, GY and GZ MODIFIERS: Suppliers must add a KX modifier to a code for the inFlow device, a catheter, an external urinary collection device, or a supply used with one of these items only if both 1 and 2 are met. The statutory benefit criteria described in the NONMEDICAL NECESSITY COVERAGE AND PAYMENT RULES section above are met, and The applicable reasonable and necessary (R&N) criteria described in the COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY section of the related LCD are met. If all of the criteria in the NONMEDICAL NECESSITY COVERAGE AND PAYMENT RULES section above are not met, a GY modifier must be added to the code. If all of the applicable R&N criteria in the COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY section in the related LCD have not been met, a GA or GZ modifier must be added to the code. When there is an expectation of a medical necessity (R&N) denial, suppliers must enter the GA modifier on the claim line if they have obtained a properly executed Advance Beneficiary Notice (ABN) or the GZ modifier if they have not obtained a valid ABN. Claim lines billed without a KX, GA, GY or GZ modifier will be rejected as missing information. MISCELLANEOUS Adhesive strips or tape used with male external catheters are included in the allowance for the code and are not separately payable. Catheter insertion trays (A4297, A4310, A4311, A4312, A4313, A4314, A4315, A4316, A4353, and A4354) that contain component parts of the urinary collection system, (e.g., drainage bags and tubing) are inclusive sets and payment for additional component parts will be allowed only per the stated criteria in each section of the policy. Irrigation supplies that are used for care of the skin or perineum of incontinent beneficiaries are non-covered. Claims for sterile water/saline (A4217) and tape (A4450 or A4452) that are billed without an AU modifier or another modifier indicating coverage under a different policy will be rejected as missing information. Extension tubing (A4331) will be covered for use with a latex urinary leg bag (A5112). It is included in the allowance for codes A4314, A4315, A4316, A4354, A4357, A4358, and A5105 and should not be separately billed with these codes. Other supplies used in the management of incontinence, including but not limited to the following items, will be denied as non-covered because they are not prosthetic devices nor are they required for the effective use of a prosthetic device: Creams, salves, lotions, barriers (liquid, spray, wipes, powder, paste) or other skin care products (A6250) Catheter care kits (A9270) Adhesive remover (A4455, A4456) (Coverage remains for use with ostomy supplies.) Catheter clamp or plug (A9270) Non-Disposable underpads (A4553) Disposable underpads, e.g., Chux (A4554) Diapers, or incontinent garments, disposable or reusable (A4520) Drainage bag holder or stand (A9270) Urinary suspensory without leg bag (A9270) Measuring container (A9270) Urinary drainage tray (A9270) Gauze pads (A6216, A6217, A6218) and other dressings (coverage remains under other benefits, e.g. surgical dressings) Other incontinence products not directly related to the use of a covered urinary catheter or external urinary collection device (A9270) Disposable external urethral clamp or compression device, w