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Intermittent Catheters 

Medicare Prescription Requirements

When a Medicare patient is prescribed Intermittent Catheters, Medicare requires Byram and all DME suppliers to include the following documentation in order for the prescription to be shipped in a timely manner.

 

 

Coverage Guidelines

HCP’s Code

Catheter Type

30-Day Maximum Allowable

Standard Written Order (SWO)

Chart Notes

Reimbursement Criteria

A4351

Straight Tip

200

Yes

Yes

Permanent urinary incontinence (PUI), permanent urinary retention (PUR)*, chronic urinary retention (CUR) or incontinence/retention expect to last indefinitely

A4352

Coude Tip

200

Yes

Yes

PUI, PUR*, CUR, or incontinence/retention expect to last indefinitely plus, inability to catheterize (obstruction) including the documented medical reason.

A4353

Sterile Tip

200

Yes

Yes

PUI, PUR*, CUR, or incontinence/retention expect to last indefinitely plus, 2 UTI’s within 12 months using sterile catheterization or, immunosuppressed or, pregnant female SCI with neurogenic bladder, or resides in nursing facility, or radiologically documented vesicoureteral reflux

Local Coverage Determination (LCD): Urology Supplies (2019, January). Retrieved from https://med.noridianmedicare.com/documents/2230703/7218263/Urological+Supplies+LCD+and+PA
*Permanence is defined as a condition that is not expected to be corrected within 3 months.
** PUI or PUR is covered on the LCD

Intermittent Catheter Urological Condition

Primary

Underlying

N39.46 Stress/Urge Incontinence (mixed)

N35.919 Male Stricture, Unspecified **

N39.41 Urge Incontinence

N35.92 Female Stricture, Unspecified **

N39.3 Stress Incontinence

N40.1 BPH with LUTS

R32 Urinary Incontinence, Unspecified **

N40.0 BPH without LUTS

R33.9 Urinary Retention, Unspecified **

G35 Multiple Sclerosis

R39.14 Incomplete Bladder Emptying

G80.9 Cerebral Palsy, Unspecified **

 

G82.20 Paraplegia, Unspecified **

 

G82.50 Quadriplegia, Unspecified **

ICD Data: https://www.icd10data.com/ICD10CM/Codes/N00-N99/N30-N39
** Unspecified code ICD-10 code should be provided to indicate the highest degree, when applicable. 

Straight and Coude-Tip Intermittent Catheters (A4351, A4352)

  • Chart notes must be included
  • The primary diagnosis must be included along with the diagnosis of permanent urinary retention, incontinence retention or chronic retention that is not expected to be medically or surgically corrected within 3 months.
  • The prescription form must include catheterization frequency per day and the chart notes must match the frequency that is no the prescription form.
  • Chart notes for the patient need to be within the 12 months’ prior of the initial order.
  • Chart notes need to be signed and dated by the prescriber. No other signatures are accepted.
  • If a Coude-Tip catheter is prescribed, there must be documentation in the chart notes indicating that the patient is unable to pass a straight catheter and requires a coude-tip catheter. PLEASE NOTE that a diagnosis is not sufficient on its own.
  • If an addendum is requested, it must be part of the original chart notes. If the healthcare provider uses electronic medical records, an addendum must be electronically added to the chart notes, signed and dated, not hand written.
  • A letter of medical necessity is not accepted by Medicare.

Sterile Intermittent Catheterization: Closed System with Collection Bag or Intermittent Catheter with Kit/Insertion Supplies (A4353)

  • Patient is immunosuppressed, due to medication (post-transplant, chemotherapy, chronic oral corticosteroid, Aids, autoimmune diseases, etc.)
  • Patient has radiologically documented vesicoureteral reflux while on a regular program of single-use intermittent catheterization.
  • Patient has had 2 distinct urinary tract infections while intermittently catheterizing with a regular non-kit intermittent catheter (either A4351 or A4352) during the 12 months preceding the initiation of sterile intermittent catheterization (A4353).

UTI’s must be document by:

Urine culture showing > 10,000 bacteria and presence of one of the following:

  • Urinalysis showing greater than 5 WBC’s per hpf
  • Fever of at least 100.5 degrees Fahrenheit
  • Systemic Leukocytosis (blood test showing high WBC’s)
  • Physical signs of prostatitis, epididymitis or orchitis (males)
  • Appearance of new or increase in autonomic dysreflexia or increased muscle spasms or incontinence.