A Clinician’s Guide to Prescribing Intermittent Catheters
Prescribing intermittent catheters has become increasingly difficult and complex given the variety of products available.
The following clinician’s guide provides practitioners with the tools they need to properly prescribe intermittent catheters for their urological patients.
What are HCPCS codes?
The Healthcare Common Procedure Coding System, or HCPCS for short, are identifying codes that are used to identify medical services or supplies for which a patient’s insurance bills for. HCPCS codes are different for each type of intermittent catheter and insurance coverage and requirements are different for each HCPCS, which is why it is so important to reference the correct code. The three most common HCPCS codes for intermittent catheters are A4351, A4352 and A4353.
Intermittent Catheter Coverage Guidelines
| HCPCS Code | Catheter Type | For each episode of covered catheterization, Medicare will cover | 30-Day Maximum Allowable |
|---|---|---|---|
| A4351 | Straight Tip | 1 catheter and an individual packet of lubricant (A4332) | 200 units |
| A4352 | Coude Tip | 1 catheter and an individual packet of lubricant (A4332) | 200 units |
| A4353 | Closed System Catheter | 1 sterile intermittent catheter kit, if additional coverage criteria is met. | 200 units |
General qualifications for A4351s, A4352s, and A4353s are as follows:
- Permanence – Patient must have a chronic or permanent condition of urinary incontinence or permanent urinary retention. Medicare defines permanence as a condition that is not expected to be medically or surgically cured within three months.
- Diagnosis – Diagnosis including and not limited to Neuromuscular Dysfunction of Bladder, Retention / Incontinence. Please refer to the diagnosis codes below.
- Frequency – Recommended number of times the patient should catheterize per day
Example: Mr. Brown needs to self-cath 3 times per day to manage his chronic urinary retention for three months. – Dr. Smith
When prescribing intermittent catheters, this information must be listed in the clinical notes to meet Medicare’s requirements for coverage and reimbursement. Clinical notes need to be signed and dated by the prescriber. No other signatures are accepted.
Intermittent Catheter ICD-10 Urological Diagnosis Codes
| Primary | Underlying |
|---|---|
| R33.9 Urinary Retention, Unspecified | N35.919 Male Stricture, Unspecified** |
| R39.14 Incomplete Bladder Emptying | N35.92 Female Stricture, Unspecified** |
| R33.8 Urinary Retention, Other Specified | N40.1 BPH with LUTS |
| R32 Urinary Incontinence, Unspecified** | N40.0 BPH without LUTS |
| N39.46 Stress/Urge Incontinence (mixed) | G35 Multiple Sclerosis |
| N39.41 Urge Incontinence | G80.9 Cerebral Palsy, Unspecified** |
| N39.3 Stress Incontinence | G82.20 Paraplegia, Unspecified** |
| G82.50 Quadriplegia, Unspecified** |
** Unspecified code. ICD-10 code should be provided to indicate the highest degree of specificity, when appliable.
Prescribing Sterile Intermittent Closed System Catheters Kits (A4353)
When prescribing sterile intermittent closed system catheter kits, additional coverage criteria must be met for it to be covered by Medicare. Clinical notes must provide documentation of 1 of the following:
- The patient resides in a nursing facility,
- The patient is immunosuppressed, for example (not all-inclusive):
- on a regimen of immunosuppressive drugs post-transplant,
- on cancer chemotherapy,
- has AIDS,
- has a drug-induced state such as chronic oral corticosteroid use.
- The patient has radiologically documented vesico-ureteral reflux while on a program of intermittent catheterization,
- The patient is a spinal cord injured female with neurogenic bladder who is pregnant (for duration of pregnancy only),
- The patient has had distinct, recurrent urinary tract infections, while on a program of sterile intermittent catheterization with A4351/A4352 and sterile lubricant A4332, twice within the 12-month prior to the initiation of sterile intermittent catheter kits.
Patient History of UTIs
If your patient has a history of urinary tract infections, you must provide documentation in the patient’s medical records to support the medical necessity for sterile intermittent closed system catheter or intermittent catheter kit. If you do not provide documentation, Medicare may deny claims as not reasonable or necessary.
Medicare considers urinary tract infections as having a urine culture with greater than 10,000 colony forming units of a urinary pathogen AND concurrent presence of one or more of the following signs, symptoms, or laboratory findings:
- Fever (oral temperature greater than 38º C [100.4º F])
- Systemic leukocytosis
- Change in urinary urgency, frequency, or incontinence
- Appearance of new or increase in autonomic dysreflexia (sweating, bradycardia, blood pressure elevation)
- Physical signs of prostatitis, epididymitis, orchitis
- Increased muscle spasms
- Pyuria (greater than 5 white blood cells [WBCs] per high-powered field)
Each UTI occurrence must be separated by at least 30 days, and concurrent symptoms must be documented for each occurrence.
Prescribing Intermittent Coude Catheters (A4352)
If your patient cannot pass a straight intermittent catheter (A4351), Medicare requires documented justification in the patient’s medical records as to why they require a coude (curved) intermittent catheter.
Provided documentation must demonstrate the patient’s inability to catheterize using a straight tip catheter, including the documented medical reason, such as obstruction, stricture, enlarged prostate, etc.
