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Understanding Medicare Guidelines for Closed System Catheters

Medicare can be stressful and confusing, and you are not alone if you don’t understand Medicare guidelines for intermittent catheters, especially when it comes to qualifying for closed system catheters.

At MTG, we strive to provide closed system catheters that provide protection against UTIs and are covered by insurance, but we often get questions about how individuals can qualify for closed system catheters under their Medicare insurance plan, so we decided to put together the following guide.

Join us as we review Medicare guidelines for intermittent catheters and how you may qualify for Medicare reimbursement of closed system catheters.

Basic Medicare Guidelines for Intermittent Catheters

To qualify for Medicare reimbursement of intermittent catheters, you will need both a valid prescription from your doctor or physician and proper documentation in your medical records.

The general qualifications for Medicare coverage of A4351, A4352, and A4353 intermittent catheters must include the following in the clinical notes:

  • Permanence: Beneficiary 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
  • Frequency: Recommended number of times the beneficiary should catheterize per day

Medicare covers intermittent catheter supplies when deemed medically necessary. Some conditions that require self-catheterization include:

  • Urinary Incontinence
  • Spinal Cord Injury
  • Urinary Retention
  • Multiple Sclerosis
  • Parkinson’s Disease
  • Other Diagnoses that Cause Complications with Urinating

Depending on how often you catheterize and your specific needs, Medicare will cover up to 200 intermittent catheters per month, allowing you to catheterize up to 6 times a day, with additional supplies leftover.

If you have a history of recurrent urinary tract infections while using intermittent catheters, you may be eligible for a higher quantity of catheters or catheter kits with insertion supplies.

What are the Medicare Guidelines for Closed System Catheters?

Unfortunately, Medicare does not cover closed system catheters for everyone. There are certain qualifying criteria that must be met and properly documented in your medical records for Medicare to cover closed system catheters. One of the most common qualifying criteria is recurrent urinary tract infections.

Recurrent UTIs

If you have had two UTIs documented while using sterile intermittent catheters and sterile lubricant, you can qualify for Medicare reimbursement of closed system catheters. These UTIs must be within twelve months and be at least 30 days apart to ensure that they are two separate infections.

If you believe you have a UTI, it is important to go to your doctor for a urine culture so it can be confirmed and put in your medical records. A positive urine culture test will show greater than 10,000 colony forming units.

If you have had two or more UTIs within a year, but it has not been documented properly, Medicare can deny the claim as not necessary.

In addition to a urine culture, your UTI symptoms must also be documented at the time of diagnosis and must line up with Medicare’s accepted symptoms of a UTI. Symptoms include:

  • A fever greater than 100.4°F
  • Change in urgency, frequency, or incontinence
  • Sweating, bradycardia (slow heart rate), blood pressure elevation
  • Increased muscle spasms

Exceptions to UTI Guidelines

If you do not suffer from recurrent UTIs, Medicare may cover closed system catheters if documentation proves one of the following:

  • The patient resides in a nursing home/facility as their permanent residence
  • The patient is immunosuppressed, for example (no 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
  • Spinal cord-injured female who is pregnant and has a neurogenic bladder (covered only for the duration of pregnancy only)

The guidelines outlined above exist to help you and your doctor correctly diagnose and document your condition to ensure you receive full coverage from Medicare.

If you are still struggling to understand Medicare Guidelines for closed system catheters, contact us today to speak with a member of our team who can answer your questions and offer free samples of MTG closed system catheters.