Notification



Notification Issue Date:



Claim Payment Policy


Title:Insertion or Application of Urinary Catheters and the Associated Supplies Provided in the Office Setting

Policy #:03.12.04c

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.

Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

The Company covers and considers for reimbursement the professional component for the insertion or application of a urinary catheter and the specific evaluation and management (E&M) appropriate to the level of service when provided in the office setting as follows:
  • For physicians contracted on a fee-for-service basis, Modifier 25 (significant, separately identifiable E&M service by the same physician on the same day of the procedure or other service) must be appended to the E&M for separate reimbursement consideration for the following services whether provided alone or in conjunction with each other:
    • The urinary catheter and its associated supplies listed in the Coding Table
    • The specific E&M appropriate to the level of service code
    • The professional component for the insertion or application of the catheter
  • Physicians contracted on a pre-paid (ie, capitated) basis are eligible for reimbursement consideration for the insertion or application of the urinary catheters and the provision of associated supplies above the monthly capitation allowance. However, reimbursement for the E&M associated with the service is included in the monthly capitation and, therefore, not eligible for separate reimbursement consideration.

Urinary catheters and the associated supplies may be covered under the Company's durable medical equipment (DME) or prosthetic benefit. The DME and prosthetic benefit vary by product and/or group contract. Therefore, individual member benefits must be verified.

Guidelines

Reimbursement for urinary catheters and the associated supplies is limited to once per date of service in the physician's office.

Catheter insertion or application in the office setting should be reported using the appropriate Current Procedural Terminology (CPT) insertion codes and the associated supplies should be reported using the appropriate Healthcare Common Procedural Coding System (HCPCS) Level II codes.

MEDICARE
Although Medicare applies limitations for the coverage of urinary catheters and the associated supplies provided in the office setting, the Company's Medicare Advantage members are covered in accordance with Company policy.

BENEFIT APPLICATION
Subject to the terms and conditions of the applicable benefit contract, urinary catheters and the associated supplies provided in the office setting are covered under the Company's durable medical equipment (DME) or prosthetic benefit. Therefore, individual member benefits must be verified.

Description

Internal urinary catheters are tubes systems that are inserted into the body. External urinary collection devices include male external catheters and female pouches or metal cups. Internal and external urinary catheters are used to drain or collect urine from the bladder and of individuals who have urinary incontinence or urinary retention.

Supplies associated with urinary catheters are those that may be used to assist with the insertion or application of a urinary catheter. Associated supplies can include things such as an insertion tray with drainage bags and urinary leg bags.

References

Company Benefit Contracts.

Medicare, NHIC Corp. Local Coverage Determination (LCD) for Urological Supplies. LCD # L5080. [Medicare NHIC Web Site.] Original Effective Date: 10/01/93. (Revised: 01/01/10). Available at: http://www.medicarenhic.com/dme/medical_review/mr_lcds/mr_lcd_current/L5080_2010-01-01_PA_2010-01.pdf. Accessed December 2, 2010.


Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

51701, 51702, 51703


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

A4310: Insertion tray without drainage bag and without catheter (accessories only)


A4311: Insertion tray without drainage bag with indwelling catheter, Foley type, two-way latex with coating (Teflon, silicone, silicone elastomer or hydrophilic, etc.)

A4312: Insertion tray without drainage bag with indwelling catheter, Foley type, two-way, all silicone

A4313: Insertion tray without drainage bag with indwelling catheter, Foley type, three-way, for continuous irrigation

A4314: Insertion tray with drainage bag with indwelling catheter, Foley type, two-way latex with coating (Teflon, silicone, silicone elastomer or hydrophilic, etc.)

A4315: Insertion tray with drainage bag with indwelling catheter, Foley type, two-way, all silicone

A4316: Insertion tray with drainage bag with indwelling catheter, Foley type, three-way, for continuous irrigation

A4326: Male external catheter with integral collection chamber, any type, each

A4327: Female external urinary collection device; metal cup, each

A4328: Female external urinary collection device; pouch, each

A4333: Urinary catheter anchoring device, adhesive skin attachment, each

A4334: Urinary catheter anchoring device, leg strap, each

A4338: Indwelling catheter; Foley type, two-way latex with coating (Teflon, silicone, silicone elastomer, or hydrophilic, etc.), each

A4340: Indwelling catheter; specialty type, (eg, coude, mushroom, wing, etc.), each

A4344: Indwelling catheter, Foley type, two-way, all silicone, each

A4346: Indwelling catheter; Foley type, three-way for continuous irrigation, each

A4349: Male external catheter, with or without adhesive, disposable, each

A4351: Intermittent urinary catheter; straight tip, with or without coating (Teflon, silicone, silicone elastomer, or hydrophilic, etc.), each

A4352: Intermittent urinary catheter; coude (curved) tip, with or without coating (Teflon, silicone, silicone elastomeric, or hydrophilic, etc.), each

A4353: Intermittent urinary catheter, with insertion supplies

A4354: Insertion tray with drainage bag but without catheter

A4357: Bedside drainage bag, day or night, with or without anti-reflux device, with or without tube, each

A4358: Urinary drainage bag, leg or abdomen, vinyl, with or without tube, with straps, each

A5102: Bedside drainage bottle, with or without tubing, rigid or expandable, each

A5105: Urinary suspensory; with leg bag, with or without tube, each

A5112: Urinary drainage bag, leg or abdomen, latex, with or without tube, with straps, each

A5113: Leg strap; latex, replacement only, per set

A5114: Leg strap; foam or fabric, replacement only, per set

A5200: Percutaneous catheter/tube anchoring device, adhesive skin attachment



Revenue Code Number(s)

N/A


Misc Code

Modifier:

N/A


Coding and Billing Requirements


Cross References


Policy History

Effective 10/05/2017 this policy has been updated to the new policy template
format.
Version Effective Date: 01/01/2011
Version Issued Date: 01/04/2011
Version Reissued Date: N/A

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