L11566-LCD

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Local Coverage Determination (LCD) for Urological Supplies (L11566)

Contractor Information

Contractor Name CGS Administrators, LLC

Contractor Number 18003

Contractor Type DME MAC

Jurisdiction J - G

LCD Information

Document Information

LCD ID Number L11566

LCD Title Urological Supplies

Contractor's Determination Number URO

AMA CPT/ADA CDT Copyright Statement

CPT only copyright 2002-2012 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Primary Geographic Jurisdiction opens in new window

Alabama Arkansas Colorado Florida Georgia Louisiana Mississippi North Carolina New Mexico Oklahoma Puerto Rico

South Carolina Tennessee Texas

Virginia

Virgin Islands West Virginia

Oversight Region Region IV

DME Region LCD Covers Jurisdiction C

Original Determination Effective Date

For services performed on or after 10/01/1993

Original Determination Ending Date

Revision Effective Date

For services performed on or after 08/05/2011

Revision Ending Date

CMS National Coverage Policy

CMS Pub. 100-3, Medicare National Coverage Determinations Manual, Chapter 1, Section 230.17

Indications and Limitations of Coverage and/or Medical Necessity

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. For the items addressed in this local coverage determination, the criteria for "reasonable and necessary", based on Social Security Act § 1862(a)(1)(A) provisions, are defined by the following indications and limitations of coverage and/or medical necessity.

For an item to be covered by Medicare, a written signed and dated order must be received by the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving the completed order, the item will be denied as not reasonable and necessary.

GENERAL

The statutory coverage criteria for coverage of urological supplies are specified in the related Policy Article.

The medical necessity for use of a greater quantity of supplies than the amounts specified in the policy must be well documented in the patient's medical record and must be available upon request.

INDWELLING CATHETERS (A4311 - A4316, A4338 - A4346)

No more than one catheter per month is covered for routine catheter maintenance. Non-routine catheter changes are covered when documentation substantiates medical necessity, such as for the following indications:

1. Catheter is accidentally removed (e.g., pulled out by patient)

2. Malfunction of catheter (e.g., balloon does not stay inflated, hole in catheter)

3. Catheter is obstructed by encrustation, mucous plug, or blood clot

4. History of recurrent obstruction or urinary tract infection for which it has been established that an acute event is prevented by a scheduled change frequency of more than once per month

A specialty indwelling catheter (A4340) or an all silicone catheter (A4344, A4312, or A4315) is covered when the criteria for an indwelling catheter (above) are met and there is documentation in the patient's medical record to justify the medical need for that catheter (such as recurrent encrustation, inability to pass a straight catheter, or sensitivity to latex(not all-inclusive)). In addition, the particular catheter must be necessary for the patient. For example, use of a Coude (curved) tip indwelling catheter (A4340) in female patients is rarely reasonable and necessary. If documentation is requested and does not substantiate medical necessity payment for A4340, A4344, A4312,or A4315 will be denied as not reasonable and necessary.

A three way indwelling catheter either alone (A4346) or with other components (A4313 or A4316) will be covered only if continuous catheter irrigation is reasonable and necessary. (Refer to the section "Continuous Irrigation of Indwelling Catheters" for indications for continuous catheter irrigations.) In other situations, A4346, A4313 and A4316 will be denied as not reasonable and necessary.

CATHETER INSERTION TRAY (A4310-A4316, A4353, and A4354)

One insertion tray will be covered per episode of indwelling catheter insertion. More than one tray per episode will be denied as not reasonable and necessary.

One intermittent catheter with insertion supplies (A4353) will be covered per episode of reasonable and necessary sterile intermittent catheterization (see below).

URINARY DRAINAGE COLLECTION SYSTEM (A4314-A4316, A4354, A4357, A4358, A5102, and A5112)

Payment will be made for routine changes of the urinary drainage collection system as noted below. Additional charges will be allowed for reasonable and necessary non-routine changes when the documentation substantiates the medical necessity, (e.g., obstruction, sludging, clotting of blood, or chronic, recurrent urinary tract infection).

Usual Maximum Quantity of Supplies

Code Number per month

A4314 1

A4315 1

A4316 1

A4354 1

A4357 2

A4358 2

A5112 1

Code Number per 3 month

A5102 1

Leg bags are indicated for patients who are ambulatory or are chair or wheelchair bound. The use of leg bags for bedridden patients would be denied as not reasonable and necessary.

If there is a catheter change (A4314-A4316, A4354) and an additional drainage bag (A4357) change within a month, the combined utilization for A4314-A4316, A4354, and A4357 should be considered when determining if additional documentation should be submitted with the claim. For example, if 1 unit of A4314 and 1 unit of A4357 are provided, this should be considered as two drainage bags, which is the usual maximum quantity of drainage bags needed for routine changes.

Payment will be made for either a vinyl leg bag (A4358) or a latex leg bag (A5112). The use of both is not reasonable and necessary.

The medical necessity for drainage bags containing absobant material such as gel matrix or other material, which are intended to be disposed of on a daily basis has not been established. Claims for this type of bag will be denies as not reasonable and necessary.

INTERMITTENT IRRIGATION OF INDWELLING CATHETERS

Supplies for the intermittent irrigation of an indwelling catheter are covered when they are used on an as needed (non-routine) basis in the presence of acute obstruction of the catheter. Routine intermittent irrigations of a catheter will be denied as not reasonable and necessary. Routine irrigations are defined as those performed at predetermined intervals. In individual cases, a copy of the order for irrigation and documentation in the patient's medical record of the presence of acute catheter obstruction may be requested when irrigation supplies are billed.

Covered supplies for reasonable and necessary non-routine irrigation of a catheter include either an irrigation tray (A4320) or an irrigation syringe (A4322), and sterile water/saline (A4217). When syringes, trays, sterile saline,

or water are used for routine irrigation, they will be denied as not reasonable and necessary. Irrigation solutions containing antibiotics and chemotherapeutic agents (A9270) will be denied as noncovered. Irrigating solutions such as acetic acid or hydrogen peroxide, which are used for the treatment or prevention of urinary obstruction (A4321), will be denied as not reasonable and necessary.

CONTINUOUS IRRIGATION OF INDWELLING CATHETERS

Supplies for continuous irrigation of a catheter are covered if there is a history of obstruction of the catheter and the patency of the catheter cannot be maintained by intermittent irrigation in conjunction with reasonable and necessary catheter changes. Continuous irrigation as a primary preventative measure (i.e., no history of obstruction) will be denied as not reasonable and necessary. Documentation must substantiate the medical necessity of catheter irrigation and in particular continuous irrigation as opposed to intermittent irrigation. The records must also indicate the rate of solution administration and the duration of need. This documentation must be available upon request.

Covered supplies for reasonable and necessary continuous bladder irrigation include a 3-way Foley catheter (A4313, A4316, and A4346), irrigation tubing set (A4355), and sterile water/saline (A4217). More than one irrigation tubing set per day for continuous catheter irrigation will be denied as not reasonable and necessary.

Irrigation solutions containing antibiotics and chemotherapeutic agents (A9270) will be denied as noncovered. Payment for irrigating solutions such as acetic acid or hydrogen peroxide will be based on the allowance for sterile water/saline (A4217).

Continuous irrigation is a temporary measure. Continuous irrigation for more than 2 weeks is rarely reasonable and necessary. The patient's medical records should indicate this medical necessity and these medical records must be available upon request

INTERMITTENT CATHETERIZATION

Intermittent catheterization is covered when basic coverage criteria are met and the patient or caregiver can perform the procedure.

For each episode of covered catheterization, Medicare will cover:

A. One catheter (A4351, A4352) and an individual packet of lubricant (A4332); or

B. One sterile intermittent catheter kit (A4353) if additional coverage criteria (see below) are met. Intermittent catheterization using a sterile intermittent catheter kit (A4353) is covered when the patient requires

catheterization and the patient meets one of the following criteria (1-5):

1. The patient resides in a nursing facility,

2. 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

3. The patient has radiologically documented vesico-ureteral reflux while on a program of intermittent catheterization,

4. The patient is a spinal cord injured female with neurogenic bladder who is pregnant (for duration of pregnancy only),

5. 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

A patient would be considered to have a urinary tract infection if they have 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)

Usual Maximum Quantity of Supplies

Code Number per Month

A4332 200

A4351 200

A4352 200

A4353 200

Refer to Coding Guidelines section of the related Policy Article for contents of the kit (A4353). A4353 should not be used for billing if the components are packaged separately rather than together as a kit. Separately provided components do not provide the equivalent degree of sterility achieved with an A4353. If separate componants are provided instead of a kit (A4353) they will be denied as not reasonable and necessary.

Use of a Coude (curved) tip catheter (A4352) in female patients is rarely reasonable and necessary. When a Coude tip catheter is used (either male or female patients), there must be documentation in the patient's medical record of the medical necessity for that catheter. An example would be the inability to catheterize with a straight tip catheter. This documentation must be available upon request. If documentation is requested and does not substantiate medical necessity, claims will be denied as not reasonable and necessary.

EXTERNAL CATHETERS/URINARY COLLECTION DEVICES

Male external catheters (condom-type) or female external urinary collection devices are covered for patients who have permanent urinary incontinence when used as an alternative to an indwelling catheter.

The utilization of male external catheters (A4349) generally should not exceed 35 per month. Greater utilization of these devices must be accompanied by documentation of medical necessity.

Male external catheters (condom-type) or female external urinary collection devices will be denied as not reasonable and necessary when ordered for patients who also use an indwelling catheter.

Specialty type male external catheters (A4326) such as those that inflate or that include a faceplate or extended wear catheter systems are covered only when documentation substantiates the medical necessity for such a catheter. If documentation does not justify the medical need claims will be denied as not reasonable and necessary.

For female external urinary collection devices, more than one meatal cup (A4327) per week or more than one pouch (A4328) per day will be denied as not reasonable and necessary.

MISCELLANEOUS SUPPLIES

Appliance cleaner (A5131) is covered when used to clean the inside of certain urinary collecting appliances (A5102, A5105, A5112). More than one unit of service (16 oz.) per month is rarely reasonable and necessary.

One external urethral clamp or compression device (A4356) is covered every 3 months or sooner if the rubber/foam casing deteriorates.

Tape (A4450, A4452) which is used to secure an indwelling catheter to the patient's body is covered. More than 10 units (1 unit = 18 sq. in.; 10 units = 180 sq. in. = 5 yds. of 1 inch tape) per month will be denied as not reasonable and necessary.

Adhesive catheter anchoring devices (A4333) and catheter leg straps (A4334) for indwelling urethral catheters are covered. More than 3 per week of A4333 or 1 per month of A4334 will be denied as not reasonable and necessary. A catheter/tube anchoring device (A5200)is covered and separately payable when it is used to anchor a covered suprapubic tube or nephrostomy tube. If code A5200 is used to anchor an indwelling urethral catheter, the claim will be denied as not reasonable and necessary.

Urethral inserts (A4336) are covered for adult females with stress incontinence (ICD-9 625.6) when basic coverage criteria are met and the patient or caregiver can perform the procedure. They are not indicated for women:

• With bladder or other urinary tract infections (UTI)

• With a history of urethral stricture, bladder augmentation, pelvic radiation or other conditions where urethral catheterization is not clinically advisable

• Who are immunocompromised, at significant risk from UTI, interstitial cystitis, or pyleonephritis, or who have severely compromised urinary mucosa

• Unable to tolerate antibiotic therapy

• On anticoagulants

• With overflow incontinence or neurogenic bladder

The supplier must monitor the amount of supplies and accessories a patient is actually using and assure that the patient has nearly exhausted the supply on hand prior to dispensing any additional items. CMS’ Program Integrity Manual (Internet-Only Manual, CMS Pub. 100-8, Chapter 4, section 4.26.1) requires, “Contact with the

beneficiary or designee regarding refills should take place no sooner than approximately 7 days prior to the delivery/shipping date. For subsequent deliveries of refills, the supplier should deliver the DMEPOS product no sooner than approximately 5 days prior to the end of usage for the current product.”

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

CPT/HCPCS Codes

The appearance of a code in this section does not necessarily indicate coverage.

HCPCS MODIFIERS:

AU – Item furnished in conjunction with a urological, ostomy, or tracheostomy supply EY - No physician or other licensed health care provider order for this item or service

GY – Item or service statutorily excluded or does not meet the definition of any Medical benefit

Printed on 1/26/2013. Page 6 of 11

KX - Requirements specified in the medical policy have been met

HCPCS CODES:

A4217 STERILE WATER/SALINE, 500 ML

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

A4320 IRRIGATION TRAY WITH BULB OR PISTON SYRINGE, ANY PURPOSE A4321 THERAPEUTIC AGENT FOR URINARY CATHETER IRRIGATION

A4322 IRRIGATION SYRINGE, BULB OR PISTON, EACH

A4326 MALE EXTERNAL CATHETER WITH INTEGRAL COLLECTION CHAMBER, ANY TYPE, EACH A4327 FEMALE EXTERNAL URINARY COLLECTION DEVICE; MEATAL CUP, EACH

A4328 FEMALE EXTERNAL URINARY COLLECTION DEVICE; POUCH, EACH

A4331 EXTENSION DRAINAGE TUBING, ANY TYPE, ANY LENGTH, WITH CONNECTOR/ADAPTOR, FOR USE WITH URINARY LEG BAG OR UROSTOMY POUCH, EACH

A4332 LUBRICANT, INDIVIDUAL STERILE PACKET, EACH

A4333 URINARY CATHETER ANCHORING DEVICE, ADHESIVE SKIN ATTACHMENT, EACH A4334 URINARY CATHETER ANCHORING DEVICE, LEG STRAP, EACH

A4335 INCONTINENCE SUPPLY; MISCELLANEOUS

A4336 INCONTINENCE SUPPLY, URETHRAL INSERT, ANY TYPE, 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

A4355 IRRIGATION TUBING SET FOR CONTINUOUS BLADDER IRRIGATION THROUGH A THREE-WAY INDWELLING FOLEY CATHETER, EACH

A4356 EXTERNAL URETHRAL CLAMP OR COMPRESSION DEVICE (NOT TO BE USED FOR CATHETER CLAMP), EACH

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 A4360 DISPOSABLE EXTERNAL URETHRAL CLAMP OR COMPRESSION DEVICE, WITH PAD AND/OR POUCH, EACH A4402 LUBRICANT, PER OUNCE

A4450 TAPE, NON-WATERPROOF, PER 18 SQUARE INCHES A4452 TAPE, WATERPROOF, PER 18 SQUARE INCHES

A4455 ADHESIVE REMOVER OR SOLVENT (FOR TAPE, CEMENT OR OTHER ADHESIVE), PER OUNCE

A4456 ADHESIVE REMOVER, WIPES, ANY TYPE, EACH

A4520 INCONTINENCE GARMENT, ANY TYPE, (E.G. BRIEF, DIAPER), EACH A4554 DISPOSABLE UNDERPADS, ALL SIZES

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

A5131 APPLIANCE CLEANER, INCONTINENCE AND OSTOMY APPLIANCES, PER 16 OZ.

A5200 PERCUTANEOUS CATHETER/TUBE ANCHORING DEVICE, ADHESIVE SKIN ATTACHMENT A9270 NON-COVERED ITEM OR SERVICE

ICD-9 Codes that Support Medical Necessity

The presence of an ICD-9 code listed in this section is not sufficient by itself to assure coverage. Refer to the section on Indications and Limitation of Coverage and/or Medical Necessity for other coverage criteria and payment information.

For HCPCS code A4336:

625.6 STRESS INCONTINENCE FEMALE

Diagnoses that Support Medical Necessity Refer to previous section.

ICD-9 Codes that DO NOT Support Medical Necessity

For the specific HCPCS codes indicated above, all ICD-9 codes that are not specified in the preceding section.

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity

For the specific HCPCS codes indicated above, all diagnoses codes that are not specified in the preceding section.

General Information

Documentations Requirements

Section 1833(e) of the Social Security Act precludes payment to any provider of services unless "there has been furnished such information as may be necessary in order to determine the amounts due such provider." It is expected that the patient's medical records will reflect the need for the care provided. The patient's medical records include the physician's office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be available upon request.

An order for each item billed must be signed and dated by the treating physician, kept on file by the supplier, and made available upon request. Items billed before a signed and dated order has been received by the supplier must be submitted with an EY modifier added to each affected HCPCS code.

The order must include the type of supplies ordered and the approximate quantity to be used per unit of time.

KX and GY MODIFIERS:

Suppliers must add a KX modifier to a code only if the order indicates the patient has permanent urinary incontinence or urinary retention, and if the item is a catheter, an external urinary collection device, or a supply used with one of these items.

If all the criteria in the related Policy Article are not met, the GY modifier must be added to the code. Claims lines billed without a KX or GY modifier will be rejected as missing information.

Refer to the Supplier Manual for more information on documentation requirements.

Appendices

Utilization Guidelines Refer to Indications and Limitations of Coverage and/or Medical Necessity.

Sources of Information and Basis for Decision

Reserved for future use Advisory Committee Meeting Notes

Start Date of Comment Period 04/30/1993

End Date of Comment Period 06/14/1993

Start Date of Notice Period 08/01/1993

Revision History Number 018

Revision History Explanation Revision Effective Date: 02/04/2011 INDICATIONS AND LIMITATIONS OF COVERAGE:

Deleted: Least costly alternative language for multiple codes Revised: Instructions for A4353

Revised: Coverage of A4336

Added: A5105 to list of codes used with A5131 Added: 625.6 for HCPCS Code A4336

Revision Effective Date: 01/01/2010 INDICATIONS AND LIMITATIONS OF COVERAGE:

Added: Coverage statement for urethral inserts.

Added: Statement about checking before refilling orders HCPCS CODES AND MODIFIERS:

Added: A4336, A4360, A4456

Revision Effective Date: 12/01/2009 INDICATIONS AND LIMITATIONS OF COVERAGE:

Revised: Additional quantity denial statements for tape, anchoring devices and leg-bag straps HCPCS and MODIFIERS:

Revised: KX modifier DOCUMENTATION REQUIREMENTS:

Added: Instructions for the use of GY modifier Removed: Instructions for additional quantities

11/15/2009 - CPT/HCPCS code A4365 was deleted from group 1 Revision Effective Date: 04/01/2008

INDICATIONS AND LIMITATIONS OF COVERAGE:

Revised: Indications for intermittent catheterization HCPCS CODES:

Revised: A5105 (Effective 01/01/2008) APPENDICES:

Removed: Definitions.

03/01/2008 - In accordance with Section 911 of the Medicare Modernization Act, this policy was transitioned to DME MAC CIGNA Government Services (18003) LCD L11517 from DME PSC TrustSolutions (77012) LCD L11517.

11/10/2007 - The description for CPT/HCPCS code A5105 was changed in group 1.

06/01/2007 - In accordance with Section 911 of the Medicare Modernization Act of 2003, Virginia and West Virginia were transitioned from DME PSC TriCenturion (77011) to DME PSC TrustSolutions (77012).

Revision Effective Date: 01/01/2007 INDICATIONS AND LIMITATIONS OF COVERAGE:

Removed: DMERC references Removed: Reference to A4348 HCPCS CODES:

Revised: A4326, A5105 Deleted: A4348, A4359

DOCUMENTATION REQUIREMENTS:

Removed: DMERC references

03/01/2006 - In accordance with Section 911 of the Medicare Modernization Act of 2003, this policy was transitioned to DME PSC TrustSolutions (77012) from DMERC Palmetto GBA (00885).

Revision Effective Date: 01/01/2006 DOCUMENTATION REQUIREMENTS:

Revised: Requirements for high utilization.

Revision Effective Date: 04/01/2005 LMRP converted to LCD and Policy Article HCPCS CODES AND MODIFIERS:

Deleted: A4324, A4325, A4347, A4521-A4538 Added: A4349, A4520

Revised: A4332

INDICATIONS AND LIMITATIONS OF COVERAGE:

Added references to new codes and removed deleted codes.

Revision Effective Date: 04/01/2004 HCPCS CODES AND MODIFIERS:

Added: A4217

Deleted: A4319, A4323

INDICATIONS AND LIMITATIONS OF COVERAGE:

Added references to new code and removed deleted codes. CODING GUIDELINES:

Added: A4217 to codes requiring AU modifier.

Revision Effective Date: 04/01/2003 HCPCS CODES AND MODIFIERS:

Added: AU, EY modifiers, A4450, A4452, A4521-A4538 Deleted: K0572, K0573, A4360

INDICATIONS AND LIMITATIONS OF COVERAGE:

Adds standard language concerning coverage of items without an order and use of the AU modifier CODING GUIDELINES:

Added: coding definitions from “LMRP Description” section DOCUMENTATION REQUIREMENTS:

Adds standard language concerning use of EY modifier for items without an order

The revision dates listed below are the dates the revisions were published and not necessarily the effective dates for the revisions.

04/01/2002 - Added HCPCS codes A4319, A4324, 4325,

A4331-A4333, A4348, A4360, K0572, K0573. Deleted from policy HCPCS codes A4329, A4359, A4554, A5149,

A6265, K0280, K0281, K0407-K0409, K0411. Added use of GY modifier for non-covered conditions. Replaced ZX with KX modifier.

04/01/2000 - In the Winter 1999 Region D Supplier Manual update, verbiage was inadvertently omitted from the Urological Supplies regional medical review policy (RMRP) revision. The verbiage below was present in previous versions of the policy but was absent in the latest revision published. Coverage and Payment Rules for indwelling catheters (IX-37), indications #3 and #4 for non-routine changes should read:

3. Catheter is obstructed by encrustation, mucous plug, or blood clot

4. History of recurrent obstruction or urinary tract infection for which it has been established that an acute event is prevented by a scheduled change at intervals of less than one per month

The revision also reflects updates to the Coding Guidelines (IX - 37.5) which clarify the previously published payment policy for HCPCS code A5200 (Percutaneous catheter/tube anchoring device, adhesive skin attachment). (See Winter 1998 DMERC Dialogue, page 12.)

01/01/2000 – Added HCPCS codes A5200 and A6265. Added reasonable and necessary language in Coverage and Payment Rules section. Added language for A4340 in Coverage and Payment Rules section.

03/01/1998 – Deleted certain HCPCS K and XX codes. 04/01/1996 – Updated utilization table.

07/01/1995 – Added HCPCS codes. Renamed policy from Incontinence Appliances and Care Supplies to Urological Supplies. Entire policy revised.

11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:

A5112 descriptor was changed in Group 1

08/05/2011 - The Jurisdiction C contractor adopted a new business name. This LCD revision only includes the change from CIGNA Government Services to CGS Administrators, LLC. No coverage information was included in this revision and no provider action is needed regarding this revision.

Reason for Change Maintenance (annual review with new changes, formatting, etc.)