Getting the intermittent catheter the patient needs: considerations in coding, coverage, and documentation.
Key Words: Intermittent self-catheterization, ISC, Healthcare Common Procedural Coding System, HCPCS, catheter coding, catheter insurance coverage, catheter documentation, catheter prescription, Centers for Medicare & Medicaid Services, CMS.
Urologic nurses and associates spend a lot of time making sure patients get the best products for intermittent self-catheterization to effectively manage urologic conditions. Patient comfort, compliance, and clinical outcomes are all critical considerations for clinicians. Product features, such as a hydrophilic coating or a Coude tip for intermittent catheters, play a significant part in the selection of the right products for the patient. Additionally, catheter reimbursement guidelines can dictate which products are available and what steps health care providers can take to ensure patients get the right product to fit their needs. Understanding how the system works will enable clinicians to assist patients in obtaining the catheter they choose for intermittent catheterizations.
The current Healthcare Common Procedural Coding System (HCPCS) contains three codes for intermittent catheters (Optum-Insight, Inc., 2012) (see Table 1). These codes demonstrate subtle differences in product features, such as the type of tip the catheter has, straight or Coude, and whether the catheter is accompanied by insertion/collection supplies. Because these are the only distinctions between the codes, the products within each code vary greatly. Under A4351, the list includes uncoated red rubber catheters, uncoated PVC catheters, hydrophilic coated catheters, silicone catheters, and compact catheters with a straight tip. This is important because if products are billed under the same code, coverage and reimbursement are the same. The cost to the insurance carrier and the patient is the same. Therefore, uncoated PVC or red rubber catheters are reimbursed at the same rate as hydrophilic coated catheters, except that the patient will incur additional expense for the lubricant needed for insertion of uncoated catheters. See Table 2 for examples of the different types of catheters found under each code category.
Factors such as reimbursement rate and allowed catheters per month may impact availability and access to products for some patients. This may happen because of the acquisition costs encountered by the dealer for purchase of innovative catheters. Medicare, for example, allows one catheter per catheterization, up to 200 catheters per month (Centers for Medicare & Medicaid Services [CMS], 2013). The guidelines prior to the April 2008 change by CMS only allowed for four catheters per month. Similar guidelines still exist under some Medicaid and private insurance plans, which may limit the products available to those patients. While this is an issue for some patients, Medicare recipients, as well as many private and Medicaid plans, will not experience these challenges and should have access to the catheter of their choice. Understanding that products under a given code are covered and reimbursed the same will enable clinicians and patients alike to push back on suppliers to ensure access to the best catheter to suit the patient's needs.
How the prescription and medical record notes are written will influence the number and type of catheters a patient receives. The clinician can support the patient by indicating on the prescription the type of catheter, number of recommended catheterizations per day, and the number of catheters per month. If a specific brand of catheter is selected in consultation with the patient, the specific catheter's name must be indicated on the prescription. It is important to include the appropriate dispense as written/no substitute language on the prescription. By indicating dispense as written on the prescription, the dealer is required to supply the patient with the specific brand or type of catheter prescribed. Failing to indicate dispense as written on the prescription will allow the dealer to fill the order with a catheter other than the preferred catheter prescribed. This can lead to patients receiving a product other than what they were trained to use or what was prescribed. State pharmacy boards will determine the accepted way to indicate dispense as written/ do not substitute. A sample prescription is found in Figure 1.
Dealers may request additional documentation to support the patient's catheter needs. The specific documentation a dealer is required to have may vary between payers, but standardizing the information included in the medical record will help the dealer be prepared if an audit occurs. Thoroughly documenting the need for catheterization is essential for all intermittent catheter patients. As patients move from a straight-tipped catheter to a Coude or a closed system, many insurance plans may have more restrictive coverage guidelines. Examples of common clinical rationale for going from a straight tip to a Coude catheter include trouble passing a straight catheter, strictures, false passages, or for trouble locating the meatus (in females) (Newman & Willson, 2011).
Patients may require a closed system when sterile catheterization is required. Medicare's current coverage guidelines indicate five possible criteria patients could meet to qualify to use a closed system (CMS, 2013). They are:
* Patient has had two documented urinary tract infections during previous 12 months of intermittent catheterization.
* Patient resides in a nursing home.
* Patient is a spinal cord-injured, pregnant female with a neurogenic bladder.
* Patient is immunosuppressed.
* Patient has documented vesico-ureteral reflux.
Because coverage guidelines vary by insurance plan, knowing the appropriate code items will bill with, for example, A4353 for a closed system, allow individuals to check coverage and benefits for the specific item being requested.
Being detailed regarding why one catheter was chosen over another will help patients get the right catheter for their needs. Thorough documentation regarding other tried and failed modalities, difficulties catheterizing, or history can support coverage for the preferred type of catheter for the patient.
Choosing the right catheter should be based on clinical diagnosis and patient preference. Patient compliance and overall bladder health is key. Coverage and reimbursement for catheters with similar features is the same. By indicating the specific catheter choice on the prescription and supporting patients with thorough notes, patients will get the catheter they need.
Centers for Medicare & Medicaid Services (CMS). (2013). Local coverage determination (LCD): Urological supplies (L11566). Retrieved from http:// www.cms.gov/medicare-coverage-database/details/lcd-details.aspx? LCDId=11566&ContrId=140&ver=47 &ContrVer=2&CoverageSelection= Both&ArticleType=All&PolicyType_Final&s=All&CptHcpcsCode=a4353 &bc=gAAAABAAIAAAAA% 3d% 3d&
Newman, D.K., & Willson, M.M. (2011). Review of intermittent catheterization and current best practices. Urologic Nursing, 31(1), 12-27.
OptumInsight, Inc. (2012). Healthcare Common Procedural Coding System (HCPCS) Level II Expert 2013. Salt Lake City, UT: OptumInsight, Inc.
Steve Boettcher is a Reimbursement Specialist, Coloplast Corporation, Minneapolis, MN.
Table 1. HCPCS Codes for Intermittent Catheters HCPCS Code Definition A4351 Intermittent urinary catheter, straight tip, with or without coating (Teflon, silicone, silicone elastomer, or hydrophilic, etc.) A4352 Intermittent urinary catheter, Coude or curved tip, with or without coating (Teflon, silicone, silicone elastomeric, or hydrophilic, etc.) A4353 Intermittent urinary catheter, with insertion supplies Table 2. Types of Categories of Catheters with Healthcare Common Procedure Coding System (HCPCS) Code A4351 Straight, with or without coating (Same Reimbursed Amount) * * Bard Clean-Cath[R] * Coloplast SpeediCath[R] * Cure Catheter[R] Straight Tip * Hollister Apogee * Kendall Dover[TM] * Red Rubber (latex, opaque) * Rochester Medical Magic 3[R] * Teleflex Rusch Easy Cath[TM] * Wellspect LoFric[R] A4352 CoudE (curved tip), with or without coating (Same Reimbursed Amount) * Bard[R] Coude Tip Latex * Coloplast Self-Cath[R] Coude * Coloplast SpeediCath[R] Coude * Hollister Apogee Coude * Kendall Dover[TM] Coude * Red Rubber Coude * Rochester Medical Magic 3[R] * Teleflex Rusch Easy Cath[TM] Coude * Wellspect LoFric[R] Coude A4353 Sterile kits or closed systems (CS) ** (Same Reimbursed Amount) * Bard Touchless * Coloplast SpeediCath[R] Compact Set * Coloplast SureCath[R] Set * Cure Catheter[R] CS * Hollister Advance Plus * Kendall Dover[TM] * Red Rubber Closed System * Rochester Medical Magic 3[R] Closed System/Pre-Connected Tray * Teleflex Rusch Pocket Pack IC[TM] * Wellspect LoFric[R] Hydro Kit A4332. One sterile packet of lubricant per catheterization (uncoated caths) Source: Coloplast Corporation. Used with permission. Exceptions include state of California MediCal and Texas state Medicaid because they reimburse a higher amount for hydrophilic-coated catheters over uncoated catheters. Products listed include insertion and/or collection supplies as defined by CMS and PDAC.
|Printer friendly Cite/link Email Feedback|
|Title Annotation:||General Clinical Practice|
|Date:||May 1, 2013|
|Previous Article:||Successful intermittent self-catheterization teaching: one nurse's strategy of how and what to teach.|
|Next Article:||Effects of an online support group for prostate cancer survivors: a randomized trial.|