In this article, we shared coding guidelines for urology supplies updated for the year 2022. To share these guidelines, we referred CMS document on Local Coverage Determination (LCD) for urological supplies and Medicare Advantage Policy Guidelines for urological supplies from United Healthcare. Consider below mentioned guidelines as general guidelines for urology supplies. For payer-specific reimbursement policies and coverage issues, refer to insurance carrier billing guidelines and reimbursement policies.
Coding Guidelines for Urology Supplies
- Urinary catheters and external urinary collection devices are covered to drain or collect urine for a beneficiary who has permanent urinary incontinence or permanent urinary retention. Permanent urinary retention is defined as retention that is not expected to be medically or surgically corrected in that beneficiary within 3 months.
- If the catheter or the external urinary collection device meets the coverage criteria then the related supplies that are necessary for their effective use are also covered. Urological supplies that are used for purposes not related to the covered use of catheters or external urinary collection devices (i.e., drainage and/or collection of urine from the bladder) will be denied as non-covered.
- The beneficiary must have a permanent impairment of urination. This does not require a determination that there is no possibility that the beneficiary’s condition may improve sometime in the future. If the medical record, including the judgment of the treating practitioner, indicates the condition is of long and indefinite duration (ordinarily at least 3 months), the test of permanence is considered met. Catheters and related supplies will be denied as non-covered in situations in which it is expected that the condition will be temporary.
- The use of a urological supply for the treatment of chronic urinary tract infection or other bladder conditions in the absence of permanent urinary incontinence or retention is non-covered. Since the beneficiary’s urinary system is functioning, the criteria for coverage under the prosthetic benefit provision are not met.
- When inserting an inFlow device or using urological supplies in a treating practitioner’s office as part of a professional service that is billed to Medicare, the supplies are considered the incident to the professional services of the health care practitioner and are not separately payable. Claims for these devices must not be submitted. Claims for the professional service, which includes the device, must be submitted to the A/B MAC.
- If additional inFlow devices or urological supplies are sent home with the beneficiary, claims for these devices may be billed to the DME MAC only if the beneficiary’s condition meets the definition of permanence as defined in the Prosthetic Device benefit. In this situation, use the place of service corresponding to the beneficiary’s residence; Place of Service Office (POS) 11 must not be used. If the beneficiary’s condition is expected to be temporary, urological supplies may not be billed. In this situation, they are considered as supplies provided incident to a treating practitioner’s service, and payment is included in the allowance for the treating practitioner services, which are processed by the A/B MAC.
Non-Medical Necessity Coverage and Payment Rules
Urology supplies are covered under the Prosthetic Device benefit i.e., Social Security Act § 1861(s)(8)). In order for a beneficiary’s equipment to be eligible for reimbursement the reasonable and necessary (R&N) requirements set out in the related Local Coverage Determination (LCD) must be met. In addition, there are specific statutory payment policy requirements, discussed in this article, that also must be met. For any item to be covered by Medicare, it must
- be eligible for a defined Medicare benefit category,
- be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and
- meet all other applicable Medicare statutory and regulatory requirements.
Requirements for Specific DMEPOS Items
Final Rule 1713 (84 Fed. Reg Vol 217) requires a face-to-face encounter and a Written Order Prior to Delivery (WOPD) for specified HCPCS codes. CMS and the DME MACs provide a list of the specified codes, which is periodically updated. You can refer to the CMS webpage for the required Face-to-Face Encounter and Written Order Prior to the Delivery List.
Claims for the specified items subject to Final Rule 1713 (84 Fed. Reg Vol 217) that do not meet the face-to-face encounter and WOPD requirements specified in the LCD-related Standard Documentation Requirements Article (A55426) will be denied as not reasonable and necessary.
If a supplier delivers an item prior to receipt of a WOPD, it will be denied as not reasonable and necessary. If the WOPD is not obtained prior to delivery, payment will not be made for that item even if a WOPD is subsequently obtained by the supplier. If a similar item is subsequently provided by an unrelated supplier who has obtained a WOPD prior to delivery, it will be eligible for coverage.
Continued Medical Need
For all DMEPOS items, the initial justification for medical need is established at the time the item(s) is first ordered, therefore, beneficiary medical records demonstrating that the item is reasonable and necessary are created just prior to, or at the time of, the creation of the initial prescription. Once the initial medical need is established, unless continued coverage requirements are specified in the LCD, an ongoing need for urological supplies is assumed to drain or collect urine for a beneficiary who has permanent urinary incontinence or permanent urinary retention. There is no requirement for further documentation of continued medical need as long as the beneficiary continues to meet the Prosthetic Devices benefit.
Medical Billers and Coders (MBC) is a leading medical billing company providing complete medical billing and coding services. You can refer following reference links to a detailed understanding on coding guidelines for urology supplies. In case of any assistance needed in urology billing and coding, call us at 888-357-3226 or drop an email at: email@example.com.