A4353 Intermittent Urinary Catheter

For those of you who either dabble in urological supplies or offer these products in mass, there are many variables attached that can lead to denials and takebacks. According to an analysis from RemitDATA, the overall Medicare denial rate for claims for A4353, intermittent urinary catheter, is 18.5 percent. The top reasons for denial are attributed to patients being on a home health stay and lack of medical necessity.

Looking closer, many of the medical necessity denials can be assigned to the fact that the patient received more supplies than Medicare deems necessary. Medicare states that the usual and customary level of supplies for a patient is 200 units of service in a 30-day period, and 600 units of service in a 90-day period.

To help avoid these denials, review medical documentation to ensure you have information to support the need of the urological supplies that are given. (If you operate in Jurisdiction B, be aware that in April, National Government Services announced it would be initiating a prepayment medical review for A4353 claims.)

Documentation should include a detailed written order signed and dated by the treating physician including the item(s) to be dispensed; the specific frequency of testing; the treating physician's signature, and the date of the treating physician's signature.

Note that a start date of the order is required only if the start date is different than the signature date. Either the signature date or the separate start date must be prior to the date of service on the claim, and the signature date must be prior to the date of claim submission. An order that only states “as needed” or “PRN” for frequency alone will result in those items being denied as not medically necessary. A new order must be obtained when there is a change in the catheterization frequency.

You should also have documentation from the physician's records, prior to the date of service on the claim that supports the medical necessity for the frequency of catheterization that is ordered:

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;