There is an interesting thing about what is true and what people are told about Medicare and Catheters. We are going to clear the air on a few topics and follow those up with quotes from Medicare code.
Subject 1: Medicare only pays for 30 catheters a month.
This is false. Medicare will pay for up to 200 catheters per month depending on usage. As of April 1st, 2008, Medicare will allow for the usual maximum of 200 catheters per month or one catheter for each episode of catheterization. So, this means that your DME (Durable Medical Equipment) supplier will contact you monthly and check the available supply that you have left from the previous month and then resupply you appropriately.
Subject 2: Medicare does not cover Hydrophyllic Catheters.
This is also false. HCPCS codes for catheters are as follows:
A4351- Intermittant Urinary Catheters: straight tip, with or without coating, each (this includes Hydrophyllic Coatings)
A4352- Intermittant Urinary Catheters: Coude (curved) tip, with or without coating, each (this includes Hydrophyllic Coatings)
A4353- Intermittant Urinary Catheters, with insertion supplies (this includes complete kits)
A4332- Lubricant- individual sterile packet for insertion of urinary catheters with sterile technique
Lets talk the financial issues with Hydrophyllic Catheters. The reimbursement for A4351 is $1.54 each catheter. This represents the 80% that the DME company will be paid by Medicare (20% is paid by the patient or $0.38 each). Hydrophyllic catheters cost the DME much more than this from most manufacturers so, fiscally, it is not possible to cover hydrophyllics under the code A4351. Under A4352, the reimbursement is $6.42 and A4353 is $7.00. It is much more profitable for the companies to cover hydrophyllics with these codes. That is not to say that DME companies will not cover hydro's under 51, but do the math.
Subject 3: I cannot get Kits from Medicare.
Again, False. The HCPCS code for kits is A4353. It does require documented proof of two UTIs within a 12 month period. Rules of what constitutes a UTI is as follows
- 10,000 colony forming units of a urinary pathogen and concurrent presence of one or more of the following signs, sympthoms, or laboratory findings
x fever greater than 100.4f
x systemic leukocytosis (increase in white blood cells)
x new or increase in autonomic dysreflexia
x physical signs of prostatitis, epididymitis, orchitis (swelling, painful urination, etc)
x increase muscle spasms
x pyuria (greater than 5 white blood cells)
Overall, you must have baterial counts of your urine in order to qualify under the UTI guidelines.
- you reside in a nursing facility
- you are immunosuppressive
- you have radiologically documented cesico-ureteral reflux
- you are a pregnant SCI
Subject 4: I have to pay for catheters even though I have Medicare.
Partially True. There is an 80/20 co-pay on medicare meaning you are required to pay 20 percent. Many DME companies will waive the 20% if you are under financial hardship. You should ask you supplier if they have a financial waiver program for hardships. Also, you may have to pay for your supplies upon order if your DME does not accept Medicare Assignment. This means, you pay the bill, Medicare reimburses you. Most DMEs accept assignment so that you just pay the 20% (if required).
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