Urology Coding Alert

Understand Medicare's definition of 'permanent' for accurate catheter payment

If you're asking for reimbursement for many urological supplies, expect a big "No" -- unless your supplies meet Medicare's "three-month rule."

Payoff: "If you're giving the patient catheters to take home, and he meets the Medicare guidelines for a permanent condition and he has an incontinence or a retention issue, the catheters would likely be paid as long as medical necessity is proven," says Morgan Hause, CCS, CCS-P, privacy and compliance officer for urology of Indiana LLC, a 22-urologist practice
in Indianapolis.

In this example, you would use HCPCS Codes A4338 (Indwelling catheter; Foley type, two-way latex with coating [Teflon, silicone, silicone elastomer or hydrophilic, etc.], each) and A4358 (Urinary drainage bag, leg or abdomen, vinyl, with or without tube, with straps, each) for the claim to the durable medical equipment regional carrier (DMERC). Link the HCPCS Codes to the relevant 788.3x ICD-9 Codes incontinence code to demonstrate medical necessity. Hause suggests that you check with your DMERC to see if you need to append -KX (Specific required documentation on file) to indicate that the patient's condition meets Medicare's standard of permanence.

If the doctor expects the patient's condition to last three months, Medicare considers it permanent. Otherwise, expect supplies for that condition to be bundled into the E/M or procedure codes.

Even for Permanent Supplies, Get an ABN

If you are still on the hook for supplies, have your patient sign an advance beneficiary notice (ABN) for supplies that are not permanent -- lasting less than three months -- and append HCPCS modifier -GA (Waiver of liability statement on file) to ensure payment from the patient if not the carrier. If the condition lasts fewer than three months, however, supplies related to incontinence or retention are still bundled with E/M or procedures, and modifier -GA and an ABN would not be appropriate.

"The idea is that if it's not going to last three months, it's incidental to the other services you're providing," Hause says. "It's part of the E/M services you're providing. It's not a medical-necessity denial, which is when an ABN would be appropriate; it's a bundling denial."

Hause also warns that Medicare no longer pays for surgical trays (HCPCS A4550), although other payers might. "We continue to bill some other payers, and we continue to be paid," he says, "but Medicare does not allow those separately."

Don't Get Your Hopes Up for 99070

Physicians can bill for supplies using code 99070 (Supplies and materials [except spectacles], provided by the physician over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies or materials rendered]) or its HCPCS level II equivalent only if the supplies used are over and above what is normally considered part of the procedure the supplies are used in.

But not many providers are reimbursing for 99070 these days. It's a generic code, created in the years before HCPCS codes, says Kathy Pride, CPC, a coding consultant for QuadraMed in Port St. Lucie, Fla. Besides workers' compensation, she says, very few carriers recognize the code any more.