NON-ROUTINE MEDICAL SUPPLIES
A4326 Male external catheter
COVERAGE AND PAYMENT RULES:
For any item to be covered by Medicare, it must (1) be eligible for a defined Medicare benefit category, (2) be reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member, and (3) meet all other applicable Medicare statutory and regulatory requirements. For the items addressed in this medical policy, "reasonable and necessary" is defined by the following coverage and payment rules.
Urinary catheters and external urinary collection devices are covered to drain or collect urine for a patient 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 patient 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 noncovered. Urological supplies billed without a KX modifier (see Documentation section) will be denied as noncovered.
The patient must have a permanent impairment of urination. This does not require a determination that there is no possibility that the patient's condition may improve sometime in the future. If the medical record, including the judgement of the attending physician, 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 noncovered in situations in which it is expected that the condition will be temporary.
You need a prescription and verbal order under Medicare for payment---not included in consolidated billing.