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:
The patient resides in a nursing facility;
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;
The patient has radiologically documented vesico-ureteral reflux while on a program of intermittent catheterization;
The patient is a spinal cord-injured female with neurogenic bladder who is pregnant (for duration of pregnancy only);
The patient has had distinct, recurrent urinary tract infections, while on a program of sterile intermittent catheterization with A4351/A4352 and sterile lubricant A4332, twice within the 12-month prior to the initiation of sterile intermittent catheter kits.
Be sure to refer to the “Coding Guidelines” section of the related Policy Article of the LCD for contents of the kit. If a HCPC code exists that includes multiple products, that kit code should be used in lieu of the individual HCPC codes. The kit code should be used for billing even if the components are packaged separately rather than together as a kit.
A urinary intermittent catheter with insertion supplies (A4353) is a kit, which includes a catheter, lubricant, gloves, antiseptic solution, applicators, drape and a tray or bag in a sterile package intended for single use. The collection tray/bag is a separate item included as part of the kit. Materials that serve as packaging for the kit do not meet this requirement. A4353 must not be billed if individual components (i.e., insertion tray, lubricant and catheter) are provided as separate items rather than in a single sterile package. When providing a sterile kit, the individual components must not be separately billed.
Also note that you must add a KX modifier to a code only if the order indicates that the patient has permanent urinary incontinence or urinary retention, and if the item is a catheter, an external urinary collection device or a supply used with one of these items. If all the criteria in the related Policy Article are not met, the GY modifier must be added to the code. Claim lines billed without a KX or GY modifier will be rejected as missing information.
As always, reference your jurisdiction's Supplier Manual for more information on documentation requirements.
Sarah Hanna is a reimbursement consultant and vice president of ECS Billing & Consulting, Tiffin, Ohio, specializing in proper billing protocols, Medicare coverage guidelines and billing office procedures. You can reach her at 419/448-5332 or sarahhanna@bright.net.
Based on anlysis of Medicare claims for RemitDATA customers during the fourth quarter of 2010. The average DSO for A4353 claims is 60 days. Source: RemitDATA, 866/885-2974 or www.remitdata.com
