Rule 5160-10-32 | DMEPOS: ostomy supplies and urological supplies.
(A) No particular form or format is specified for the certification of medical necessity.
(B) Stoma maintenance supplies. If more than one type of supply serve the same function, then payment may be made only for the dispensing of one type at a time (e.g., skin barrier applied as a liquid, in a spray, or with a wipe or swab; drainage management with a stoma cap, a stoma plug, or gauze pads).
(C) Urination aids.
(1) Indwelling catheters.
(a) Frequency limits imposed on catheter replacement may be exceeded without prior authorization (PA) for reasons including but not limited to the following examples:
(i) Accidental removal of a catheter;
(ii) Malfunction of a catheter;
(iii) Obstruction of a catheter by encrustation, mucus plug, or blood clot; or
(iv) A history of recurrent obstruction or infection, as a precaution against which the prescriber has specified more frequent changing of the catheter.
(b) Additional documentation of medical necessity is needed for either of the following items:
(i) A specialty indwelling catheter or all-silicone catheter used in lieu of a standard coated Foley catheter; or
(ii) A three-way indwelling catheter used either alone or with other components.
(2) Supplies for intermittent irrigation of indwelling catheters.
(a) Payment may be made for either an irrigation tray or an irrigation syringe used on an as-needed basis to clear an obstruction from an indwelling catheter by irrigation.
(b) Payment may be made for sterile water or saline solution for irrigation. No additional payment is made if the irrigation solution contains acetic acid or hydrogen peroxide. No payment is made for an irrigation solution containing antibiotics or chemotherapeutic agents.
(c) No payment is made for supplies used for the irrigation of an indwelling catheter at predetermined intervals (routine irrigation).
(3) Supplies for continuous irrigation of indwelling catheters.
(a) Payment may be made for an irrigation tubing set, as well as for a three-way Foley catheter, if there is a history of catheter obstruction and catheter patency cannot be maintained by intermittent irrigation and necessary changing of the catheter.
(b) Payment may be made for sterile water or saline solution for irrigation. No additional payment is made if the irrigation solution contains acetic acid or hydrogen peroxide. No payment is made for an irrigation solution containing antibiotics or chemotherapeutic agents.
(c) No payment is made for supplies if continuous irrigation is used as a preventive measure.
(d) Additional documentation is needed to establish the medical necessity of continuous irrigation used instead of intermittent irrigation. This documentation is to indicate the rate of administration and the duration of need.
(e) Additional documentation is needed to establish the medical necessity of continuous irrigation lasting more than two weeks.
(4) Intermittent catheters and related supplies.
(a) Payment may be made for a sterile intermittent catheter and related supplies (or a catheter kit) rather than a clean intermittent catheter and related supplies if sterile catheterization is medically necessary. Sterile intermittent catheterization is presumed to be medically necessary if the individual experiences any of the following conditions:
(i) Immunosuppression, without regard to cause;
(ii) Both neurogenic bladder dysfunction and pregnancy;
(iii) Documented vesicoureteral reflux; or
(iv) At least two distinct urinary tract infections within the preceding year.
(b) Additional documentation is needed to establish the medical necessity of a coudé catheter used instead of a straight catheter. The use of a coudé catheter by a female is rarely necessary.
(5) External urinary collection devices.
(a) Payment may be made for a medically necessary external urinary collection device (e.g., a condom-style catheter for a male, a meatal cup or a pouch for a female) as an alternative to an indwelling catheter for an individual who has permanent urinary incontinence.
(b) Payment will not be made for the concurrent dispensing of both an external urinary collection device and an indwelling catheter.
(c) Additional documentation is needed to establish the medical necessity of a specialty external urinary collection device (e.g., an inflatable condom-style catheter, a pouch with a faceplate).
(6) Urinary drainage systems.
(a) Payment may be made for the routine changing of a urinary drainage system.
(b) Payment will not be made for the concurrent dispensing of a vinyl and a latex bag.
(c) Payment will not be made for leg bags for individuals who do not leave their bed.
(7) Miscellaneous supplies.
(a) Payment may be made for cleaner for a urinary collection device or drainage system only if the individual is using the collection device or drainage system.
(b) Payment may be made for a medically necessary adhesive anchoring device used to secure an indwelling urethral catheter, a suprapubic catheter, or a nephrostomy tube.
(c) Payment may be made for a medically necessary leg strap used to secure an indwelling urethral catheter.
Last updated January 2, 2024 at 9:00 AM
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