Acronyms
LCD/LCA
Local Coverage Determination/Article
What is the timeframe for when a face-to-face encounter is to be performed?
As a condition for payment, 42 CFR 410.38 and Final Rule 1713 (84 Fed. Reg Vol 217) require that a treating practitioner have a face-to-face encounter with a beneficiary within the six (6) months prior to prescribing items that appear on the Required List.
What are the HCPCS codes under review?
A4351, A4352, A4353
True/False- If a bene history has exceeded 200 supplies per month, the excess will be denied. This is not a tracked item.
False. Do not deny the excess (this information will be added to the tracker).
Why are women more prone to UTI's than men?
A woman’s urethra is shorter than a male’s and therefore bacteria have less distance to travel to reach the bladder.
UTI
Urinary Tract Infection
True/False- The SWO can be provided via a verbal order and signed electronically.
True
What HCPCS code should have a consult submitted if billed for a female?
A4352- this code is rarely reasonable and necessary for females
GBB11
What is the size range for urinary catheters?
Catheters range from size 6-26 French (FR) - A French size is comparable to the circumference of the catheter in millimeters. “French” or “FR” is equivalent to 0.33 millimeters, which converts to .013 inch or 1/77 inch in diameter. French size does not apply to the length of the catheter.
HCPCS
Healthcare Common Procedure Coding System
The refill record must include what?
Beneficiary name or authorized provider
Description of each item being requested
Documentation of affirmative response indicating a need for refill
Date of refill request
If a claim is billed with codes 0504U or 10504U, what does this indicate?
A genetic test was utilized to establish diagnosis of UTI (and will need to be put on the tracking sheet).
Documentation shows separate components of the kit are billed instead of the full kit (A4353).
GDW18 (this is considered unbundling)
Where does the word catheter originate from?
The word “catheter” is derived from Greek (kathiénai), meaning “to send down”.
POD
Proof of Delivery
What elements must be contained in the Proof of Delivery?
Beneficiary Name
Delivery address
Description of the items being delivered
Quantity delivered
Date delivered
Beneficiary Signature
Evidence of delivery (if through shipping service/mail order)
What HCPCS code should be billed for intermittent urinary catheter; straight tip, with or without coating (Teflon, silicone, silicone elastomer, or hydrophilic, etc).
A4351
Enter info for these instances in the tracking sheet.
1. Documentation does not support beneficiary/caregiver is able to perform the intermittent catheterization.
2. If billed with UTI diagnosis/genetic testing utilized.
3. Bene has exceeded the maximum quantity of supplies.
What is the earliest record of a catheter being utilized?
1500 BC- The earliest record in ancient Egyptian papyrus of treatment of urinary retention by means of transurethral bronze tubes, reeds, straws, and curled-up palm leaves (OUCH).
Standard Written Order
The Standard Written Order must contain what elements?
Beneficiary Name
Delivery address
Description of the items being delivered
Quantity delivered
Date delivered
Beneficiary Signature
Evidence of delivery (if through shipping service/mail order)
One of five criteria needs to be met for HCPCS code A4353- what are those 5 criteria?
• Resides in a nursing home; or
• Is immunosuppressed; or
• Has radiologically documented vesico-ureteral reflux while on a program of intermittent catheterization; or
• Is a spinal cord injured female with neurogenic bladder who is pregnant; or
• Has had distinct, recurrent urinary tract infections, while on a program of intermittent catheterization (with A4351/A4352), twice within the 12-months prior to the initiation of sterile intermittent catheter kits.
The internal codes utilized are -
PCG88- if POD was not submitted
PCG24- Third party ADR requested for insufficient documentation
PCG29- Third party successfully submitted documentation
PCG30- Third party failed to submit documentation
What volume does a normal bladder hold and what is the record for retention?
A healthy human bladder can hold between 400-500ml of urine. In a case study published in 2018, an 80-year-old man with diabetes and a spinal cord injury presented with 10,995 ml in his bladder.