Equipment and Supplies - Urological and Bowel Supplies (2025)

Table of Contents

Overview Eligible Providers TPL and Medicare Eligible Members Covered Services Indwelling Catheters or Insertion Trays Intermittent Catheterization Drainage Collection Devices Irrigation Supplies Anal Irrigation System and Accessory Unit (A4459 and A4453) Authorization Excess Quantities of Anal Irrigation Systems (A4459) Excess Quantities of Anal Irrigation Accessory Units (A4453) Excess Quantities of Intermittent Catheters Excess Quantities of Drainage Collection Devices Billing

Revised: December 6. 2024

·Overview

·Eligible Providers

·TPL and Medicare

·Eligible Members

·Covered Services

·Indwelling Catheters or Insertion Trays

·Intermittent Catheterization

·Drainage Collection Devices

·Irrigation Supplies

·Anal Irrigation System and Accessory Unit

·Authorization

·Excess Quantities of Intermittent Catheters

·Excess Quantities of Drainage Collection Devices

·Billing

Overview

Catheters and related supplies are used to drain urine from the bladder or promote emptying of the contents of the colon when a member is unable to completely empty the bladder by voiding or unable to control their bowel movements.

Eligible Providers

The following providers may provide catheters and related supplies:

·Federally qualified health center

·Home health agencies

·Indian Health Services

·Medical suppliers

·Pharmacies

·Rural health clinic

TPL and Medicare

Providers must meet any provider criteria, including accreditation, for third-party insurance or for Medicare to assist members for whom Minnesota Health Care Programs (MHCP) is not the primary payer.

MHCP quantity limits and thresholds apply to all members unless only Medicare coinsurance or deductible is requested.

Eligible Members

Catheters and related supplies are covered for eligible MHCP members who are unable to completely empty their bladder by voiding or unable to control their bowel movements.

Covered Services

·A4310 - A4316 and A4354 (insertion trays for indwelling catheters)

·A4338 - A4346 (indwelling catheters without insertion trays)

·A4351 - A4353 (intermittent catheters)

·A4357 - A4358, A5102 and A5112 (drainage collection systems)

·A4320 - A4334, A4349, A4355 – A4356 (related supplies)

·A4335 (Miscellaneous incontinence supplies)

·A4459 (anal irrigation system)

·A4453 (rectal catheter for use with the manual pump-operated enema system)

Indwelling Catheters or Insertion Trays

Most members can be served with one indwelling catheter per month. A second catheter may be allowed if the catheter is accidentally removed, malfunctions, or becomes obstructed or if the person has a medical history that requires the catheter to be replaced more than once per month. One insertion tray is covered per episode of indwelling catheter insertion. An insertion tray is not covered for use with an intermittent catheter. In rare situations, a person may require daily changes of indwelling catheters. Documentation must support the quantity dispensed.

Documentation of medical necessity (such as recurrent encrustation, inability to pass a straight catheter or sensitivity to latex) is required for a specialty indwelling catheter (A4340) or a silicone catheter (A4312, A4315, A4344).

Intermittent Catheterization

Most members can be served with 150 - 180 intermittent catheters per month. Up to 300 intermittent catheters without insertion supplies may be allowed if the person has a medical history that requires more than six episodes of catheterization daily. MHCP does not encourage the reuse of intermittent catheters. Reuse of intermittent catheters can cause infection. Intermittent catheters with sterile insertion supplies are covered if the person has a medical history that requires sterile, rather than clean, catheterization and documentation of medical necessity for sterile catheterization is maintained in the medical supplier’s files. The member’s living arrangement alone does not support the need for sterile catheterization. More than 300 intermittent catheters with insertion supplies per month require authorization. Documentation must support the quantity dispensed. Review the Authorization subsection for thresholds.

Drainage Collection Devices

Most members can be served with one to two drainage bags or bottles per month. Additional drainage bags or bottles may be allowed if the person has a medical history that requires the bag to be replaced more frequently.

Exception: Due to the Centers for Medicare & Medicaid Services-required Medically Unlikely Edits (MUEs), A5102 is limited to one per month. Documentation must support the quantity dispensed. Review the Authorization subsection for thresholds.

Irrigation Supplies

Most members who require intermittent irrigation can be served with one irrigation tray or syringe per week. Up to 31 irrigation syringes or trays may be allowed per month if the person has a medical condition that requires daily irrigation with a new syringe. Documentation must support the quantity dispensed. Supplies for intermittent irrigation of an indwelling catheter include either an irrigation tray or an irrigation syringe, and sterile water or saline.

Most members who require continuous irrigation can be served with one irrigation tubing set per day for up to two weeks. Up to 31 continuous days may be allowed if the person has persistent obstructions. Supplies for continuous irrigation include a three-way Foley catheter, irrigation tubing set and sterile water or saline.

Authorization thresholds for urological supplies

HCPCS code(s)	Code category	Monthly threshold
A4353	Intermittent catheters with insertion supplies	300 units per month
A4357, A4358, A5112	Drainage collection devices	10 units in any combination per month

Anal Irrigation System and Accessory Unit (A4459 and A4453)

Anal irrigation is used for fecal incontinence, chronic constipation, or time-consuming bowel management procedures when other conservative bowel management alternatives have been tried and failed.

The member must meet the following criteria:

·Has one of the following:

·Fecal incontinence

·Chronic constipation

·Bowel management methods or combination of methods requiring more than 30 minutes a day

·The following first-line bowel management methods have been prescribed and demonstrated failure:

·Dietary modification

·Medication

·Enema bag

·Physical therapies (pelvic floor stimulation, biofeedback, electrical stimulation)

For AA459, one unit is one kit and MHCP covers up to four units per year if medically necessary due to daily irrigation.

For A4453, one accessory unit equals one box of 15 catheters and one water bag. MHCP covers up to two units per month.

Authorization

Authorization is required for quantities of intermittent catheters with insertion supplies, or drainage collection systems exceeding limits.

Authorization is always required for code A4459 and accessory units under code A4453. Include documentation of demonstrated failure and length of trial for first-line bowel management methods.

Submit authorization requests and required documentation to the authorization medical review agent.

Excess Quantities of Anal Irrigation Systems (A4459)

·For requests more than two units per year, include documentation supporting the need for daily catheter use.

Excess Quantities of Anal Irrigation Accessory Units (A4453)

·For requests of more than two accessory units per month, include documentation supporting the need for daily catheter use.

Excess Quantities of Intermittent Catheters

·Authorization is required for billing more than 300 intermittent catheters with insertion supplies per month.

·Documentation must include an order from the physician stating how often the person must be catheterized and the medical justification for exceeding 300 catheters per month. Document why clean catheterization techniques are not appropriate for the person.

Excess Quantities of Drainage Collection Devices

·Authorization is required for billing more than 10 drainage bags or bottles per month.

·Documentation must include an order from the physician stating how often the collection bag or bottle must be changed and the medical justification for replacing the bag or bottle more than twice per week.

Billing

·Bill services approved through the authorization process on a separate claim from services not requiring authorization Example: submit one claim (no authorization required) for the number of units up to the authorization threshold. Submit another claim with the prior authorization number for the additional quantity dispensed over the threshold.

·Bill A4459 and A4453 with a diagnosis, long description and a pricing attachment.

·If the member has Medicare, MHCP will pay the deductible or coinsurance on any units for which Medicare has made payment. Any units that Medicare denies payment for must meet MHCP quantity and authorization requirements. Authorization can be requested retroactively.

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