For Clinicians: urological catheter resources

Patients whose insurance follows Medicare guidelines must be diagnosed with either Permanent Urinary Retention or Permanent Urinary Incontinence.

• Medicare defines “permanence” as a condition expected to last greater than 90 days.
• The patient must have some form of Urinary Retention or Incontinence documented within their medical record as explained above.

Patients whose insurance does not follow Medicare guidelines are subject to the Medical Coverage Criteria of their respective insurer.

The patient’s medical record needs to explicitly state they require Coudé catheters and the medical reason they are not able to use a traditional straight-tipped catheter.

• Medicare does not consider Patient/Clinician preference as a justifiable reason when considering medical necessity.

The most commonly-observed justifications for Coudé Catheters include some form of Urethral Stricture or other anatomical obstruction that makes insertion of a normal straight-tipped catheter to be difficult or outright dangerous for the patient.

Medicare believes Female use of Coudé Catheters is rarely reasonable or necessary. To this effect, the chart notes will need to be comprehensive and explain exactly why they are necessary.

Please provide two positive UTI cultures within the last 12 months with urinalysis and the corresponding chart notes with documented symptoms.

Please ensure that the patient’s history of recurrent UTIs was while using single-use catheters for at least the last 12 months.

Please advise why the patient needs to perform self-catheterization using sterile kits.

• Example: “Patient needs to use the closed system catheter kits for the prevention of future urinary tract infections. Patient must self-cath 5 times a day due to urinary retention.”

All-silicone foley catheters require one or more of the following be documented within the medical record:

• Latex Allergy or Sensitivity
• Frequent Encrustation (blockage) using a regular latex A4338 indwelling catheter.

Note: This only applies to All-silicone Foleys.

• Silicone-Coated Foleys aren’t generally considered a specialty product.

View office coding requirements for Foley catheter billing.

Following the requirement for Coudé Catheters to be justified versus a Straight-tipped catheter, Specialty Externals also require the patient’s medical record to explicitly name and justify why that specific Specialty External Device is necessary. Example of a Specialty External Device includes:

• GeeWhiz External Condom Catheter