Catheters for Medicare and Medicaid Patients
Basic Medicare Coverage Criteria
The patient must have permanent urinary incontinence or urinary retention, and the patient or caregiver must be able to perform the procedure.
Catheter Prescription for Medicare
Medicare and most insurers require that a catheter prescription contain the following elements:
- patient’s name
- description of the item ordered
- quantities per month
- the date order was signed
- start date of order (only if different than date order was signed)
- note: a prescription for a coude tip catheter must indicate that the patient is unable to use straight catheters
Quantities of Catheters Covered
Medicare programs allow 200 intermittent catheters per month without additional medical documentation.
Medicaid programs typically allow 120 intermittent catheters per month without additional medical documentation. Note: Benefits vary by state Medicaid plan.
Other insurance coverage varies by plan, and benefits must be verified at the time of intake.
Types of Catheters Covered by Medicare Programs
Straight intermittent catheters
Coude tip intermittent catheters
Catheter Kits (gloves, antiseptic wipes, drapes, lubricant, and drainage bags), with the following additional criteria and medical documentation:
While on a program of intermittent catheterization, the
patient has had two documented distinct, recurrent urinary
tract infections, within a 12-month period, OR
The patient resides in a nursing facility, 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
Types of Catheters Covered by Medicaid Programs
Medicaid covers straight catheters, coude catheters, and catheter kits, as well as most brands of catheters with hydrophilic coating and antibacterial coating. Medicaid uses an authorization process using its own authorization form for the beneficiary’s medical supplier and physician.
Medicare Policy and Coverage Change
Modernizes Intermittent Catheterization
Effective April 1, 2008—The Medicare policy for intermittent catheterization recognized catheters as single-use devices, meaning doctors can prescribe catheters for single use, and users are reimbursed for each covered catheterization. The policy changes will likely reduce UTI (Urinary Tract Infection) risk and make more choices available to people living with incontinence or who have permanent conditions requiring bladder care and management programs.
Now clinicians can focus on prescribing the best quality/performing product for their patient, rather than having clinical care decisions impaired by insurance requirements.
And patients can live better with access to more product choices, fewer hospital or urgent care visits and less exposure to bacteria.
Why the Centers for Medicare and Medicaid Services covers a new catheter each time
Reason #1: Washing and reusing catheters increases the likelihood of bacteria remaining in the catheter to be reinserted into the urinary tract, thereby causing infection. UTI’s are one of the most frequent and significant complications for intermittent catheter users. Symptoms of infection include: burning sensation with urination, having the urge to urinate more frequently, opaque or bloody urine, nausea and fever.
Reason #2: The benefits of hydrophilic-coated catheters are only available for a single use. This is because the hydrophilic coating is removed when washed, and the catheter requires manual lubrication for reuse. Clinical studies have documented that single-use hydrophilic-coated catheters significantly reduce the incidence of urinary tract infections, as well as urethral damage and trauma, and withdrawal friction, while simultaneously increasing user preference and patient satisfaction, as compared to uncoated catheters with lubrication.
Reason #3: The cost of treating urinary tract infections in catheter users (an estimated $3.5 billion so far) is much higher than the cost of providing single use intermittent catheters. Based on these research findings, the Department of Veterans Affairs (VA) and the Centers for Medicare and Medicaid Services (CMS) have eliminated mandatory reuse practices, and now allow for sterile single use catheters for each catheterization.
Reason #4: Intermittent catheters were never made or approved by the FDA for repeated use. They are Single Use Devices (SUDs), and when used repeatedly pose significant risk for infection or product failure, endangering patient health and safety.
Reason #5: Why struggle and fuss with washing, and drying catheters? Individuals with neurogenic bladder and their caregivers should have the quality, freedom and convenience of sterile single use intermittent catheters. Single use intermittent catheters represent the best practices in medicine our healthcare system has to offer.
Reason #6: Individuals who experience infections even with sterile single use catheters should increase their efforts to avoid infection by using catheter kits. They should not give up their efforts to avoid urinary tract infections, and go back to washing and reusing catheters. Medicare provides catheter kits for individuals who experience two distinct documented urinary tract infections in a twelve month period while using sterile intermittent catheters. Catheter kits are sterile insertion supplies containing gloves, antiseptic wipe, drapes, and lubricant. Closed system catheter kits additionally contain a drainage bag.
Additional preventative measure include: thoroughly washing your hands with soap and water before and after each catheterization, ensuring the bladder is completely empty at each catheterization, catheterizing at least 6 times a day, ensuring adequate water and Vitamin C intake, and dietary improvement.