Part 1 — Navigating Insurance Coverage for Intermittent Catheter Supplies

It can be a challenge to understand insurance coverage for your intermittent catheter supplies. Once you understand the basics, you’ll have a better chance of getting these supplies covered or reimbursed.

Learn essential insurance information about catheters.

If you use intermittent catheters, it is important to understand how your insurance plan works in order to get your supplies covered or reimbursed. It’s common to use multiple intermittent catheters each day, which can end up being a lot for you to pay out of your own pocket. To increase your chances of getting your claims approved by your insurance plan, you’ll need to learn how healthcare insurance works, what your various options are, and other vital information.

Understanding HCPCS codes for intermittent catheter supplies

Before looking at your various insurance options (see part two of this article), it’s important to understand how your insurer – whether it’s Medicare, Medicaid, or a private insurance company – categorizes or “codes” intermittent catheter claims in order to process them consistently.

The system that insurers use to categorize different types of healthcare expenses is called the Healthcare Procedure Coding System, or HCPCS. HCPCS codes are assigned to medical services and supplies so they can be identified quickly, which expedites the claim process. Within each reimbursement category or code, there are also product options.

For intermittent catheters, three HCPCS codes apply:

1. A4351: This code is for an intermittent catheter with a straight tip, and with or without coating (i.e., Teflon, silicone, silicone elastomeric, or hydrophilic)
2. A4352: This HCPCS code is for an intermittent catheter with a coudé (curved) tip, and with or without coating (i.e., Teflon, silicone, silicone elastomeric, or hydrophilic)
3. A4353: This code is for an intermittent catheter kit with supplies needed for a single, sterile insertion

Rules for the A4353 code (intermittent catheter kits)

While HCPCS codes A4351 and A4352 are relatively straightforward, HCPCS code A4353 stipulates certain product options and can be used only if any of the following is included in the intermittent catheter kit:

• A single sterile package containing both an intermittent catheter and all necessary insertion/collection supplies
• A sterile intermittent catheter plus a separately packaged sterile kit containing all necessary insertion/collection supplies
• A sterile “no-touch” intermittent catheter system, which is an all-inclusive, self-contained product for sterile intermittent catheterization with its own collection chamber and without additional supplies

Medicare A4353 guidelines for qualifying for a “no-touch” intermittent catheter system

Has your healthcare team recommended that you use a “no-touch” intermittent catheter for ease of use and protection against bacteria? If Medicare is your primary source of healthcare insurance, it’s important to know the criteria for coverage.

There are five ways to qualify for Medicare coverage of “no-touch” intermittent catheters under the A4353 HCPCS code. You need to meet at least one of these criteria:

1. You reside in a nursing home
2. You are immunosuppressed. Some examples (not all-inclusive) include: you’re on a regimen of immunosuppressive drugs post-transplant, you’re undergoing cancer chemotherapy, you have AIDS, or you have a drug-induced state (such as chronic oral corticosteroid use).
3. You have radiologically-documented vesico-ureteral reflux (an abnormal flow of urine from the bladder) while on a program of intermittent catheterization
4. You are a female with a spinal cord injury and neurogenic bladder who is pregnant (usage for the duration of the pregnancy only)
5. You have had distinct, recurrent urinary tract infections (UTIs), while on a program of sterile intermittent catheterization (HCPCS codes A4351/A4352) and sterile lubricant (code A4332), twice within a 12-month period before the initiation of sterile intermittent catheter kits

For many people with a spinal cord injury, the last criteria may be the most relevant to Medicare covering your “no-touch” intermittent catheter insurance claim. However, it’s critical to understand how Medicare defines a UTI.

First, your physician must diagnose and document the UTI as having a urine culture greater than 10,000 colony-forming units of a urinary pathogen. In addition, your physician must document one or more of these signs and symptoms of a UTI:

Choosing the right intermittent catheter with the right coverage

The good news is that you have a range of intermittent catheter product choices within the three HCPCS codes. So, it’s important to work with your healthcare team to find the best intermittent catheter for you that may be covered by your insurance.

This article is part 1 of a 2-part series. Now that you’ve learned about the HCPCS codes related to intermittent catheters, be sure to read part 2, which focuses on your various insurance options for coverage or reimbursement. You can also visit our intermittent catheter reimbursement page for more information.

Prior to the use of an intermittent catheter, be sure to read the Instructions for Use for information regarding Intended Use, Contraindications, Warnings, Precautions and Instructions.

And don’t forget that Hollister Secure Start Services is always available to help you navigate the insurance market. Based on your insurance plan, our Consumer Service Advisors can explain your options and answer your questions.