Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 122 - DURABLE MEDICAL EQUIPMENT, PROSTHETIC ORTHOTICS AND SUPPLIES (DMEPOS) › Section 410-122-0560 - Urological Supplies

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Indications
			 and Limitations of Coverage and Medical Appropriateness:
(a) The Division may cover the following
			 urinary catheters, external urinary collection devices, and medically
			 appropriate related supplies when used to drain or collect urine for a client
			 who has permanent urinary incontinence or permanent urinary
			 retention;
(b) Indwelling Catheters
			 (A4311-A4316, A4338-A4346):
(A) No more than
			 one catheter per month for routine catheter maintenance;
(B) Non-routine catheter changes when
			 documentation substantiates medical appropriateness, such as for the following
			 indications:
(i) Catheter is accidentally
			 removed (e.g., pulled out by client);
(ii) Catheter malfunctions (e.g., balloon
			 does not stay inflated, hole in catheter);
(iii) Catheter is obstructed by encrustation,
			 mucous plug, or blood clot;
(iv)
			 History of recurrent obstruction or urinary tract infection for which it has
			 been established that an acute event is prevented by a scheduled change
			 frequency of more than once per month;
(C) A specialty indwelling catheter (A4340)
			 or an all silicone catheter (A4344, A4312, or A4315) when documentation in the
			 client's medical record supports the medical appropriateness for that catheter
			 rather than a straight Foley type catheter with coating (such as recurrent
			 encrustation, inability to pass a straight catheter, or sensitivity to
			 latex);
(D) A three way indwelling
			 catheter either alone (A4346) or with other components (A4313 or A4316) only if
			 continuous catheter irrigation is medically appropriate;
(c) Catheter Insertion Tray (A4310-A4316,
			 A4353, and A4354):
(A) Only one insertion tray
			 per episode of indwelling catheter insertion;
(B) One intermittent catheter with insertion
			 supplies (A4353) per episode of medically appropriate sterile intermittent
			 catheterization;
(d)
			 Urinary Drainage Collection System (A4314-A4316, A4354, A4357, A4358, A5102,
			 and A5112):
(A) For routine changes of the
			 urinary drainage collection system as noted in Table 122-0560-1;
(B) Additional charges for medically
			 appropriate non-routine changes when the documentation substantiates the
			 medical appropriateness (e.g., obstruction, sludging, clotting of blood, or
			 chronic, recurrent urinary tract infection);
(C) A vinyl leg bag (A4358) or a latex leg
			 bag (A5112) only for clients who are ambulatory or are chair or wheelchair
			 bound;
(e) Intermittent
			 Irrigation of Indwelling Catheters:
(A)
			 Supplies for the intermittent irrigation of an indwelling catheter when they
			 are used on an as needed (non-routine) basis in the presence of acute
			 obstruction of the catheter;
(B)
			 Routine intermittent irrigations of a catheter are not covered;
(C) Routine irrigations are defined as those
			 performed at predetermined intervals;
(D) Covered supplies for medically
			 appropriate non-routine irrigation of a catheter include either an irrigation
			 tray (A4320) or an irrigation syringe (A4322), and sterile water/saline
			 (A4217);
(f) Continuous
			 Irrigation of Indwelling Catheters:
(A)
			 Supplies for continuous irrigation of a catheter when there is a history of
			 obstruction of the catheter and the patency of the catheter cannot be
			 maintained by intermittent irrigation in conjunction with medically appropriate
			 catheter changes;
(B) Continuous
			 irrigation as a primary preventative measure (i.e., no history of obstruction)
			 is not covered;
(C) Documentation
			 must substantiate the medical appropriateness of catheter irrigation and in
			 particular continuous irrigation as opposed to intermittent
			 irrigation;
(D) The records must
			 also indicate the rate of solution administration and the duration of
			 need;
(E) Covered supplies for
			 medically appropriate continuous bladder irrigation include a three-way Foley
			 catheter (A4313, A4316, and A4346), irrigation tubing set (A4355), and sterile
			 water/saline (A4217):
(i) The Division may
			 cover one irrigation tubing set per day for continuous catheter
			 irrigation;
(ii) Continuous
			 irrigation is considered a temporary measure and may only be covered for up to
			 14 days;
(g)
			 Intermittent Catheterization: Intermittent catheter supplies when basic
			 coverage criteria are met and the client or caregiver can perform the
			 procedure:
(A) For each episode of covered
			 catheterization, one catheter (A4351, A4352) and an individual packet of
			 lubricant (A4332); or
(B) One
			 sterile intermittent catheter kit (A4353) when the client requires
			 catheterization and meets one of the following criteria (i-iv):
(i) The client is immunosuppressed. Examples
			 of immunosuppressed clients include (but are not limited) clients who are:
(I) On a regimen of immunosuppressive drugs
			 post-transplant;
(II) On cancer
			 chemotherapy;
(III) Has
			 AIDS;
(IV) Has a drug-induced state
			 such as chronic oral corticosteroid use;
(ii) The client has radiologically documented
			 vesico-ureteral reflux while on a program of intermittent
			 catheterization;
(iii) The client
			 is a pregnant, spinal cord-injured female with neurogenic bladder (for duration
			 of pregnancy only);
(iv) The client
			 has had distinct, recurrent urinary tract infections, while on a program of
			 sterile intermittent catheterization with A4351/A4352 and sterile lubricant
			 (A4332), twice within the 12 month period prior to the initiation of sterile
			 intermittent catheter kits. A urinary tract infection means a urine culture
			 with greater than 10,000 colony forming units of a urinary pathogen; and
			 documentation in the client's medical records of concurrent presence of one or
			 more of the following signs, symptoms or laboratory findings:
(I) Fever (oral temperature greater than
			 38° C [100.4° F]);
(II)
			 Systemic leukocytosis;
(III) Change
			 in urinary urgency, frequency, or incontinence;
(IV) Appearance of new or increase in
			 autonomic dysreflexia (sweating, bradycardia, blood pressure
			 elevation);
(V) Physical signs of
			 prostatitis, epididymitis, orchitis;
(VI) Increased muscle spasms;
(VII) Pyuria (greater than five white blood
			 cells [WBCs] per high-powered field);
(C) The kit code (A4353) must be used for
			 billing even if the components are packaged separately rather than together as
			 a kit;
(h) Coude
			 (Curved) Tip Catheters:
(A) Use of a Coude
			 (curved) tip catheter (A4352) in female clients is rarely medically
			 appropriate;
(B) For any client,
			 when a Coude tip catheter is dispensed and billed, there must be specific
			 documentation in the client's medical record why a Coude tip catheter is
			 required rather than a straight tip catheter;
(i) External Catheters/Urinary Collection
			 Devices:
(A) Male external catheters
			 (condom-type) or female external urinary collection devices for clients who
			 have permanent urinary incontinence when used as an alternative to an
			 indwelling catheter;
(B) Coverage
			 for male external catheters (A4349) is limited to 35 per month;
(C) Greater utilization of these devices must
			 be accompanied by documentation of medical appropriateness;
(D) Male external catheters (condom-type) or
			 female external urinary collection devices are not covered for clients who also
			 use an indwelling catheter;
(E) The
			 Division may cover specialty type male external catheters such as those that
			 inflate or that include a faceplate (A4326) or extended wear catheter systems
			 (A4348) only when documentation substantiates the medical appropriateness for
			 such a catheter;
(F) Coverage of
			 female external urinary collection devices is limited to one metal cup (A4327)
			 per week or one pouch (A4328) per day;
(j) Miscellaneous Supplies:
(A) Appliance cleaner (A5131): One unit of
			 service (16 oz) per month when used to clean the inside of certain urinary
			 collecting appliances (A5102, A5105, A5112);
(B) One external urethral clamp or
			 compression device (A4356) every three months or sooner if the rubber/foam
			 casing deteriorates;
(C) Adhesive
			 catheter anchoring devices (A4333, three per week) and catheter leg straps
			 (A4334, one per month) for indwelling urethral catheters;
(D) A catheter/tube anchoring device (A5200)
			 separately payable when it is used to anchor a covered suprapubic tube or
			 nephrostomy tube;
(E) Non-Sterile
			 Gloves - The Division will not pay for more than 200 pairs of non-sterile
			 gloves (A4927) per month;
(k) The following services are not covered:
(A) Creams, salves, lotions, barriers
			 (liquid, spray, wipes, powder, paste) or other skin care products
			 (A6250);
(B) Catheter care kits
			 (A9270);
(C) Adhesive remover
			 (A4456, A4455);
(D) Catheter clamp
			 or plug (A9270);
(E) Disposable
			 underpads, all sizes, diapers or incontinence garments, any type, disposable or
			 reusable unless authorized under 410-122-0630  Incontinent Supplies;
(F) Drainage bag holder or stand
			 (A9270);
(G) Urinary suspensory
			 without leg bag (A4359);
(H)
			 Measuring container (A9270);
(I)
			 Urinary drainage tray (A9270);
(J)
			 Gauze pads (A6216-A6218) and other dressings;
(K) Other incontinence products not directly
			 related to the use of a covered urinary catheter or external urinary collection
			 device (A9270);
(L) Irrigation
			 supplies that are used for care of the skin or perineum of incontinent
			 clients;
(M) Syringes, trays,
			 sterile saline, or water used for routine irrigation;
(N) Disposable external urethral clamp or
			 compression device, with pad and/or pouch, each.