The Centers for Medicare & Medicaid Services (CMS) will discuss coding changes for intermittent urinary catheters at its May 28 First Biannual 2024 Healthcare Common Procedure Coding System (HCPSCS) Public Meeting.
Catheters are the first home medical equipment (HME) item on the May 28 agenda. The coding meeting will run from May 28 through May 30.
In a May 6 bulletin, the American Association for Homecare (AAHomecare) said it had submitted a proposal to expand the current HCPCS codes list after analyzing and reviewing it with the Intermittent Catheter Coding Reform Coalition (ICCRC), an association of intermittent catheter manufacturers.
“CMS proposes to modify the current three IC [intermittent catheter] HCPCS codes to six HCPCS codes — establishing five new IC codes to distinguish the coating types and discontinuing existing codes that do not distinguish coating types, A4351 and A4352,” AAHomecare said in its announcement. “CMS will maintain A4353 as is. CMS also plans to maintain pricing continuity as per regulatory requirements when implementing the new codes. This would entail mapping previous fee schedule amounts for discontinued codes to the new ones to ensure consistent pricing.
“ICCRC is pleased that CMS has established new HCPCS codes for intermittent catheters, recognizing hydrophilic features separately from other catchers. AAHomecare, in collaboration with ICCRC, will be commenting on the proposed changes.”
What the HME industry requested
In its meeting agenda, CMS said it had received a “request to discontinue three existing HCPCS Level II codes: A4351, Intermittent urinary catheter; straight tip, with or without coating (Teflon, silicone, silicone elastomer, or hydrophilic, etc.), each; A4352, Intermittent urinary catheter, coude (curved) tip, with or without coating (Teflon, silicone, silicone elastomeric, or hydrophilic, etc.), each; and
A4353, Intermittent urinary catheter, with insertion supplies.”
The initial request also asked CMS to establish 19 new HCPCS codes.
“The wide variation in functionality between products currently classified under HCPCS Level II codes A4351, A4352, and A4353 creates a lack of transparency, which may result in patients receiving the least
expensive intermittent urinary catheter or supply. However, this catheter or supply may not
meet the patient’s clinical needs to consistently perform successful self-catheterization,” CMS said in quoting the AAHomecare/ICCRC request.
The request also said that because of current codes’ failure to “accurately reflect the different features and functionalities of various intermittent urinary catheters, payers other than the Medicare program have been forced to implement a variety of coding ‘workarounds’ in order to better identify and separately reimburse for catheters with different features.
“This conflicts with the federal requirement and purpose of the uniform code set that CMS has been charged with overseeing for the benefit of all payers, not just the Medicare program.”
CMS provides preliminary coding recommendations
In response, CMS said it contracted with the Health Federally Funded Research and Development Center, operated by MITRE Corp., “to conduct an environmental scan and inform our clinical understanding of the use of intermittent urinary catheters.”
The resulting report said, “There is good evidence that, for some patients, hydrophilic catheters may reduce the incidence of urinary tract infection.” But the report also said, “For most of the potential codes considered (from the applicant’s request), there is a lack of evidence to support performance differentiation when compared to current catheter codes.”
CMS added that HCPCS coding “is not a barrier to writing an accurate prescription or for revising a
prescription for urinary catheters. However, suppliers do have latitude in what is supplied unless the prescribing physician includes a ‘dispense as written’ notation on the written order. Physicians hesitate to take this step since doing may result in increased costs for patients who may not have sufficient insurance to fully cover the cost of the ordered supplies.
“From its systematic review, MITRE concluded that the evidence base is insufficient to determine that all coatings impact health outcomes, but there was evidence supporting that hydrophilic coating may influence health outcomes.”
CMS added that MITRE “did not observe significant workarounds by payers in regard to extensive use of modifiers to differentiate what types of catheters were covered and paid, in a way that was otherwise distinct from HCPCS Level II codes.”
Based on MITRE’s findings, CMS said, the agency “believes that clinical evidence and current payer policies would support HCPCS Level II codes to identify hydrophilic coatings.”
What CMS is proposing
At the May 28 meeting, CMS will discuss the following recommendations:
— Establish a new HCPCS Level II code AXXXX, Intermittent urinary catheter; straight tip, with or without coating (Teflon, silicone, silicone elastomer, etc.), each;
— Establish a new HCPCS Level II code AXXXX, Intermittent urinary catheter; coude (curved) tip, with or without coating (Teflon, silicone, silicone elastomeric, etc.), each;
— Establish a new HCPCS Level II code AXXXX, Intermittent urinary catheter; straight tip, hydrophilic coating, each;
— Establish a new HCPCS Level II code AXXXX, Intermittent urinary catheter; coude (curved) tip, hydrophilic coating, each;
— Establish a new HCPCS Level II code AXXXX, Intermittent urinary catheter; hydrophilic coating, with insertion supplies;
— Discontinue existing HCPCS Level II code A4351, Intermittent urinary catheter; straight tip, with or without coating (Teflon, silicone, silicone elastomer, or hydrophilic, etc.), each;
— Discontinue existing HCPCS Level II code A4352, Intermittent urinary catheter; coude (curved) tip, with or without coating (Teflon, silicone, silicone elastomeric, or hydrophilic, etc.), each.
Because the code changes “would likely necessitate updating long-established coverage policies and/or payment instructions across nearly every payer,” CMS also suggested an implementation date of Jan. 1, 2026. A final determination would be expected “at a date later than our anticipated July/August 2024 timeframe for this cycle,” the agency added.
View the May 28 agenda for information on joining the Zoom meeting.
