Ohio Admin. Code 5160-10-32 - DMEPOS: ostomy supplies and urological supplies
(A)
Stoma maintenance supplies.
(1)
Stoma maintenance
supplies may be dispensed on a monthly basis.
(2)
If more than one
type of supply serve the same function, then payment may be made only for the
dispensing of one type at a time (e.g., skin barrier applied as a liquid, in a
spray, or with a wipe or swab; drainage management with a stoma cap, a stoma
plug, or gauze pads).
(B)
Urination
aids.
(1)
Indwelling catheters.
(a)
Frequency limits
imposed on catheter replacement may be exceeded without prior authorization
(PA) for any of the following reasons:
(i)
Accidental
removal of a catheter;
(ii)
Malfunction of a catheter;
(iii)
Obstruction of
a catheter by encrustation, mucus plug, or blood clot; or
(iv)
A history of
recurrent obstruction or infection, as a precaution against which the
prescriber has specified more frequent changing of the
catheter.
(b)
Additi following items:onal documentation of medical
necessity is needed for either of the
(i)
A specialty
indwelling catheter or all-silicone catheter used in lieu of a standard coated
Foley catheter; or
(ii)
A three-way indwelling catheter used either alone or
with other components.
(c)
Payment will not
be made for more than one insertion tray per episode of indwelling catheter
insertion.
(2)
Supplies for intermittent irrigation of indwelling
catheters.
(a)
Payment may be made for either an irrigation tray or an
irrigation syringe used on an as-needed basis to clear an obstruction from an
indwelling catheter by irrigation.
(b)
Payment may be
made for sterile water or saline solution for irrigation. No additional payment
is made if the irrigation solution contains acetic acid or hydrogen peroxide.
No payment is made for an irrigation solution containing antibiotics or
chemotherapeutic agents.
(c)
No payment is made for supplies used for the irrigation
of an indwelling catheter at predetermined intervals (routine
irrigation).
(3)
Supplies for continuous irrigation of indwelling
catheters.
(a)
Payment may be made for an irrigation tubing set, as well as
for a three-way Foley catheter, if there is a history of catheter obstruction
and catheter patency cannot be maintained by intermittent irrigation and
necessary changing of the catheter. Payment will not be made for more than one
irrigation tubing set per day.
(b)
Payment may be
made for sterile water or saline solution for irrigation. No additional payment
is made if the irrigation solution contains acetic acid or hydrogen peroxide.
No payment is made for an irrigation solution containing antibiotics or
chemotherapeutic agents.
(c)
No payment is made for supplies if continuous
irrigation is used as a preventive measure.
(d)
Additional
documentation is needed to establish the medical necessity of continuous
irrigation used instead of intermittent irrigation. This documentation must
indicate the rate of administration and the duration of need.
(e)
Additional
documentation is needed to establish the medical necessity of continuous
irrigation lasting more than two weeks.
(4)
Intermittent
catheters and related supplies.
(a)
Payment may be made for a sterile intermittent catheter
and related supplies (or a catheter kit) only if at least one of the following
additional criteria is met:
(i)
The individual is immunosuppressed;
(ii)
The individual
has neurogenic bladder dysfunction because of a spinal cord injury or defect
and is currently pregnant;
(iii)
The individual
currently performs intermittent catheterization but has documented
vesicoureteral reflux; or
(iv)
The individual
currently performs sterile intermittent catheterization and had at least two
distinct urinary tract infections in the year before starting sterile
intermittent catheterization.
(b)
Payment will not
be made for more than one kit containing an intermittent catheter with
insertion supplies per episode of intermittent catheterization.
(c)
Additional documentation is needed to establish the medical
necessity of a coudé catheter used instead of a straight catheter. The
use of a coudé catheter by a female is rarely necessary.
(5)
External urinary collection devices.
(a)
Payent may be
made for a medically necessary external urinary collection device (e.g., a
condom-style catheter for a male, a meatal cup or a pouch for a female) as an
alternative to an indwelling catheter for an individual who has permanent
urinary incontinence.
(b)
Payment will not be made for the concurrent dispensing
of both an external urinary collection device and an indwelling catheter.
(c)
Additional documentation is needed to establish the medical
necessity of a specialty external urinary collection device (e.g., an
inflatable condom-style catheter, a pouch with a faceplate).
(d)
Payment will not
be made for more than one meatal cup per week or one pouch per day.
(6)
Urinary drainage systems.
(a)
Payment may be
made for the routine changing of a urinary drainage system.
(b)
Payment will not
be made for the concurrent dispensing of a vinyl and a latex bag.
(c)
Payment will not be made for leg bags for individuals who do
not leave their bed.
(d)
Payment will not be made for more than one type of leg
bag or leg bag strap within a twelve-month period.
(7)
Miscellaneous
supplies.
(a)
Payment may be made for cleaner for a urinary collection device or drainage
system only if the individual is using the collection device or drainage
system.
(b)
Payment may be made for a medically necessary adhesive
anchoring device used to secure an indwelling urethral catheter, a suprapubic
catheter, or a nephrostomy tube.
(c)
Payment may be
made for a medically necessary leg strap used to secure an indwelling urethral
catheter.
Replaces: 5160-10-32
Notes
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 08/17/2009, 08/02/2011
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