Coated catheters need distinct HCPCS code

Friday, December 20, 2013

In the current HCPCS fee schedule, hydrophilic coated and uncoated intermittent catheters (IC) are lumped together within the same three codes (A4351-52-53). However, due to the distinctly unique coating, the patient, provider and healthcare system would all benefit from the assignment of a separate and distinct hydrophilic coated IC code.

Most recurrent IC users are patients with challenging health conditions, such as SCI, spina bifida and MS, or older adults who have non-neurogenic conditions that require it. Hydrophilic catheters were developed specifically to improve clinical outcomes of patients who rely on IC for a lifetime, reduce complications associated with UTI and enable a high-quality life.

Hydrophilic differs greatly from uncoated by its technologically advanced “slippery” coating—a layer of PVP, salt and PVC polymer bound to the catheter surface—that enables the catheter to become smooth and slippery when hydrated. This results in a near friction-free IC insertion that helps minimize potential UTI contributing factors, such as contamination/introduction of bacteria to bladder through manual application of gel lubricant in a non-sterile environment; catheter related trauma or stricture to the urethra; and non-compliance of physician prescribed IC frequency regimen.

Hydrophilic-coated catheters are also well suited to those with incomplete injury and intact or slightly reduced sensation to IC insertion, who have undergone prostate cancer or other urethral treatments, or reside in a home/facility.

Using indwelling or external condom catheters for drainage can contribute to the risk of damage from catheter related use. In fact, indwelling catheters are by far the largest contributing cause of catheter-related UTI, which can lead to increased risk of death.

Unlike uncoated catheters, which require manually applied gel lubricant that can introduce contamination, hydrophilic all-in-one packaging and ease of self-insertion/removal minimizes patient discomfort. Thus, they are more likely to comply with their physician’s prescribed IC frequency regimen. Another distinguishing benefit to the hydrophilic specialized coating is that it limits exposure to the catheter core, diminishing the risk of developing an allergy to the material. Only hydrophilic has the ability to eliminate this risk.

All of these medical benefits, and more, have been referenced in many studies—the majority supporting that hydrophilic significantly reduces UTI incidents versus uncoated. For example, one evidence-based, randomized study from 2009 showed that only 50% of patients using hydrophilic catheters required antibiotics to treat the first incidence of UTI, versus 70% of those using uncoated. Another study from 2011 showed an impressive 21% UTI reduction rate specifically attributed to patients using hydrophilic.

Unfortunately, despite the proven benefits of hydrophilic catheters over uncoated, a provider’s willingness to offer them is still primarily attributed to manufacturing cost and reimbursement. With the advanced nature of the hydrophilic coating there is a slight up-front increased cost in production. Due to the disproportionate HCPCS fee schedule reimbursement rate to the slightly increased cost, suppliers are reluctant to provide hydrophilic at a loss. Instead they substitute the lesser, uncoated catheters, sacrificing patient benefit and access. In fact, it’s estimated that less than 30% of U.S. urinary IC users have true access to their physician-prescribed hydrophilic coated catheters.

Some private insurance companies and state Medicaid programs (such as California and Texas) do recognize the advanced nature and increased medical benefit of hydrophilic. They contend that despite the slightly increased up-front cost, the long-term savings from reduced future catheter-related UTI medical expenses (i.e. hospitalization, ER visits, home health needs, etc.) greatly outweigh any initial minor additional expense. While they’ve been unable to assign hydrophilic a separate code—due to HIPAA regulations—a slightly higher reimbursement rate has been designated.

In conclusion, the reasons for expanding HCPCS categories and assigning hydrophilic catheters a new code are abundant. Clinical benefits are clear indicators that hydrophilic should be viewed distinctly from uncoated, especially for patients who rely on a lifetime of IC. The significant and documented reduction in UTI and increased patient compliance to prescribed IC regimen—attributed to the use of hydrophilic—has generated improved patient health, longevity and quality of life. Although a few private insurance and state Medicaid programs have worked around the issue by establishing a higher reimbursement rate for hydrophilic, true patient access is still tied to it being incorrectly described as “equal” to uncoated in the current fee schedule. Therefore, by assigning a new code to hydrophilic, providers can bill appropriately for these distinct catheters correctly; patients will receive the medically-necessary supplies their physician intended; and future catheter-related UTI expenses incurred by the healthcare system can be reduced.

William Blank, M.D. received his MD degree from the University of Oklahoma and completed a urology residency in his native New York City. He has been in practice for 28 years. His office is located in Brooklyn, N.Y.