Cath changes: Stakeholders anxious about next steps

WASHINGTON – As the PDAC continues to ready its roll-out of new HCPCS codes for certain catheters, the $1 million question for stakeholders is still, what will be in the local coverage determination? 

The PDAC is currently working with manufacturers to determine if their products qualify for one of the new codes (A4295, A4296 and A4297 are brand new, while A4351 and A4352 are revised and A4353 remains unchanged). The PDAC is expected to identify the products that qualify under the new existing codes in October and implement them Jan. 1, 2026. 

“We are, of course, delighted that CMS is recognizing the benefits of a hydrophilic coating,” said Jacqueline Smith, senior manager of public affairs for Coloplast. “There's (still) another step required for Medicare and other insurances down the line to ensure (providers) can bill for and receive payment for the catheters for hydrophilic with these new codes.” 

AAHomecare recently created a landing page with information and resources for the new codes, including links to the PDAC Hydrophilic Intermittent Urinary Catheter Crosswalk, and a primer on the new HCPCS codes in PowerPoint format for providers to use to present information on the new codes to payers.  

While providers say they are always careful to get proper documentation, the changes to the cath codes are sweeping enough to raise the specter of big changes to existing coverage guidelines, they say. 

“The main thing they are focusing on now are the hypdrophilics, but where are the diagnostic requirements going to fall,” said Gayle Devin, CEO of Home Care Delivered. “What additional medical criteria and documentation will be required? I mean we're getting documentation up front for all of our catheters now, but I'm wondering how they're going to differentiate any requirements for the different catheter codes.” 

CMS in May 2024 proposed the coding changes in response to a request from AAHomecare and its manufacturer members, which, together, comprise the Intermittent Catheter Coding Reform Coalition. They originally requested 16 new codes, saying the changes were needed to better reflect current technology. 

“Incontinence is not a one-size-fits-all philosophy and I do think (the new codes) will help us get a little more specific to meeting the patient's needs,” said Devin. 

• Related: Catheter proposal is huge step forward.