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    BCG instillation: Why you can’t get reimbursed for catheters

    Payment for all supplies is bundled into the procedure code or facility fee

    Ray Painter, MDRay Painter, MD Mark PainterMark Painter


    I am coding a bacillus Calmette–Guérin instillation. While I know I cannot bill for the cathed urinalysis or the insertion of the indwelling catheter, can we bill for the catheter trays or catheters used to do the procedure? Medicare and durable medical equipment do pay for some instances when the patient wears the catheter home.

    Unfortunately, the answer is no. The payment for all supplies is bundled into the procedure code when billed in the office and in the facility fee when billed in the ambulatory surgery center or hospital setting. Medicare only pays for catheters for home use when a medical condition is permanent (or long-lasting–over 3 months) and a plan of care prescribed by a doctor indicates the need for the catheter, including the frequency of catheterizations, for certain specific conditions such as retention of urine or urinary incontinence.


    Can you tell me how to code and bill for pentosan polysulfate sodium (Elmiron) used for interstitial cystitis treatment? I can’t find a code for the actual drug. Our urologist said the code may also include heparin and bupivacaine (Marcaine).

    You are correct; Elmiron does not have a code. It is an oral pain medication used in the treatment of interstitial cystitis. Normally, it is covered by Medicare Part D and Medicare Part C plans for self-administration per oral route. The drug does have a National Drug Code (NDC) and some have reported J3490 (Unclassified drugs). We have not seen much success in getting payment for this drug as it is considered self administered as an oral drug.

    Also by the Painters: CMS releases pay, Quality Payment Program rules

    Likewise, Marcaine is difficult from a reimbursement perspective as it is typically not covered by Medicare. We have seen two separate codes used to report Marcaine: J3490 (Unclassified drugs) or S0020 (Injection, bupivicaine hydrochloride, 30 mL), which is the correct code within the Healthcare Common Procedure Coding System. S codes are typically not covered by Medicare but may be paid by some private payers. Heparin has two J codes and should be reported based on the amount used during the instillation: J1642 (Injection, heparin sodium [Heparin Lock Flush], per 10 units) or J1644 (Injection, heparin sodium, per 1000 units).

    Next: "As with any drug, you will need to report appropriate NDCs and watch coverage policies regarding purchase of the drugs."

    Ray Painter, MD
    Urologist Ray Painter, MD, is president of Physician Reimbursement Systems, Inc., in Denver, and is also publisher of Urology Coding and ...
    Mark Painter
    Mark Painter is CEO of PRS Urology SC in Denver.


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