PHYSICIAN ORDERS—CATHETERS

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Fax: (800) 638-0294

PATIENT INFORMATION

PATIENT NAME: DOB: SSN:

PATIENT PHONE NUMBER: (____) ____ -________ ALT PHONE NUMBER: (____) ____ -________

PLAN OF CARE

 Retention of Urine (788.20/R33.9)  Urinary Incontinence (788.30/R32)

 Incomplete Bladder Emptying (788.21/R39.14)  Urge Incontinence (788.31/N39.41)

 Other Specified Retention of Urine (78829/R33.8)  Other Diagnosis

Does Patient Have Permanent Urinary Incontinence or Retention?  Yes  No

(Note: Permanency is defined a s a condition that is expected to last greater than 90 days)

Do any of the following conditions apply?  Two UTIs/12 months  Immunosuppressed  BPH  Stricture
Spina Bifida Paraplegia Quadriplegia

Number of Refills (Length of Need) 99 (Lifetime) 12 (one year) Other _______________

Brand: hi-slip (Hydrophilic) Cure Medical Bard Coloplast Other ____________

Catheter Supplies Qty to Dispense Frequency Size

 Straight Tip Catheter  with  Hydrophilic per
(A4351) lubricant __________ month _______time(s) ______Fr
per day
 Coudé Catheter  with  Hydrophylic per
(A4352) lubricant __________ month _______time(s) ______Fr
per day
 Closed System Catheter Kit Straight  Hydrophilic per
(A4353) Coudé __________ month _______time(s) ______Fr
per day
 90 Day Supply Authorized: Patient may receive up to a 90 day supply at patient’s own choosing. Quantity to dispense will be three times the
monthly amount.

I certify that I am the treating physician identified on this form. I have received and completed the sections of this Prescription/Detailed Written Order (DWO). Any statement on my
letterhead, attached hereto, has been reviewed and signed by me. I certify that the medical necessity information is true, accurate and complete, to the best of my knowledge, and I certify
that any falsification, omission, or concealment of material fact may subject me to civil or criminal liability.

Physician Signature (No Stamps) NPI # Order Date (Required)

Physician Name: Office Name:

Office Address: Phone:
City, State, ZIP: Fax:

Phone: (844) 205-CATH (2284) Fax: (800) 638-0294 www.abcplus.net

 ICD – 9 ICD – 10 Diagnosis ICD – 9 ICD – 10 Diagnosis
Code Code Description Code Code Description
340 G35 Multiple sclerosis 788.33 N39.46 Mixed incontinence (urge & stress)
female & male
344.0 G82.5 Quadriplegia 788.34 N39.42 Incontinence without sensory
awareness
344.1 G82.2 Paraplegia 788.35 N39.43 Post-void dribbling
344.6 G83.4 Cauda equina syndrome 788.36 N39.44 Nocturnal enuresis
344.61 G83.4 Cauda equina syndrome with 788.37 N39.45 Continuous leakage
neurogenic bladder
564.81 K59.2 Neurogenic bowel 788.38 N39.490 Overflow incontinence
595.1 N30.1 Chronic interstitial cystitis 788.39 N39.49 Other urinary incontinence
596.0 N32.0 Bladder neck obstruction 788.41 R35.0 Urinary frequency
596.4 N31.2 Atony of bladder 788.43 R35.1 Nocturia
596.54 N31.9 Neurogenic bladder 788.62 R9.12 Slowing of urinary stream
598 N35 Urethral stricture 788.63 R39.15 Urgency of urination
599.0 N39.0 Urinary tract infection 625.6 Stress incontinence, female
788.32 N39.3 Stress incontinence, male
599.60 N13.8 Urinary obstruction, unspecified V44.2 Z93.2 Ileostomy status
600.0 N40 Hypertrophy (benign) of prostate V44.3 Z93.3 Colostomy status
741 Q05 Spina bifida V44.52 Z93.52 Appendicovesicostomy (Mitrofanoff)
741.0 Q05.4 Spina bifida with hydrocephalus V44.6 Z93.6 Other artificial opening of urinary tract
status
741.9 Q05.8 Spina bifida without hydrocephalus V55.2 Z43.2 Attention to ileostomy
753.5 Q64.1 Exstrophy of urinary bladder V55.3 Z43.3 Attention to colostomy
753.6 Q64.3 Atresia and stenosis of urethra and V55.6 Z43.6 Attention to other artificial opening of
bladder neck urinary tract
788.1 R30.0 Dysuria 591. N13.30 Hydronephrosis
788.20 R33.9 Retention of urine, unspecified 596.51 N32.81 Hypertonicity of bladder
788.21 R39.14 Incomplete bladder emptying 600.01 N40.1 Hypertrophy (benign) of prostate with
urinary obstruction
788.29 R33.8 Other specified retention of urine 600.21 N40.1 Benign localized hyperplasia of prostate
with urinary obstruction
788.30 R32 Urinary incontinence, unspecified 788.69 N39.19 Other abnormality of urination, other
788.31 N39.41 Urge incontinence V43.5 Z96.0 Bladder replaced by other means

Documentation Requirements for Medicare Patients

Medicare requires that certain documentation be documented in the patient’s chart/record in order for Medicare to reimburse for
catheters. Medicare also highly recommends these documents be collected and maintained by the provider of supplies. These
requirements include:

History of urological condition to include:

 Permanency: Medicare defines permanency as a condition that is expected to last greater than 90 days
 Diagnosis: Urological diagnosis
 Frequency: Frequency the patient is instructed to catheterize

Note: If patient requires a coudé catheter, additional documentation is required stating the reason patient is unable to
pass/use a straight catheter.

Reference: the requirements listed above can be referenced by referring to LCD for Urological Supplies (L11566). The above information is
provided for reference only and is not intended as advice or instruction on how to complete a patient’s plan of care.

Phone: (844) 205-CATH (2284) Fax: (800) 638-0294 www.abcplus.net