OAR 410-122-0630: Incontinent Supplies

(1) The Division may cover incontinent supplies for urinary or fecal incontinence in accordance with Prioritized List of Health Services Fecal Incontinence Guideline Note and as follows: (a) Category I Incontinent Supplies: For up to 200 units (any code or product combination in this category) per month, unless documentation supports the medical appropriateness for a higher quantity. For quantities over this limit a prior authorization shall be required. When requesting multiple Category I product types (i.e., diapers and liners) that exceed the allowable, prior authorization and documentation as described in (4)(a)(D) of this rule are required; (b) Category II Underpads: (A) Disposable underpads: For up to 100 units (any combination of T4541 and T4542) per month, unless documentation supports the medical appropriateness for a higher quantity, up to a maximum of 150 units per month; (B) Reusable/washable underpads: For up to eight units (any combination of T4537 and T4540) in a 12-month period; (C) Category II Underpads may be separately payable with Category I Incontinent Supplies with documentation that supports medical appropriateness for the use of this product; (D) T4541 and T4542 are not separately payable with T4537 and T4540 for the same dates of service or anticipated coverage period. For example, if a provider bills and is paid for eight reusable/washable underpads on a given date of service, a client would not be eligible for disposable underpads for the subsequent 12 months; (c) Category III Washable Protective Underwear: (A) For up to 12 units in a 12 month period; (B) Category III Washable Protective Underwear is not separately payable with Category I Incontinent Supplies for the same dates of service or anticipated coverage period. For example, if a provider bills and is paid for 12 units of T4536 on a given date of service, a client would not be eligible for Category I Incontinent Supplies for the subsequent 12 months; (d) The following services require PA: (A) A4335 (Incontinence supply; miscellaneous); (B) T4543 (Disposable incontinence product, brief/diaper, bariatric); (C) T4544 (Disposable incontinence product, protective underwear/pull-on); (D) Quantity of supplies greater than the amounts listed in this rule as the maximum monthly utilization (e.g., more than 200 units per month of Category I Incontinent Supplies, or two (2) units per month of gloves). (2) Incontinent supplies are not covered: (a) For nocturnal enuresis; or (b) For children under the age of three (3). (3) A provider may only submit A4335 when there is no definitive Healthcare Common Procedure Coding System (HCPCS) code that meets the product description. (4) Documentation requirements: (a) The client’s medical records shall support the medical appropriateness for the services provided or being requested by the medical equipment, prosthetics, orthotics and supplies (DMEPOS) provider, including, but not limited to: (A) For all categories, the medical reason and condition causing the incontinence; and (B) When a client is using urological or ostomy supplies at the same time as incontinent products specified in this rule, information that clearly corroborates the overall quantity of supplies needed to meet bladder and bowel management is medically appropriate; (C) For all clients not residing in their home subsequent PA requests for incontinence product(s), the provider shall submit a log with the PA request. This log shall be the most recent log for the client documenting the number and frequency of incontinent product changes; (D) PA requests for multiple Category I incontinence product types for the same client (i.e. doubling up) shall be accompanied by adequate explanation from the client’s ordering practitioner to explain why a single, more appropriate, incontinence product cannot be used; (E) Although PA is not required for Category II incontinence products, the DMEPOS provider shall have documentation on file from the prescribing practitioner supporting medical appropriateness; (F) When requesting PA for T4543 (Bariatric Brief/Diaper) or T4544 (Protective underwear/pull-on), submit product information showing that the item is size XXL or larger. The request shall also include client weight and measurements that support the use of the bariatric incontinence product (e.g., client weight, waist and hip size). These items are manually priced following payment methodology outlined in OAR 410-122-0186. (b) For services requiring PA, submit documentation as specified in (4)(a)(A)–(E) and (F); (c) The DMEPOS provider is required to keep supporting documentation on file and make available to the Division on request. (5) Quantity specification: (a) For PA and reimbursement purposes, a unit count for Category I–III codes is considered as a single or individual piece of an item and not as a multiple quantity; (b) If an item quantity is listed as number of boxes, cases or cartons, the total number of individual pieces of that item contained within that respective measurement (box, case or carton) shall be specified in the unit column on the PA request. See table 122-0630-2; (c) For gloves (Category IV Miscellaneous), 100 each (50 pairs) equal one (1) unit. (6) Table 122-0630-1, Incontinent Supplies (7) Table 122-0630-2, Incontinent Supplies — Counting Units and Pieces [ED. 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