24.5.13.1 Incontinence SuppliesSkin sealants, protectants, moisturizers, and ointments for clients 4 years of age and older may be considered for reimbursement with prior authorization for clients who have a medical condition that results in chronic incontinence and increased risk of skin breakdown. Skin sealants, protectants, moisturizers and ointments are limited to a maximum of two per month for clients four years of age and older. Prior authorization for clients younger than 4 years of age must be obtained through THSteps-CCP. Note: Diapers and briefs are defined as incontinence items attached with tabs. Protective underwear and pull-ons are defined as incontinence items that do not attach with tabs and are slip-on items. Liners are intended to be worn inside diapers, briefs, and pull-ons to increase absorbency. For clients four years of age and older with a medical condition that results in chronic incontinence, diapers, briefs, protective underwear, pull-ons, and liners may be considered for reimbursement without prior authorization up to a total combination of 300 per month. Amounts beyond 300 per month may be considered for reimbursement when prior authorized. A combination of diapers, briefs, and liners may be considered for reimbursement. A total accumulation of one or more of the following products is limited to a maximum of 300 per month: diapers, briefs, pull-ons, and liners. Amounts beyond 300 per month require prior authorization. Reusable diapers/briefs are not a benefit of Home Health Services. Note: Gloves used to change diapers and briefs (including pull-ups) are not considered medically necessary unless the client has skin breakdown or a documented disease that may be transmitted through the urine or stool. Diaper wipes (9-A4335), other than urinary skin cleansing products, may be considered for reimbursement without prior authorization for clients who are 4 years of age and older and are also receiving diapers/briefs/pull-ons. Diaper wipes, other than urinary skin cleansing products, are limited to a maximum of two boxes per month. Exceptions will not be considered through Home Health Services. Additional quantities may be considered through THSteps-CCP for clients who are younger than 21 years of age with documentation of medical necessity and prior authorization. Note: Providers are to bill procedure code 9-A4335 instead of procedure code 9-A5120 when providing diaper wipes. Inappropriate billing of 9-A5120 will cause the procedure to deny. Underpads may be considered for reimbursement without prior authorization for clients who also receive diapers/briefs, urine collection devices, or bowel management supplies. Underpads are limited to a maximum of 150 per month without prior authorization. Amounts greater than 150 per month may be considered for prior authorization with documentation of medical necessity. Reusable underpads are not a benefit of Home Health Services. Note: The Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form for the supplies listed above must reflect a one month's supply of the incontinence product. More than the maximum allowed amount should not be on the Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form without prior authorization, unless it has been prior authorized. Ostomy supplies may be considered for reimbursement without prior authorization. The physician must specify the type of ostomy device/system to be used and how often it is to be changed on the Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form without prior authorization. The quantity of ostomy supplies billed for a one-month period should relate to the number of changes per month based on the frequency ordered by the physician. Urine Collection Devices. The home setting is considered a clean environment, not a sterile one. Sterile incontinence supplies, including gloves, will not be reimbursed in the home setting except when requested by a physician familiar with the client for the following:
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• Note: Nonsterile gloves may be considered for reimbursement with prior authorization when a family member or friend is performing the catheterization. Nonsterile/sterile gloves for use by a health-care provider in the home setting, such as an RN, LVN, or attendant, are not a benefit of Home Health Services. Indwelling catheters and related insertion supplies may be considered for reimbursement without prior authorization for clients who have a documented medical condition that results in a permanent impairment of urination. Indwelling catheters and related supplies are limited to a maximum of two per month. More than two indwelling catheters and related insertion supplies per month requires prior authorization. The physician must indicate on the Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form how often the client is required to change their indwelling catheter. Intermittent catheters and related insertion supplies may be considered for reimbursement for those who have a documented medical condition that results in a permanent impairment of urination. Intermittent catheters and related supplies are limited to a maximum of 120 per month. More than 120 intermittent catheters and related insertion supplies requires prior authorization. The physician must indicate on the Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form how often the client is required to perform intermittent catheterization. Use procedure codes 9-A4351, and/or 9-A4352 when billing for intermittent catheters. Use procedure code 9-A4353 when billing for Intermittent catheters with insertion supplies. When billing these codes for intermittent hydrophilic catheters use the SC modifier. External urinary collection devices for clients 4 years of age and older, such as male external catheters and female collection devices, and related supplies may be considered for reimbursement without prior authorization for clients who have a documented and/or diagnosed medical condition that results in a permanent impairment of urination. Male external catheters are limited to 31 per month. Female collection devices may be considered for reimbursement without prior authorization for a maximum of four per month. Prior authorization is required for medically necessary services beyond the limits listed in the Incontinence Procedures and Limitations table. The physician must indicate on the Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form how often the client is required to change their external urinary collection device. External urinary collection devices for clients younger than 4 years of age require prior authorization through THSteps-CCP. Documentation of a medical condition that results in an increased urine and/or stool output beyond the typical output for this age group is required for reimbursement consideration. |
Indwelling urinary catheters.
