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43.4.5.10 Incontinence Supplies for Clients Younger Than 4 Years of Age
Incontinence supplies, such as diapers/briefs/liners, wipes, and underpads, may be considered for reimbursement through THSteps-CCP for those clients younger than 4 years of age with a medical condition resulting in an increased urine and/or stool output beyond the typical output for this age group, such as celiac disease, short bowel syndrome, Crohn's disease, thymic hypoplasia, AIDS, congenital adrenal hyperplasia, diabetes insipidus, Hirschsprung's disease, or radiation enteritis.
Lack of bladder and/or bowel control is considered normal development up to 4 years of age.
Prior authorization is required for incontinence supplies through THSteps-CCP. A completed THSteps-CCP Prior Authorization Request Form prescribing the supplies must be signed and dated by the prescribing physician familiar with the client before requesting prior authorization. All signatures and dates must be current, unaltered, original, and handwritten. Computerized or stamped signatures and dates will not be accepted. The completed THSteps-CCP Prior Authorization Request Form must be maintained by the DME provider and the prescribing physician in the client's medical record.
Note: Prior authorization is a condition for reimbursement, not a guarantee of payment.
To facilitate a determination of medical necessity and avoid unnecessary denials, the physician must provide correct and complete information, including accurate documentation of the medical necessity of the supplies requested.
To request prior authorization for incontinence supplies, the following documentation must be provided for the item(s) requested:
• Accurate diagnostic information pertaining to the underlying diagnosis/condition as well as any other medical diagnoses/conditions, to include the client's overall health status.
•Diagnosis/condition causing increased urination/stooling.
•Client height, weight, and waist size.
•Number of times per day the physician has ordered the supply be used.
•Quantity of disposable supplies requested per month
A determination is made by HHSC or its designee as to the number of incontinence supplies prior authorized based on the client's medical needs.
A combination of diapers, briefs, and liners may be considered for authorization for clients younger than 4 years of age and are limited to 300 per month.
Note: Procedure codes identified with (*) in the table below indicate those considered in the combination of 300 per month. Requests for services exceeding the amounts listed must be submitted with documentation of medical necessity.
Providers must use the following procedure codes when billing for incontinence supplies for clients younger than 4 years of age:
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