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24.5.13.2 Incontinence Equipment
Incontinence equipment may be considered for reimbursement for clients 4 years of age and older who have a medical condition that results in an inability to ambulate to the bathroom safely (with or without mobility aids).
Urinals and bed pans may be considered for reimbursement without prior authorization for clients who have a documented and/or diagnosed medical condition that results in an inability to ambulate to the bathroom safely (with or without mobility aids). Urinals and bed pans are considered a purchase as a purchase only. Urinals and bed pans that exceed two per year may be considered with prior authorization.
Commode chairs and foot rests will be considered for prior authorization and reimbursement based on the level of need. The client must meet the criteria for the level commode chair or foot rest requested.
Reimbursement may be considered for a commode chair with or without foot rest if the client also has a stationary bath chair without a commode cutout.
Commode Chairs
Commode chairs are limited to one per five years. Documentation must support the medical necessity of a customized commode chair or the addition of attachments to a standard commode chair.
Level 1: Stationary Commode Chair
A stationary commode chair may be considered for reimbursement with prior authorization for clients who have a medical condition that results in an inability to ambulate to the bathroom safely (with or without mobility aids).
Use procedure codes J-E0163 or J-E0165 for stationary or mobile commode chairs.
Level 2: Mobile Commode Chair
A mobile commode chair with fixed or removable arms may be considered for reimbursement for clients who have a documented medical condition that results in an inability to ambulate to the bathroom safely (with or without mobility aids).
A mobile commode chair with fixed or removable arms may be considered for prior authorization and reimbursement when:
• The client has a medical condition that results in the inability to ambulate to the bathroom safely (with or without mobility aids).
•The client must be on a bowel Program and require a combination commode/bath chair for performing the bowel program and bathing after.
•The client does not also have any type of bath chair. If the client meets the criteria for a stationary bath chair, prior authorization of a stationary chair may be considered.
If the client owns a bath chair and has medical necessity for a mobile commode chair, one may be considered through THSteps-CCP for clients under 21 years of age.
Level 3: Custom Commode Chair
A custom stationary or mobile commode chair with fixed or removable arms and head, neck and or trunk support attachments may be considered for prior authorization and reimbursement when:
•The criteria for a Level 1 or 2 commode chair has been met.
•The client must have a medical condition that results in an inability to support their head, neck, and/or trunk without assistance.
•The client does not also have any type of bath chair.
If the client owns a bath chair and has medical necessity for a mobile commode chair, one may be considered through THSteps-CCP for clients under 21 years of age.
Use procedure codes J-E0163 or J-E0165 and modifier TG (custom) when billing for custom stationary or mobile commode chairs.
Use procedure codes J-E0163 or J-E0165 and modifier TF (non-custom mobile) when billing for non-custom mobile commode chairs.
Extra wide/Heavy Duty Commode Chair
An extra wide/heavy-duty commode chair is defined as one with a width greater than or equal to 23 inches and capable of supporting a client who weighs 300 pounds or more.
An extra wide/heavy-duty commode chair will be considered for prior authorization and reimbursement when the client has met the criteria for a Level 1, 2, or 3 commode chair and weigh 300 pounds or more.
Use procedure code J-E0168 and modifiers TF (mobile) or TG (custom) for an extra-wide/heavy-duty commode chair.
Foot Rest
A foot rest is used to support feet during use of commode chair and may be considered for prior authorization and reimbursement when:
•The client has met the criteria for a Level 1, 2, or 3 commode chair.
•The foot rest is necessary to support contractures of the lower extremities; for a client who is paraplegic or quadriplegic.
Use procedure code J-E1399 when billing for a foot rest.
Replacement Commode Pail/Pan
Replacement commode pails or pans may be considered for prior authorization once per year. Additional quantities may be considered for prior authorization with documentation of medical necessity.
Use procedure code J-E0167 when billing for a commode pail or pan.
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