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2012 Texas Medicaid Provider Procedures Manual

Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook : 2. Texas Medicaid (Title XIX) Home Health Services : 2.2 Services, Benefits, Limitations and Prior Authorization : 2.2.12 Incontinence Supplies : 2.2.12.6 Indwelling or Intermittent Urine Collection Devices

2.2.12.6
The home setting is considered a clean environment, not a sterile one. Sterile incontinence supplies, (including the supplies in procedure codes A4311, A4312, A4313, A4314, A4315, A4316, and A4353) are a benefit in the home setting when requested for the following:
Have a history of distinct, recurrent urinary tract infections, defined as a minimum of two within the prior 12‑month period, while on a program of clean intermittent catheterization
Nonsterile or sterile gloves for use by a health-care provider in the home setting, such as a registered nurse (RN), licensed vocational nurse (LVN), or attendant, are not a benefit of Home Health Services.
2.2.12.6.1 Indwelling Catheters and Related Insertion Supplies
Indwelling catheters and related supplies may be considered without prior authorization up to a maximum of 2 per month for clients who have a medical condition that results in an impairment of urination. Quantities in excess of 2 per month may be considered with documentation of medical necessity and prior authorization.
2.2.12.6.2 Intermittent Catheters and Related Insertion Supplies
Intermittent catheters and related supplies, up to a maximum of 150 per month, may be considered without prior authorization for clients who have a medical condition that results in an impairment of urination. Quantities in excess of 150 per month may be considered with documentation of medical necessity and prior authorization.
A completed Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form may be valid for up to 12 months for intermittent catheters and related insertion supplies for quantities within the stated benefit limits for clients who have one of the following chronic conditions:
For clients who have a diagnoses other than those listed in the above table, the completed Title XIX Form may be valid for up to six months for intermittent catheters and related insertion supplies for quantities within the stated benefit limits.
Note:
For quantities greater than the stated benefit limits, prior authorization will be required and may be granted for up to six months regardless of diagnosis.
Nonsterile gloves are a benefit with prior authorization when a family member or friend is performing the catheterization.
Providers must use procedure codes A4351 or A4352 when billing for intermittent catheters. Providers must use procedure code A4353 when billing for intermittent catheters with insertion supplies. When billing these codes for intermittent hydrophilic catheters, providers must use the SC modifier.
2.2.12.6.3 External Urinary Collection Devices
For clients who are 4 years of age and older and have a medical condition that results in a permanent impairment of urination, external urinary collection devices, including, but not limited to, male external catheters, female collection devices, and related supplies may be considered without prior authorization. Male external catheters are limited to 31 per month. Female collection devices are limited to 4 per month. Male external catheters in excess of 31 per month and female collection devices in excess of 4 per month may be considered with documentation of medical necessity and prior authorization.
2.2.12.6.4 Urinals and Bed Pans
Urinals and bed pans may be considered without 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) up to a limit of 2 per year. Quantities in excess of 2 per year may be considered with documentation of medical necessity and prior authorization.
Urinals and bed pans are purchase only.

Texas Medicaid & Healthcare Partnership
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