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December 2016 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 2 Medicaid Children’s Services Comprehensive Care Program (CCP) : 2.6 Durable Medical Equipment (DME) Supplier (CCP) : 2.6.9 Incontinence Supplies

2.6.9
2.6.9.1
Incontinence supplies, such as diapers, briefs, pull-ons, liners, wipes, and underpads, may be considered for reimbursement through CCP for those clients who are birth through 3 years of age with a medical condition resulting in an increased urine or stool output beyond the typical output for this age group, such as celiac disease, short bowel syndrome, Crohn’s disease, thymic hypoplasia, Acquired Immunodeficiency Syndrome (AIDS), congenital adrenal hyperplasia, diabetes insipidus, Hirschsprung’s disease, or radiation enteritis.
For clients who are 4 years of age and older, incontinence supplies may be considered through Title XIX Home Health Services when their medical condition results in an impairment of urination and/or stool. For clients who do not meet criteria through Title XIX Home Health Services, incontinence supplies may be considered through CCP with documentation of medical necessity.
Lack of bladder or bowel control is considered normal development for clients who are 4 years of age or younger.
Reusable diapers, briefs, pull-ons, liners, wipes, and underpads are not a benefit of CCP. Gloves used to change diapers, briefs, and pull-ons are not considered medically necessary unless the client has skin breakdown or a documented disease that may be transmitted through the urine.
2.6.9.1.1
Skin sealants, protectants, moisturizers, and ointments may be considered for clients with documented incontinence associated dermatitis.
Note:
Skin sealants, protectants, moisturizers, and ointments for diagnoses other than incontinence-associated dermatitis (e.g., wounds, decubitus ulcers, periwound skin complications, peristomal skin complications) may be considered for prior authorization through home health services wound care supplies and systems.
Incontinence-associated dermatitis is classified using the following categories:
Category 1. A small area of skin breakdown (less than 20 cm2) with mild redness (blotchy and non-uniform) and mild erosion involving the epidermis only.
Category 2. A moderate area of skin breakdown (20 cm2 through 50 cm2) with moderate redness (severe in spots, but not uniform in appearance) and moderate erosion involving epidermis and dermis with no or little exudate.
Category 3. A large area of skin breakdown (greater than 50 cm2) with severe redness (uniformly severe in appearance) and severe erosion of epidermis with moderate involvement of the dermis and no or small volume of exudate.
Category 4. A large area of skin breakdown (greater than 50 cm2) with severe redness (uniformly severe in appearance) and extreme erosion of epidermis and dermis with moderate volume of persistent exudate.
The category of incontinence-based dermatitis determines the benefit limitation and whether to use a modifier when submitting a claim for procedure code A6250, as shown in the following table:
 
Dermatitis Category
Up to 2 containers (no less than 4 ounces per container) of skin sealants, protectants, moisturizers, and ointments per month.
2.6.9.1.2
The following procedure codes must be used when billing for diapers, briefs, and liners and are limited to a combined total of 240 per month:
 
2.6.9.1.3
Diaper wipes may be considered for clients who are receiving diapers, briefs, or pull-ons through CCP.
Providers must use procedure code A4335 and modifier U9 when billing for diaper wipes. Procedure code A4335 is limited to 2 boxes per month.
2.6.9.1.4
Underpads may be considered for clients who are receiving diapers, briefs, or pull-ons through CCP.
Providers must use procedure code A4554 when billing for underpads. Procedure code A4554 is limited to 120 per month.
2.6.9.1.5
External urinary collection devices, including, but not limited to, male external catheters, female collection devices, and related supplies may be considered with a documented medical condition resulting in an increased urine or stool output beyond the typical output.
The following procedure codes must be used when billing for external urinary collection devices:
 

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