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December 2016 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 : 2.2.13 Incontinence Supplies : Diaper Wipes
For clients who are 4 years of age and older and are receiving diapers/briefs/pull-ons, up to 2 boxes of diaper wipes do not require prior authorization. Exceptions will not be considered through Title XIX Home Health Services. Quantities in excess of 2 boxes per month may be considered through CCP for clients who are 20 years of age and younger with documentation of medical necessity and prior authorization.
Providers must use procedure code A4335 with modifier U9 instead of procedure code A5120 when billing for diaper wipes.
If there is not an appropriate procedure code for supplies, providers may request prior authorization using procedure code A4335.

Texas Medicaid & Healthcare Partnership
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