OAR 410-122-0630
Incontinent Supplies

(1)

The Division of Medical Assistance Programs (Division) may cover incontinent supplies for urinary or fecal incontinence as follows:

(a)

Category I Incontinent Supplies: For up to 200 units (any code or product combination in this category) per month, unless documentation supports the medical appropriateness for a higher quantity. For quantities over this limit a prior authorization shall be required. When requesting multiple Category I product types (i.e., diapers and liners) that exceed the allowable, prior authorization and documentation as described in (4)(a)(D) of this rule are required;

(b)

Category II Underpads:

(A)

Disposable underpads: For up to 100 units (any combination of T4541 and T4542) per month, unless documentation supports the medical appropriateness for a higher quantity, up to a maximum of 150 units per month;

(B)

Reusable/washable underpads: For up to eight units (any combination of T4537 and T4540) in a 12 month period;

(C)

Category II Underpads may be separately payable with Category I Incontinent Supplies with documentation that supports medical appropriateness for the use of this product;

(D)

T4541 and T4542 are not separately payable with T4537 and T4540 for the same dates of service or anticipated coverage period. For example, if a provider bills and is paid for eight reusable/washable underpads on a given date of service, a client would not be eligible for disposable underpads for the subsequent 12 months;

(c)

Category III Washable Protective Underwear:

(A)

For up to 12 units in a 12 month period;

(B)

Category III Washable Protective Underwear is not separately payable with Category I Incontinent Supplies for the same dates of service or anticipated coverage period. For example, if a provider bills and is paid for 12 units of T4536 on a given date of service, a client would not be eligible for Category I Incontinent Supplies for the subsequent 12 months;

(d)

The following services require PA:

(A)

A4335 (Incontinence supply; miscellaneous);

(B)

T4543 (Disposable incontinence product, brief/diaper, bariatric);

(C)

T4544 (Disposable incontinence product, protective underwear/pull-on);

(D)

Quantity of supplies greater than the amounts listed in this rule as the maximum monthly utilization (e.g., more than 200 units per month of Category I Incontinent Supplies, or 100 gloves per month).

(2)

Incontinent supplies are not covered:

(a)

For nocturnal enuresis; or

(b)

For children under the age of three.

(3)

A provider may only submit A4335 when there is no definitive Healthcare Common Procedure Coding System (HCPCS) code that meets the product description.

(4)

Documentation requirements:

(a)

The client’s medical records shall support the medical appropriateness for the services provided or being requested by the medical equipment, prosthetics, orthotics and supplies (DMEPOS) provider, including, but not limited to:

(A)

For all categories, the medical reason and condition causing the incontinence; and

(B)

When a client is using urological or ostomy supplies at the same time as incontinent products specified in this rule, information that clearly corroborates the overall quantity of supplies needed to meet bladder and bowel management is medically appropriate;

(C)

For all clients not residing in their home subsequent PA requests for incontinence product(s), the provider shall submit a log with the PA request. This log shall be the most recent log for the client documenting the number and frequency of incontinent product changes;

(D)

PA requests for multiple Category I incontinence product types for the same client (i.e. doubling up) shall be accompanied by adequate explanation from the client’s ordering practitioner to explain why a single, more appropriate, incontinence product cannot be used;

(E)

Although PA is not required for Category II incontinence products, the DMEPOS provider shall have documentation on file from the prescribing practitioner supporting medical appropriateness;

(F)

When requesting PA for T4543 (Bariatric Brief/Diaper) or T4544 (Protective underwear/pull-on), submit product information showing that the item is size XXL or larger. The request shall also include client weight and measurements that support the use of the bariatric incontinence product (e.g., client weight, waist and hip size). These items are manually priced following payment methodology outlined in OAR 410-122-0186 (Payment Methodology).

(b)

For services requiring PA, submit documentation as specified in (4)(a)(A)–(E) and (F);

(c)

The DMEPOS provider is required to keep supporting documentation on file and make available to the Division on request.

(5)

Quantity specification:

(a)

For PA and reimbursement purposes, a unit count for Category I–III codes is considered as a single or individual piece of an item and not as a multiple quantity;

(b)

If an item quantity is listed as number of boxes, cases or cartons, the total number of individual pieces of that item contained within that respective measurement (box, case or carton) shall be specified in the unit column on the PA request. See table 122-0630-2;

(c)

For gloves (Category IV Miscellaneous), 100 gloves equal one unit.

(6)

Table 122-0630-1, Incontinent Supplies

(7)

Table 122-0630-2, Incontinent Supplies — Counting Units and Pieces
[ED. NOTE: Tables referenced are available from the agency.]
[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

Source: Rule 410-122-0630 — Incontinent Supplies, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=410-122-0630.

410–122–0010
Definitions 410–122–0020
Orders 410–122–0040
Prior Authorization 410–122–0080
Conditions of Coverage, Limitations, and Restrictions 410–122–0090
Face-to-Face Encounter Requirements (for Fee-For-Service Clients) 410–122–0180
Healthcare Common Procedure Coding System Level II Coding 410–122–0182
Legend 410–122–0184
Repairs, Servicing, Replacement, Delivery, and Dispensing 410–122–0186
Payment Methodology 410–122–0188
DMEPOS Rebate Agreements 410–122–0200
Pulse Oximeter for Home Use 410–122–0202
Positive Airway Pressure (PAP) Devices for Adult Obstructive Sleep Apnea 410–122–0203
Oxygen and Oxygen Equipment 410–122–0204
Nebulizer 410–122–0205
Respiratory Assist Devices 410–122–0206
Intermittent Positive Pressure Breathing 410–122–0207
Respiratory Supplies 410–122–0208
Suction Pumps 410–122–0209
Tracheostomy Care Supplies 410–122–0210
Ventilators 410–122–0211
Cough Stimulating Device 410–122–0220
Pacemaker Monitor 410–122–0240
Apnea Monitors for Infants 410–122–0250
Breast Pumps 410–122–0260
Home Uterine Monitoring 410–122–0280
Heating/Cooling Accessories 410–122–0300
Light Therapy 410–122–0320
Manual Wheelchair Base 410–122–0325
Power Wheelchair Base 410–122–0330
Power-Operated Vehicle 410–122–0340
Wheelchair Options/Accessories 410–122–0360
Canes and Crutches 410–122–0365
Standing and Positioning Aids 410–122–0375
Walkers 410–122–0380
Hospital Beds 410–122–0400
Pressure Reducing Support Surfaces 410–122–0420
Hospital Bed Accessories 410–122–0475
Therapeutic Shoes for Diabetics 410–122–0510
Osteogenesis Stimulator 410–122–0515
Neuromuscular Electrical Stimulator (NMES) 410–122–0520
Glucose Monitors and Diabetic Supplies 410–122–0525
External Insulin Infusion Pump 410–122–0540
Ostomy Supplies 410–122–0560
Urological Supplies 410–122–0580
Bath Supplies 410–122–0590
Patient Lifts 410–122–0600
Toilet Supplies 410–122–0620
Miscellaneous Supplies 410–122–0625
Surgical Dressing 410–122–0630
Incontinent Supplies 410–122–0640
Eye Prostheses 410–122–0655
External Breast Prostheses 410–122–0658
Gradient Compression Stockings/Sleeves 410–122–0660
Orthotics and Prosthetics 410–122–0662
Ankle-Foot Orthoses and Knee-Ankle-Foot Orthoses 410–122–0678
Dynamic Adjustable Extension/Flexion Device 410–122–0680
Facial Prostheses 410–122–0700
Negative Pressure Wound Therapy Pumps 410–122–0720
Pediatric Wheelchairs
Last Updated

Jun. 8, 2021

Rule 410-122-0630’s source at or​.us