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