Skip To: Main content|Subnavigation|
Minnesota Department of Human Services Provider Manual
Advanced Search|  

Incontinence Products

Revised: 09-09-2016

  • Overview
  • Eligible Providers
  • Eligible Recipients
  • Covered Services
  • Noncovered Services
  • Authorization
  • Billing and Documentation
  • Overview

    Disposable incontinence products are a covered service for eligible recipients who meet criteria for medical necessity.

    Eligible Providers

    Prescribing Providers

    Dispensing Providers

    Clinical Nurse Specialist

    Federally Qualified Health Centers

    Nurse Midwife

    Home Health Agency

    Nurse Practitioner

    Hospital

    Physician

    Indian Health Services

    Physician Assistant

    Medical Suppliers

     

    Rural Health Clinic

     

    Pharmacies


    Eligible Recipients

    Eligible recipients may receive a specified quantity of incontinence products with the proper diagnosis and documentation of medical necessity.

    Covered Services

    Products and services covered are disposable briefs or diapers, protective underwear or pull-on liner, shield, guard, pad, undergarment, underpad, and diaper service for reusable diaper.

    HCPCS Codes: T4521–T4535, T4541–T4544
    MHCP has one reimbursement rate per HCPCS code. Any pediatric or youth sized product and any liner, shield, guard, pad, undergarment, and underpad may be covered. Adult-sized disposable briefs, diapers and protective underwear or pull-on are only covered if they are listed on the MHCP Incontinence Product List (PDF).

    Coverage Criteria
    The recipient must have a diagnosis of an underlying medical condition that involves loss of bladder or bowel control to be eligible for covered incontinence products. Some incontinence products have specific criteria as follows:

    • For protective underwear or pull-on, the recipient must be ambulatory or toilet training. These products are appropriate for people who have light or infrequent incontinence or who are toilet training.

    • Underpads may be appropriate for other diagnosis not related to incontinence, such as wounds with heavy fluid excretion.

    Follow Table 1 and Table 2 for information about quantity limits and possible product combinations. The limits shown are calendar month limits. Authorization is required for quantities above these limits.

    Table 1

    Incontinence products and quantity limits

    Code

    Product

    Quantity Limit

    T4521

    adult brief/diaper, small

    300

    units per calendar month

    T4522

    adult brief/diaper, medium

    300

    units per calendar month

    T4523

    adult brief/diaper, large

    300

    units per calendar month

    T4524

    adult brief/diaper, extra large

    300

    units per calendar month

    T4543

    adult brief/diaper, above extra large

    300

    units per calendar month

    T4529

    pediatric brief/diaper, small/medium

    300

    units per calendar month

    T4530

    pediatric brief/diaper, large

    300

    units per calendar month

    T4533

    youth brief/diaper

    300

    units per calendar month

    T4525

    adult protective underwear/pull-on, small

    150

    units per calendar month

    T4526

    adult protective underwear/pull-on, medium

    150

    units per calendar month

    T4527

    adult protective underwear/pull-on, large

    150

    units per calendar month

    T4528

    adult protective underwear/pull-on, extra large

    150

    units per calendar month

    T4544

    adult protective underwear/pull-on, above extra large

    150

    units per calendar month

    T4531

    pediatric protective underwear/pull-on, small/medium

    150

    units per calendar month

    T4532

    pediatric protective underwear/pull-on, large

    150

    units per calendar month

    T4534

    youth protective underwear/pull-on

    150

    units per calendar month

    T4535

    liner/shield/guard/pad/undergarment

    300

    units per calendar month

    T4538

    diaper service, reusable diaper

    300

    units per calendar month

    T4541

    underpad, large

    200

    units per calendar month

    T4542

    underpad, small

    200

    units per calendar month

    Note: These limits apply when billing for one code per calendar month only. When billing for more than one code per calendar month, see Table 2.

    Table 2

    Incontinence products and quantity limits when used in combination

    Code

    Products and Combination Options

    Quantity Limit

    T4521–T4524, T4529, T4530, T4533, T4535, T4538, T4543

    Any combination of the following: brief, diaper, liner, shield, guard, pad, undergarment and reusable diaper

    300

    units per calendar month

    T4525–T4528, T4531, T4532, T4534, T4535, T4544

    any combination of the following: protective underwear, pull-on, liner, shield, guard, pad, undergarment

    150

    units per calendar month

    T4521–T4524, T4529, T4530, T4533, T4543

    Brief or diaper limit when used with protective underwear or pull-on

    60

    units per calendar month

    T4541, T4542

    any combination of underpads when not using other incontinence products

    200

    units per calendar month

    T4541, T4542

    any combination of underpads when using other incontinence products

    60

    units per calendar month

    Noncovered Services

    The following products and services are not covered. This list is not all-inclusive:

  • • Bed wetting alarms
  • • Disposable wipes and washcloths
  • • Reusable bed or chair pads
  • • Reusable incontinence undergarments, including pants to wear with disposable pads
  • • Disposable diapers, briefs, underwear or pull-on for children under age 4 when authorization has not been obtained
  • • Disposable adult-sized briefs, diapers, protective underwear, or pull-ons that are not on the MHCP Incontinence Products List
  • • Purchase of cloth diapers (recipients with services through the following waivers may contact their case managers if purchase of cloth diapers is needed: CAC, CADI, EW and BI waivers)
  • Authorization

    Authorization is required for the following:

  • • Briefs, diapers, protective underwear, or pull-ons for recipients under age 4. Documentation must include a medical condition or diagnosis of excessive urine or fecal output requiring more than 10 briefs or diapers per day.
  • • Quantities of incontinence products that exceed MHCP limits as shown in Table 1 and Table 2.
  • Quantities that exceed the MHCP limits may be authorized for recipients with medical conditions that cause frequent urination or defecation or who have experienced skin breakdown when using the maximum quantity of appropriate product. Submit documentation regarding the recipient’s medical condition or diagnosis, type of incontinence, other incontinence products the recipient is using, any skin breakdown issues, and whether the product is appropriate for the recipient’s needs. Refer to the Documentation for Excess Quantities of Incontinence Products (PDF) for guidance.
  • Submit authorization requests and required documentation to the Authorization Medical Review Agent.

    Billing and Documentation

    Refer to the following information for billing and documentation:

  • • Follow standard documentation policy for proof of delivery
  • • A new physician’s order is required annually for incontinence products for children under aged 16
  • • A new physician’s order is required one year after the initial order for incontinence products and every five years thereafter for recipients aged 16 and over
  • • Bill one unit per item (per brief, diaper, protective underwear, or pull-on, etc.)
  • • The submitted charge should be the usual and customary charge inclusive of all applicable shipping costs and sales taxes
  • • Shipping costs are not separately billable
  • • Claims must have the name of the manufacturer and product name or product code in the service line notes field
  • • Dispense and bill only a one-month supply unless the quantity limit requires opening a case. When the quantity limit requires opening a case, the provider may choose to ship the case and bill over two or more months if the cost of shipping the case is less than the cost of shipping the exact amount for two or more months. When using this alternative billing method, the provider assumes the risk of claim nonpayment if the recipient’s status changes and prevents MHCP payment for incontinence products. Status changes that may prevent payment include loss of eligibility, admission to a nursing facility, death, or other situations.
  • • Bill services approved through the authorization process on a separate claim from services not requiring authorization. Example: Submit one claim (no authorization required) for the number of units up to the quantity limit. Submit another claim with the prior authorization for the additional quantity dispensed over the quantity limit.
  • • Providers may choose to supply upgraded products but can only charge MHCP for the non-upgraded item. Use the GL modifier as described in the Provider Initiated Upgrades policy.
  • Medicare or other third party liability (TPL): Medicare does not cover incontinence products. Most other TPL policies do not cover incontinence products. Bill directly to MHCP unless the TPL is known to cover incontinence products. Verify TPL coverage of incontinence products annually.

    Rate/Report this page Report/Rate this page

    © 2017 Minnesota Department of Human Services
    Minnesota.gov is led by MN.IT Services
    Updated: 3/17/17 12:48 PM | Accessibility | Terms/Policy | Contact DHS | Top of Page | Updated: 3/17/17 12:48 PM