Incontinence Products

Revised: September 30, 2024

· Overview

· Eligible Providers

· Eligible Members

· Covered Services

· Noncovered Services

· Authorization

· Billing and Documentation

Overview

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

Refer to Minnesota Health Care Programs (MHCP) Requirements for Incontinence Products (DHS-3811) (PDF) for more information.

Eligible Providers

The following providers may prescribe incontinence products:

· Clinical nurse specialist

· Nurse midwife

· Nurse practitioner

· Physician

· Physician assistant

The following providers may dispense incontinence products:

· Federally qualified health center

· Home health agency

· Hospital

· Indian Health Services

· Medical supplier

· Rural health clinic

· Pharmacy

Eligible Members

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

Covered Services

Products and services covered include disposable:

· briefs

· diapers

· protective underwear

· liners

· shields

· guards

· pads

· belted undergarments

· underpads

HCPCS Codes: T4521–T4535, T4541–T4544
Any youth or pediatric-sized product and any underpad can be covered when medically necessary.

Adult-sized disposable briefs, diapers, protective underwear, pull-ons, liners, shields, guards and pads are covered if they are listed on the MHCP incontinence products lists by HCPCS or by manufacturer located on the Equipment and supplies resources webpage.

Coverage Criteria
The member 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:

· The member must be toilet training or have light or infrequent incontinence for protective underwear or pull-ons.

· Underpads for adults and children under the age of 4 may be appropriate for other diagnoses not related to incontinence such as wounds with heavy fluid exudate (Limit 100 per calendar month unless prior authorization is obtained)

Quantity limits for disposable briefs, diapers, underwear, pull-ons, liners, shields, guards, pads and garments (HCPCS T4521-T4535, T4543-T4544) are up to 400 units per product or combination of products per calendar month before authorization is required. Product combinations more than one size apart are not permitted. Liners, shields, guards, and pads have different absorbency levels. Refer to the MHCP incontinence products lists by HCPCS or by manufacturer located on the Equipment and supplies resources webpage.

Quantity limits for underpads (T4541-T4542) are up to 100 units per calendar month before authorization is required.

Noncovered Services

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

· Bed-wetting alarms

· Disposable wipes and washcloths

· Reusable underpads

· Reusable incontinence undergarments including pants to wear with disposable pads

· Disposable briefs or diapers for children younger than 4 years old who use fewer than 300 units per calendar month

· Disposable protective underwear or pull-ons, and disposable liners, shields, guards, pads, or undergarments for children younger than 4 years old

· Disposable adult-sized briefs, diapers, protective underwear, pull-ons, liners, shields, guards, pads, or undergarments that are not on the MHCP incontinence products lists by HCPCS or manufacturer when authorization has not been obtained

· Purchase of cloth diapers or use of a diaper service for cloth diapers

· Swim diapers

Authorization

When authorization is required, the claim must match HCPCS code, modifiers and product code as noted on the authorization letter.

Authorization is required for the following:

Disposable briefs or diapers for members under 4 years old

· Documentation must include a medical condition or diagnosis of excessive urine or fecal output requiring more than 10 briefs or diapers per day.

· The first 300 units per calendar month are the guardian’s responsibility. MHCP will authorize only the quantity that exceeds 300 per calendar month .

Quantities of incontinence products that exceed MHCP limits

· Quantities that exceed the MHCP limits may be authorized for members with medical conditions that cause frequent urination or defecation, or who have experienced skin breakdown or infection when using the maximum quantity of appropriate product.

· All requests for authorization must include documentation regarding the member’s medical condition or diagnosis, type of incontinence, other incontinence products the member is using, any skin breakdown or infection issues, and an explanation that the products are appropriate for the member’s needs.

· If the member is using a combination of products, documentation must show all quantities of all products required.

· Authorization requests for excess quantities must use modifier 76 to avoid denial as a duplicate claim if billed on the same day as nonauthorized products. Modifier 76 must be on the authorization request as well as the claim.

Nonlisted incontinence products

· Products that are not on the MHCP incontinence products lists by HCPCS or manufacturer may be authorized for members who have experienced skin breakdown, allergic reaction, infection or other medical complication when using listed products.

· All requests for authorization must demonstrate trial and failure of all listed products in the appropriate size and category, or a medical contraindication to each listed product.

Requests for authorization must include the appropriate HCPCS code, modifiers, and product codes. Submit authorization requests and required documentation to the medical supply authorization Review Agent.

Billing and Documentation

Providers are responsible to coordinate services. Review MHCP Billing Policy for general billing requirements and guidance when submitting claims.

Bill incontinence products using MN–ITS 837P. Refer to the Billing for Durable Medical Equipment, Medical Supplies, Prosthetics and Orthotics, and Augmentative Devices MN–ITS user guide for instructions.

Refer to the following information for billing and documentation:

· Follow standard documentation policy for proof of delivery. Refer to Proof of Delivery under Documentation in the Equipment and Supplies section of the MHCP Provider Manual.

· A new physician’s order is required annually.

· The submitted charge should be the usual and customary charge inclusive of all applicable shipping costs and sales taxes.

· Dispense and bill only a one-month supply.

· 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.

· Bill one unit per item (per brief, diaper, protective underwear, or pull-on, and the like) using the appropriate HCPCS code, product code, and modifiers.

· Bill T4535 using the following modifiers:

· NU and U1 for products designed for light incontinence,

· NU and U2 for products designed for moderate incontinence, and

· NU and U3 for products designed for heavy incontinence.

· Claim lines for adult-sized disposable briefs or diapers, disposable protective underwear or pull-ons, disposable liners, shields, guards, pads and undergarments and disposable underpads must have a product code from the MHCP incontinence products lists by HCPCS or manufacturer. Claim lines without a product code that matches the MHCP incontinence products lists by HCPCS or manufacturer will be denied unless authorized.

· Shipping costs are not separately billable

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.