Incontinence Supplies Monthly Limitations
| To: |
Enrolled Durable Medical Equipment and Supplies (DME) Providers and Pharmacies |
| Date: |
May 14, 2014 |
| Re: |
Incontinence Supplies Monthly Limitations |
The attached tables identify, by HCPCS code, the current incontinence products covered by HFS and quantity limits. Combinations of the products in Table 1 have a cumulative quantity limit of 200 per 30-day period. The products in Table 2 may be dispensed in addition to the products listed in Table 1.
As is current policy, whether prior approval is required or not, the quantity of medical supplies will be limited to the amount indicated by the ordering practitioner or to a reasonable quantity for a month, whichever is less. Providers must contact the patient prior to dispensing each item to ensure that the patient continues to want the same provider to serve his or her medical supply needs, and that the patient continues to need the items. The patient's medical eligibility must also be verified prior to dispensing the item.
Any questions regarding this notice may be directed to a DME billing consultant in the Bureau of Provider and Ancillary Services at 1-877-782-5565, option 3, then option 2.
Theresa A. Eagleson, Administrator
Division of Medical Programs
HFS Incontinence Products Covered as of May 1, 2014
A quantity limit of 200 per 30-day period includes the combination of the following incontinence supplies:
Code |
Description |
Age Limit |
T4521 |
Adult sized disposable incontinence product, brief/diaper, small, each |
4-99 Years |
T4522 |
Adult sized disposable incontinence product, brief/diaper, medium, each |
4-99 Years |
T4523 |
Adult sized disposable incontinence product, brief/diaper, large, each |
4-99 Years |
T4524 |
Adult sized disposable incontinence product, brief/diaper, extra large, each |
4-99 Years |
T4525 |
Adult sized disposable incontinence product, protective underwear/pull-on, small size, each |
4-99 Years |
T4526 |
Adult sized disposable incontinence product, protective underwear/pull-on, medium size, each |
4-99 Years |
T4527 |
Adult sized disposable incontinence product, protective underwear/pull-on, large size, each |
4-99 Years |
T4528 |
Adult sized disposable incontinence product, protective underwear/pull-on, extra large size, each |
4-99 Years |
T4529 |
Pediatric sized disposable incontinence product, brief/diaper, small/medium size, each |
4-99 Years |
T4530 |
Pediatric sized disposable incontinence product, brief/diaper, large size, each |
4-99 Years |
T4531 |
Pediatric sized disposable incontinence product, protective underwear/pull-on, small-medium size, each |
4-99 Years |
T4532 |
Pediatric sized disposable incontinence product, protective underwear/pull-on, large size, each |
4-99 Years |
T4533 |
Youth sized disposable incontinence product, brief/diaper, each |
4-99 Years |
T4534 |
Youth sized disposable incontinence product, protective underwear/pull-on, each |
4-99 Years |
T4543 |
Disposable incontinence product, brief/diaper, bariatric, each |
12-99 Years |
The following products may be dispensed in addition to the products listed in the above table:
HCPCS Code |
Description |
Maximum/30 Days |
Age Limit |
T4535 |
Disposable liner/shield/guard/pad/undergarment, for incontinence, each |
120/30 Days |
4-99 Years |
T4541 |
Incontinence product, disposable underpad, large, each |
150/30 Days |
4-99 Years |
