Incontinence Supplies: T4521-T4524, T4529-T4530, T4533,T4543

• Provider Manual: https://www.hsd.state.nm.us/wp-content/uploads/FileLinks/db231204433241998f49d260c6129473/8.324.5.pdf
• Clinician registration confirmation:
• Eligibility lookup portal: https://nmmedicaid.portal.conduent.com/static/providerlogin.htm
• Prior Auth Portal: https://comaginepp.zeomega.com/cms/ProviderPortal/Controller/providerLogin

Incontinence Diapers/Briefs (T4521-T4524, T4529-T4530, T4533,T4543)

• A Generic CMN or prescription from prescriber is needed
• Billed per Diaper with limitations of 200 diapers/pull ups or 150 underpads (combined up to 200 items) for ages 3+
• Cannot provide both diapers and pull-ups
• Prescription must contain quantity, order date, patient name, description of items, diagnosis, length of need, ordering practitioner name or NPI, and signature.
• CMN/Rx form is valid for 12 months
• Documentation must include neurological disorders, neuromuscular disorders, diseases associated with incontinence.
• Must document the need for incontinence
• Must document resupply call requirements
• Confirm patient does not have more than a 15-day supply when resupplying

Underwear/Pullups (T4525-T4528, T4531-T4532,T4534, T4544)

• Generic CMN or prescription needed
• Billed per Pullup with limitations of 200 diapers/pull ups or 150 underpads (combined up to 200 items) for ages 3+
• Prescription must contain: patient name, description of items, quantity, diagnosis, length of need, practitioner name or NPI, signature, order date
• CMN/Rx is valid for 12 months
• Chart notes required, including neurological or neuromuscular disorders or diseases associated with incontinence, documenting the need for incontinence, and resupply call requirements
• Confirm patient does not have more than a 15-day supply when resupplying

Underpads, Disposable (A4554)

• Billed per Underpad limited to 200 diapers/pull ups or 150 underpads (combined up to 200 items) Ages 3+
• A Generic CMN or prescription from prescriber is needed
• Prescription from prescriber must contain name, description of items, quantity, diagnosis, length of need, practitioner name or NPI, signature and order date
• CMN/Rx is valid for 12 months
• Chart notes should include the diagnosis of: neurological or neuromuscular disorders or diseases associated with incontinence
• Resupply call requirements must be documented. Confirm that the patient does not have in excess of a 15 day supply.

Barrier Cream (A6250UA)

• Billed per Tube
• Documentation of Skin Breakdown or urine transmitted disease.

Urological Intermittent Cath Kits (A4353)

• 200 per month.
• Generic CMN or prescription needed.
• Prescription must contain: patient name, description of items, quantity, diagnosis, length of need, practitioner name or NPI, signature, order date.
• The CMN/Rx form is valid for 12 months.
• Patient must have urinary incontinence/retention, be immunosuppressed, have radiologically documented vesico-ureteral reflux, or be pregnant with a neurogenic bladder due to spinal cord injury and have a history of distinct, recurrent urinary tract infections, defined as 2 infections or more within the prior 12 months.
• Must document resupply call requirements

Intermittent Catheters, Straight Tip (A4351)

• Must document resupply call requirements
• 200 per month.
• Generic CMN or prescription needed.
• Prescription must contain: patient name, description of items, quantity, diagnosis, length of need, practitioner name or NPI, signature, order date.
• The CMN/Rx form is valid for 12 months.
• Patient must have urinary incontinence/retention, and must document need and quantity.

Intermittent Catheters, Coude Tip (A4352)

• Quantity is 200 per month.
• Either Generic CMN or Practitioner prescription
• The prescription should contain: Patient name, Description of items, Quantity, Diagnosis, Length of Need, Ordering practitioner name or NPI, Signature, and Order Date.
• The CMN/ Rx form is valid for 12 Months
• Must have Urinary Incontinence or Retention and documented need and quantity.
• Must document resupply call requirements.

External Catheters (A4349)

• Quantity is 35
• Documentation of Urinary Incontinence or Retention, Documented need, Quantity.
• Either Generic CMN or Practitioner prescription
• The prescription should contain: Patient name, Description of items, Quantity, Diagnosis, Length of Need, Ordering practitioner name or NPI, Signature, and Order Date.
• The CMN/ Rx form is valid for 12 Months
• Must document resupply call requirements

Foley Catheters (A4338, A4340, A4344)

• Quantity 1 per month
• Patient has Urinary Incontinence Diagnosis or Retention
• Must have documented need
• Generic CMN or a prescription is needed
• All information must be included that is: Patient name, Description of items, Quantity, Diagnosis, Length of Need, Ordering practitioner name or NPI, Signature, Order Date.
• The CMN/Rx form is valid for 12 months.
• Must document resupply call requirements

Insertion Tray (A4310)

• Quantity 1 per month
• Chart note permanent Urinary Incontinence diagnosis or Retention
• Documented need
• Generic CMN or a prescription needed.
• The prescription form must include: Patient name, Description of items, Quantity, Diagnosis, Length of Need, Ordering practitioner name or NPI, Signature, Order Date.
• CMN/Rx form is valid for 12 months.
• Must document resupply call requirements

Irrigation Tray (A4320)

• Quantity 1 per month
• Permanent Urinary Incontinence or Retention
• Documented need
• Generic CMN or a prescription needed.
• The prescription form must include: Patient name, Description of items, Quantity, Diagnosis, Length of Need, Ordering practitioner name or NPI, Signature, Order Date.
• The CMN/Rx form is valid for 12 months.
• Must document resupply call requirements

Extension Tubing (A4331)

• Documentation Permanent Urinary Incontinence or Retention
• Documented need
• CMN RX must include: Patient name, Description of items, Quantity, Diagnosis, Length of Need, Ordering practitioner name or NPI, Signature, Order Date.
• The CMN/Rx form is valid for 12 months.
• Must document resupply call requirements

Bed Bag (A4357) and Leg Bag (A4358)

• Combined 2 quantity
• Permanent Urinary Incontinence or Retention
• Documented need
• CMN RX must include: Patient name, Description of items, Quantity, Diagnosis, Length of Need, Ordering practitioner name or NPI, Signature, Order Date.
• The CMN/Rx form is valid for 12 months.
• Must document resupply call requirements

Lubricant (A4332- per packet)

• A4402-1 unit= 1 x per oz
• 1 per instance
• Underlying/All Encompassing Diagnosis
• Can use Chart Notes
• CMN or Prescription needed and valid for 12 months.
• Generic Notes- must have all elements required
• Must document resupply call requirements

Gloves (A4927)

• Gloves must be used by Healthcare professional
• For Home Healthcare Services.
• Underlying/All Encompassing Diagnosis
• Gloves can not be billed on same claim if RN, LVN, or attendant providing the service.
• This benefit is not covered by Home Healthcare.
• The CMN/RX form is valid for 12 months

Enteral Feeding

• B4035 Feeding Bags, B4034 Kit, B4036 Bags
• Quantity is specified as noted
• The patient should contain permanent Z93.1 diagnosis
• Must ensure appropriate information is sent with a CMN or Script (Patients name/DOB, etc..)
• Resupply calls need to be documented
• The CMN/ RX form is valid for 12 Months

Irrigation Syringe (A4322)

• Quantity is 5
• The patient should contain permanent Z93.1 diagnosis
• Must ensure appropriate information is sent with a CMN or Script (Patients name/DOB, etc..)
• Resupply calls need to be documented
• The CMN/ RX form is valid for 12 Months

Enteral Formula (B4149-B4162)

• Under 21 ONLY
• 1 unit = 100 Calories
• Documentation requires Chart Notes, Gtube status, sole source or primary source nutrition, type of formula, and must include calories per day
• Must ensure appropriate information is sent with a CMN or Script (Patients name/DOB, etc..)
• The CMN/ RX form is valid for 12 Months
• Resupply calls need to be documented

Oral Formula (B4149-B4162)

• Medically Necessary, Oral method of feeding a pt.
• For Pt's over 21, it is needed to be in coordination through a wavier program.
• Must have an applicable Diagnosis and resupply information documented as a reminder.
• Must ensure appropriate information is sent with a CMN or Script (Patients name/DOB, etc..)
• The CMN/ RX form is valid for 12 Months
• Documented resupply call requirements

G-Tubes (Low Profile and Standard B4088/B4087)

• Qty is 1 per 3 months
• The patient should contain permanent Z93.1 diagnosis
• Must ensure appropriate information is sent with a CMN or Script (Patients name/DOB, etc..)
• Resupply calls need to be documented
• The CMN/ RX form is valid for 12 Months

Feeding Pump (B9002) and IV Pole (E0776)

• 1 per 5 years
• Resupply Call requirements
• Should contain permanent z93.1 diagnosis
• Resupply calls need to be documented
• The CMN/ RX form is valid for 12 Months

Thickener (B4100)

• Medically Necessary Diagnosis to support treatment
• gravity or syringe feeding is not indicated
• admin rate is less than 100 ml/hr
• Resupply calls need to be documented
• The CMN/ RX form is valid for 12 Months

Electrolyte fluid / Additive Formula (B4102 (adult) -B4103 (pedi)) -B4104

• Z93.1/Applicable Dx diagnosis
• requires a start service or submit for auth within 90 days of signature date.
• Must have Documented dehydration
• With Condition with the need to replace electrolytes or fluid, ex: vomiting, intestinal obstruction, anuria, recurrent diarrhea
• Resupply calls need to be documented.
• The CMN/ RX form is valid for 12 Months