016-06-09 Ark. Code R. § 6
Diapers and underpads are covered by the Arkansas Medicaid Program but are benefit limited and must be medically necessary.
Diaper services must be medically necessary and the medical condition that prohibits the ability to potty train must be documented. Only patients with a medical condition that results in incontinence of the bladder and/or bowel may receive diapers through the Home Health and Prosthetics Programs. This coverage does not apply to infants who would be in diapers regardless of their medical condition. Medicaid does not cover underpads or diapers for beneficiaries under the age of 3 years.
The benefit limit for diapers and underpads is $130.00 per month, per beneficiary, for diapers of any size and underpads. The benefit limit applies to any diaper or underpad, or any combination, whether provided through the Prosthetics Program, the Home Health Program or both. The limit on diapers and underpads is separate from the limit established for home health and durable medical equipment (DME) medical supplies.
The benefit may be extended with proper documentation.
To obtain an extension of benefits for diapers and underpads, the following information must be submitted to the Prosthetics Services Reviewer, DMS Utilization Review. View or print the DMS Utilization Review contact information.
Procedure codes found in this section must be billed either electronically or on paper with modifier EP for beneficiaries under 21 years of age or modifier NU for beneficiaries age 21 and over. When a second modifier is listed, that modifier must be used in conjunction with either EP or NU .
Modifiers in this section are indicated by the headings M1 and M2. Prior authorization is indicated by the heading PA. If prior authorization is required, that information is indicated with a "Y" in the column, or if not, an "N" is shown.
A(...) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product.
Diapers and Underpads, 3 Years Old and Older (section 242.130 )
Procedure Code | M1 | M2 | Description | PA | Payment Method |
A4554 | NU | Disposable underpads, all sizes (e.g., Chux's) | N | Purchase | |
T4521 | NU | Adult-sized disposable incontinence product, brief/diaper, small, each | N | Purchase | |
T4522 | NU | Adult-sized disposable incontinence product, brief/diaper, medium, each | N | Purchase | |
T4523 | NU | Adult-sized disposable incontinence product, brief/diaper, large, each | N | Purchase | |
T4524 | NU | Adult-sized disposable incontinence product, brief/diaper, extra large, each | N | Purchase | |
T4526 | NU EP | Adult-sized disposable incontinence product, protective underwear/pull-on, medium size, each | N | Purchase | |
T4527 | NU EP | Adult-sized disposable incontinence product, protective underwear/pull-on, large size, each | N | Purchase | |
T4528 | NU EP | Adult-sized disposable incontinence product, protective underwear/pull-on, extra large size, each | N | Purchase | |
T4529 | EP | A (Small diaper) Pediatric-sized disposable incontinence product, brief/diaper, small/medium size, each | N | Purchase | |
T4529 | EP | U1 | A (Medium diaper) Pediatric-sized disposable incontinence product, brief/diaper, small/medium size, each | N | Purchase |
T4530 | NU EP | Pediatric-sized disposable incontinence product, brief/diaper, large size, each | N | Purchase | |
T4531 | EP | A (Small diaper) Pediatric-sized disposable incontinence product, brief/diaper, reusable, small/medium size, each | N | Purchase | |
T4531 | EP | U1 | A (Medium diaper) Pediatric-sized disposable incontinence product, brief/diaper, reusable, small/medium size, each | N | Purchase |
T4532 | NU EP | A (Large diaper) Pediatric-sized disposable incontinence product, brief/diaper, reusable, large size, each | N | Purchase |
Diapers and Underpads, 3 Years Old and Older (section 242.130 )
Procedure Code | M1 | M2 | Description | PA | Payment Method |
T4532 | NU EP | U1 U1 | A (Extra large diaper) Pediatric-sized disposable incontinence product, brief/diaper, reusable, large size, each | N | Purchase |
T4533 | NU EP | Youth-sized disposable incontinence product, brief/diaper, each | N | Purchase | |
T4535 | NU EP | Disposable liner/shield/guard/pad/ undergarment for incontinence, each | N | Purchase | |
T4535 | NU EP | U1 U1 | Disposable liner/shield/guard/pad/ undergarment for incontinence, each | N | Purchase |
T4543 | NU | Disposable incontinence product, brief/diaper, bariatric, each | N | Purchase |
Reimbursement is based on a per unit basis with one unit equaling one item (diaper, underpad). When billing for these services that are benefit limited to a dollar amount per month, providers must bill according to the calendar month.
Providers must not span calendar months when billing for diapers and/or underpads. The date of delivery is the date of service. Providers should not bill "from" and "through" dates of service.
Refer to section 212.100 of this manual for coverage information on diapers and underpads.
016.06.09 Ark. Code R. § 006