MHCP Medical Supply Coverage Guide - Minnesota

[Pages:29630]HCPCS code

Description of code

A4206 Syringe with needle, sterile, 1cc or less, each

A4207 Syringe with needle, sterile, 2cc, each

A4208 Syringe with needle, sterile, 3cc, each

A4209 Syringe with needle, sterile, 5cc or greater, each

A4210 Needle-free injection device, each

A4211 Supplies for selfadministered injections

Medical Supply coverage guide

Updated 11/22/2022

Category

Miscellaneous Supplies

Miscellaneous Supplies

Miscellaneous Supplies

Miscellaneous Supplies

Miscellaneous Supplies

Equipment and Supplies

Auth. Required

No No No No Always

Over $400

Included in LTC per diem?

Yes Yes Yes Yes Yes

Yes

Coverage policy or guidelines. An order is always required when dispensing. When dispensing items in greater than typical quantities, or for reasons other than listed below, additional documentation may be required. (Throughout this document, "manual" refers to the MHCP Provider Manual.) Covered for members require medication administration via syringe, diagnosis required. (Insulin syringes are billed under S8490.) Covered for members require medication administration via syringe, diagnosis required. (Insulin syringes are billed under S8490.) Covered for members require medication administration via syringe, diagnosis required. (Insulin syringes are billed under S8490) Covered for members require medication administration via syringe, diagnosis required. (Insulin syringes are billed under S8490.) Covered for members who administer medication themselves or with the assistance of a caregiver and are not able to safely administer medication using a conventional syringe with needle Covered for members who administer medications themselves or with the assistance of a caregiver. Only to be used where a more specific code is not available. Used for Sharps disposal containers with modifier U3.

Quantity limits

(maximum that may be dispensed)

Medical necessity

Medical necessity

Medical necessity

Medical necessity

1 per 5 years

Medical necessity

Rental or purchase

Purchase only

Purchase only

Purchase only

Purchase only

Purchase only

Purchase only

Policy review date

October 2021

October 2021

October 2021

October 2021

October 2021

October 2021

1

Medical Supply coverage guide

Updated 11/22/2022

HCPCS code

Description of code

A4212 A4213

Noncoring needle or stylet with or without catheter

Syringe, sterile, 20cc or greater, each

A4215 Needle, sterile, any size, each

A4216 Sterile water, saline or dextrose, diluent/flush, 10 ml

A4217 Sterile water or saline, 500 ml

Category

Miscellaneous Supplies

Miscellaneous Supplies

Miscellaneous Supplies

Miscellaneous Supplies

Miscellaneous Supplies

Auth. Required

No No No For excess quantities

For excess quantities

Included in LTC per diem?

Y - NF N-ICF/DD

Coverage policy or guidelines. An order is always required when dispensing. When dispensing items in greater than typical quantities, or for reasons other than listed below, additional documentation may be required. (Throughout this document, "manual" refers to the MHCP Provider Manual.) Covered when medically necessary. Should not be billed with A4220.

Yes Covered for members who require medication administration via syringe (Insulin syringes are billed with S8490)

Yes Y - NF N-ICF/DD

Y - NF N-ICF/DD

Covered when needles are dispensed without syringes, or when dispensed with a syringe code that does not include needles when medically necessary. Covered when medically necessary. Document medical necessity for quantity. Should not be billed with A4221. Only non-legend sterile saline irrigation solutions may be billed as a medical supply. (Legend sterile saline solutions must be billed by a pharmacy as a drug). Authorization required for any limit over 300 per month. Covered when medically necessary. Document reason for need, including need for sterility, and reason for quantity. Only non-legend sterile saline irrigation solutions may be billed as a medical supply, legend sterile saline solutions must be billed by a pharmacy as a drug.

Quantity limits

(maximum that may be dispensed)

Medical necessity

Medical necessity

Medical necessity

300 units per month

100 units per month

Rental or purchase

Purchase only

Purchase only

Purchase only

Purchase only

Purchase only

Policy review date

October 2021

October 2021

October 2021

October 2017

January 2008

2

Medical Supply coverage guide

Updated 11/22/2022

HCPCS code

Description of code

A4218 Sterile Saline or water, metered dose dispenser, 10 ml

A4220 Refill kit for implantable infusion pump

A4221

Supplies for maintenance of non-insulin drug infusion catheter, per week (list drug separately)

A4222

Infusion supplies for external drug infusion pump, per cassette or bag (list drugs separately)

Category

Miscellaneous Supplies

Drug Infusion Supplies

Drug Infusion Supplies

Drug Infusion Supplies

Auth. Required

For excess quantities

For excess quantities

For excess quantities

For excess quantities

Included in LTC per diem?

Y - NF N-ICF/DD

No

Y - NF N-ICF/DD

Y - NF N-ICF/DD

Coverage policy or guidelines. An order is always required when dispensing. When dispensing items in greater than typical quantities, or for reasons other than listed below, additional documentation may be required. (Throughout this document, "manual" refers to the MHCP Provider Manual.) Covered when medically necessary for use with inhaled solutions. Only non-legend sterile saline irrigation solutions may be billed as a medical supply, legend sterile saline solutions must be billed by a pharmacy as a drug. Document medical necessity and frequency of use. Use U3 modifier for vials other than 10 ml. Covered for members with implanted infusion pump. Includes appropriate noncoring needles, filters, connectors, etc. which may not be billed separately. Usual use is 1 per month, document excess need. Covered for members with drug infusion catheters. Includes gloves, alcohol wipes, tapes, catheter insertion devices, dressings for the catheter site and flush solutions not directly related to drug infusion, as well as all cannulas, and needles. Covered for members with external drug infusion pumps. Includes the cassette or bag, diluting solutions, tubing and other administration supplies, port cap changes, compounding charges and preparation charges.

Quantity limits

(maximum that may be dispensed)

Rental or purchase

Policy review date

300 units Purchase January

per month

only

2008

5 per month Purchase January

only

2008

4 per month Purchase November

only

2016

60 per month

Purchase January

only

2008

3

Medical Supply coverage guide

Updated 11/22/2022

HCPCS code

Description of code

A4223

Infusion supplies not used with external infusion pump, per cassette or bag (list drugs separately)

A4224 A4225 A4226

Supplies for maintenance of insulin infusion catheter, per week

Supplies for external insulin infusion pump, syringe type cartridge, sterile, each Supplies for maintenance of insulin infusion pump with dosage rate adjustment (Weekly)

Category

Drug Infusion Supplies Diabetes Diabetes Diabetes

Auth. Required

For excess quantities

For excess quantities For excess quantities Always

Included in LTC per diem?

Y - NF N-ICF/DD

No

Coverage policy or guidelines. An order is always required when dispensing. When dispensing items in greater than typical quantities, or for reasons other than listed below, additional documentation may be required. (Throughout this document, "manual" refers to the MHCP Provider Manual.) Covered when medically necessary. Includes the cassette or bag, diluting solutions, tubing and other administration supplies, port cap changes, compounding charges and preparation charges. Covered for members with external insulin pumps. Refer to manual.

No Covered for members with external insulin pumps. Refer to manual.

No Covered for members with insulin infusion pumps. Refer to manual

Quantity limits

(maximum that may be dispensed)

Rental or purchase

60 per month

Purchase only

5 per month Purchase only

31 per month

Purchase only

1 per week Purchase only

Policy review date

January 2008

November 2016

November 2016

January 2021

A4230

A4231 A4232

Infusion set for external insulin pump, nonneedle cannula type

Infusion set for external insulin pump, needle type

Syringe with needle for external insulin pump, sterile, 3cc

Diabetes

Diabetes Diabetes

For excess quantities

For excess quantities For excess quantities

No Covered for members with external insulin 20 per

pumps. Refer to manual.

month

No Covered for members with external insulin 20 per

pumps. Refer to manual.

month

No Covered for members with external insulin 20 per

pumps. Refer to manual.

month

Purchase September

only

2018

Purchase only

Purchase only

September 2018

December 2020

4

HCPCS code

Description of code

Category

A4233

Replacement battery, alkaline (other than J cell), for use with medically necessary home blood glucose monitor owned by patient, each

A4234

Replacement battery, J cell, for use with medically necessary home blood glucose monitor owned by patient, each

A4235

Replacement battery, alkaline (other than J cell), for use with medically necessary home blood glucose monitor owned by patient, each

A4236

Replacement battery, silver oxide, for use with medically necessary home blood glucose monitor owned by patient, each

Diabetes Diabetes Diabetes Diabetes

Medical Supply coverage guide

Updated 11/22/2022

Auth. Required

For excess quantities

Included in LTC per diem?

Yes

Coverage policy or guidelines. An order is always required when dispensing. When dispensing items in greater than typical quantities, or for reasons other than listed below, additional documentation may be required. (Throughout this document, "manual" refers to the MHCP Provider Manual.) Covered for diabetic members who own a blood glucose monitor. A medically unlikely edit exists for this code, no more than 2 units may be dispensed per date of service.

Quantity limits

(maximum that may be dispensed)

Rental or purchase

Policy review date

2 per dispensing, 6 per year

Purchase September

only

2016

For excess quantities

For excess quantities

Yes Covered for diabetic members who own a

2 per

Purchase January

blood glucose monitor. A medically

dispensing, only

2021

unlikely edit exists for this code, no more 6 per year

than 2 units may be dispensed per date of

service.

Yes Covered for diabetic members who own a

2 per

Purchase September

blood glucose monitor. A medically

dispensing, only

2016

unlikely edit exists for this code, no more 6 per year

than 2 units may be dispensed per date of

service.

For excess quantities

Yes Covered for diabetic members who own a

2 per

Purchase September

blood glucose monitor. A medically

dispensing, only

2016

unlikely edit exists for this code, no more 6 per year

than 2 units may be dispensed per date of

service.

5

Medical Supply coverage guide

Updated 11/22/2022

HCPCS code

Description of code

A4238

Adjunctive CGM supply allowance, includes all supplies and accessories, 1 month supply = 1 unit of service

Category Diabetes

Auth. Required

Always

Included in LTC per diem?

Yes

Coverage policy or guidelines. An order is always required when dispensing. When dispensing items in greater than typical quantities, or for reasons other than listed below, additional documentation may be required. (Throughout this document, "manual" refers to the MHCP Provider Manual.) Covered for insulin dependent diabetics with a history of hypoglycemic unawareness. Refer to manual.

Quantity limits

(maximum that may be dispensed)

Rental or purchase

1

Purchase

Only

Policy review date

April 2022

A4244 A4245

Alcohol or peroxide, per pint

Alcohol wipes, per box

Miscellaneous Supplies

Miscellaneous Supplies

For excess quantities

For excess quantities

A4246 Betadine or pHisoHex

Renal Dialysis

No

solution, per pint

A4247 Betadine or iodine swabs Renal Dialysis

No

or wipes, per box

A4248 Chlorhexidine containing Miscellaneous

antiseptic, 1 ml

Supplies

Yes Covered when medically necessary for injections or sterilizing equipment.

5 pints per Purchase December

month

only

2008

Yes Covered when medically necessary for

6 boxes per Purchase December

injections or sterilizing equipment. Prior

month

only

2008

Authorization required for over 6 boxes

per month.

No Covered when dispensed by approved

Medical Purchase December

dialysis equipment supplier. Indications

necessity

only

2008

other than dialysis must be billed by a

pharmacy as a drug. Refer to manual.

No Covered when dispensed by approved

Medical Purchase December

dialysis equipment supplier. For

necessity

only

2008

indications other than dialysis, must be

billed by a pharmacy as a drug. Refer to

manual.

Not covered as a medical supply. Must be

December

billed by a pharmacy as a drug. Refer to

2008

manual.

6

HCPCS code

Description of code

A4250 Urine test or reagent strips or tablets (100 tablets or strips)

A4252 Blood ketone test or reagent strip, each

A4253

A4255 A4256

Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips (1 unit = 50 strips) Platforms for home blood glucose monitor, 50 per box typical, low and high calibrator solution / chips

A4257 Replacement lens shield cartridge for use with

Category

Diabetes

Diabetes Diabetes Diabetes Diabetes Diabetes

Medical Supply coverage guide

Updated 11/22/2022

Auth. Required

For excess quantities

For excess quantities

For excess quantities

Included in LTC per diem?

Yes

Yes Yes Yes

Coverage policy or guidelines. An order is always required when dispensing. When dispensing items in greater than typical quantities, or for reasons other than listed below, additional documentation may be required. (Throughout this document, "manual" refers to the MHCP Provider Manual.) Covered for diabetic members who choose not to use blood glucose monitoring or for diabetic members at risk for ketoacidosis. Also can be covered for members who are reliant on nasogastric or nasojejunal tube feedings in order to verify correct tube placement. A medically unlikely edit exists for this code, no more than 2 units may be dispensed per date of service. Covered for diabetics at risk of ketoacidosis for whom urine ketone testing is not sufficient. Refer to manual. Billable only for members for whom Medicare pays primary. For all other members, diabetic testing supplies are included in the Point of Sale Diabetic testing supply program. Refer to manual. Covered for diabetic members who do home blood glucose monitoring.

Quantity limits

(maximum that may be dispensed)

2 boxes per month

90 per month

1 box per month

Rental or purchase

Purchase only

Purchase only

Purchase only

Policy review date

January 2016

December 2007

September 2016

October 2021

For excess quantities

Yes

Y - NF N-ICF/DD

Billable only for members for whom Medicare pays primary. For all other members, diabetic testing supplies are included in the Point of Sale Diabetic testing supply program. Covered for diabetic members who own and use a laser skin piercing device.

September 2016

1 per month Purchase December

only

2007

7

HCPCS code

Description of code

laser skin piercing device, each

Category

Medical Supply coverage guide

Updated 11/22/2022

Auth. Required

Included in LTC per diem?

Coverage policy or guidelines. An order is always required when dispensing. When dispensing items in greater than typical quantities, or for reasons other than listed below, additional documentation may be required. (Throughout this document, "manual" refers to the MHCP Provider Manual.)

Quantity limits

(maximum that may be dispensed)

Rental or purchase

Policy review date

A4258 Spring-powered device for lancet, each

Diabetes

A4259 Lancets, per box

Diabetes

A4261 Cervical cap for contraceptive use

A4264

Permanent implantable contraceptive intratubal occlusion device (s) and delivery system

A4265 Paraffin, per lb.

A4266 Diaphragm for contraceptive use

Family Planning

Family Planning

For excess quantities

For excess quantities

Wound Care

Family Planning

For excess quantities

For excess quantities

Yes Billable only for members for whom

September

Medicare pays primary. For all other

2016

members, diabetic testing supplies are

included in the Point of Sale Diabetic

testing supply program. Refer to manual.

Yes Billable only for members for whom

September

Medicare pays primary. For all other

2016

members, diabetic testing supplies are

included in the Point of Sale Diabetic

testing supply program. Refer to manual.

No Covered for female members when

1 / year Purchase January

prescribed for contraception. A medically

only

2008

unlikely edit exists for this code.

No Covered effective Jan. 1, 2010 when

2 per

Purchase January

implanted by a physician. Cannot be

lifetime

only

2010

dispensed by medical supplier or

pharmacy.

Yes Covered when used as part of a home therapy treatment plan.

1 lb./month Purchase January

only

2008

No Covered for female members when

1 per year Purchase January

prescribed for contraception. A medically

only

2008

unlikely edit exists for this code.

8

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