2021 Medicaid DME Fee Schedule - Kentucky

1 Medicaid PROGRAM DME FEE Schedule 2021. Note: Red indicates new codes or changes for the most current revision date. PA required for rentals as indicated on the fee Schedule . The appearance on this website of a code and rate is not an indication of coverage, nor a guarantee of payment. If a quantity limit is exceeded, a CMN & PA are required. By current regulation, any item $500 or over requires a PA. CMN. Rental expiration Purchase PA& Rental Purchase HCPCS Description date for PA & CMN Limits Rental Date updated CMN Price Price purchase required required or rental Y/12 month per Coverage will be through if PA calendar pharmacy for diagnosis A4206 Syringe w/needle, sterile , 1 cc or less, each YES > 125 NO $ required month codes related to diabetes, other dx through DME. Y/12 month per A4207 Syringe with needle; sterile 2cc, each if PA YES > 10 calendar NO $ required month Y/12 month per A4208 Syringe with needle; sterile 3cc, each if PA YES > 10 calendar NO $ required month Y/12 month per A4209 Syringe with needle; sterile 5cc each if PA YES >10 calendar NO $ required month remains a covered service A4210 Needle-free injection device, each NO NO $ through DME.

2 Supplies for self-administered injections--pen Y/12 added to fee Schedule A4211 YES NO M. needles months 2/14/08. A4213 Syringe, sterile, 20cc or greater, each NO NO $ A4215 Sterile needle only,any size, each NO NO $ A4217 Sterile water/saline , 500 ml NO NO $ Y/12. A4218 Sterile Saline or H2O metered dose dispenser 10 ml YES NO M. months Y/12. A4220 Refill kit for implantable infusion pump YES NO M. months Supplies for maintenance of drug infusion catheter Rate updated 01/01/2018. A4221 NO NO $ per week, drug separate Supplies for external drug infusion pump per Rate updated 01/01/2018. A4222 NO NO $ cassette or bag, drug separate Infusion supplies not used with ext. infusion pump, rate set 01/01/2007. A4223 NO NO $ per cassette or bag Medicaid Program DME Fee Schedule 2021. CMN. Rental expiration Purchase PA& Rental Purchase HCPCS Description date for PA & CMN Limits Rental Date updated CMN Price Price purchase required required or rental Supplies for Maintance of insluin infusion catheter, Rate change effective A4224 $ per week 7/1/2018.

3 Supplies for external insulin infusion pump, syringe Rate change effective A4225 $ type cartridge, sterile, each) 7/1/2018. YES if PA 16 per rate set 01/01/2007; qty limit Infusion set for external insulin pump, non needle A4230 required YES> calendar NO $ eff. 5/1/09. cannula type each month YES if PA 16 per rate set 01/01/2007; qty limit Infusion set for external insulin pump, needle type A4231 required YES> calendar NO $ eff. 5/1/09. each month Syringe with needle for external insulin pump, sterile A4232 NO NO $ 3cc Replacement battery , other than J cell home Rate updated 01/01/2018. A4233 NO NO $ glucose mon. each Replacement battery , J cell, home glucose mon. Rate updated 01/01/2018. A4234 NO NO $ each Replacement battery, lithium, home glucose mon. Rate updated 01/01/2018. A4235 NO NO $ each Replacement battery, silver oxide, home glucose Rate updated 01/01/2018. A4236 NO NO $ mon.

4 , each Y/12 month per Coverage will be through Urine test or reagent strips or tablets 100 tablets or YES >. A4250 if PA calendar NO $ pharmacy 10/5/10 and after strips=1 unit 2unit required month Y/12 Coverage will be through A4252 Blood ketone test or reagent strip, each YES NO M. months pharmacy 10/5/10 and after Y/12 month per Coverage will be through Blood glucose test or reag. strips blood glucose YES> 4. A4253 if PA calendar NO $ pharmacy 10/5/10 and after monitor, 50 strips=1unit unit required month Rate updated 01/01/2018. Coverage will be through A4256 Normal, low and high calibrator solution/chips NO NO $ pharmacy 10/5/10 and after Rate updated 01/01/2018. Coverage will be through A4258 Spring-powered device for lancet, each NO NO $ pharmacy 10/5/10 and after Rate updated 01/01/2018. Y/12 month per Coverage will be through YES> 2. A4259 Lancets per box of 100 1 unit=100 lancets if PA calendar NO $ pharmacy 10/5/10 and after unit required month Rate updated 01/01/2018.

5 A4261 Cervical Cap Contraceptive NO NO $ A4265 Paraffin NO NO $ 2 of 95. Medicaid Program DME Fee Schedule 2021. CMN. Rental expiration Purchase PA& Rental Purchase HCPCS Description date for PA & CMN Limits Rental Date updated CMN Price Price purchase required required or rental Adhesive skin support attachment for use with A4280 NO NO $ external breast prosthesis, each IV delivery system disposable 50 ml or greater per Y/12. A4305 YES NO M. hour months Y/12. A4306 IV delivery system disposable 5 ml or less per hour YES NO M. months Y/12 month per A4310 Insert tray w/o bag/cath if PA YES > 1 calendar NO $ required month Y/12 month per Insertion tray w/o bag, with indwelling catheter, foley A4311 if PA YES> 1 calendar NO $ type, 2-way latex required month A4312 Cath w/o bag 2-way silicone NO NO $ With indwelling catheter, foley type, 3-way for A4313 NO NO $ continuous irrigation A4314 Cath w/drainage 2-way latex NO NO $ A4315 Cath w/drainage 2-way silicone NO NO $ A4316 Cath w/drainage 3-way NO NO $ Y/12 month per A4320 Irrigation tray if PA YES > 9 calendar NO $ required month Y/12 month per A4322 Irrigation syringe, bulb or piston, each if PA YES >9 calendar NO $ required month Male external catheter w/integral collection chamber, Y/12 month per A4326 any type each, made of rubber or plastice, designed if PA YES>2 calendar NO $ to be washed & reused.

6 Required month A4327 Fem urinary collect dev cup NO NO $ A4328 Fem urinary collect pouch NO NO $ A4330 Stool collection pouch NO NO $ External drainage tubing for urinary leg bag or A4331 NO NO $ urostomy, each Lubricant, individual sterile, for insertion of urinary A4332 NO NO $ catheter, each Urinary catheter anchoring device, adhesive skin A4333 NO NO $ attachment, each A4334 Urinary catheter anchoring device, leg strap, each NO NO $ Y/12 month per 07/02/2007 limit change indwelling catheter foley type, two-way latex with A4338 if PA YES >31 calendar NO $ coating, each required month 3 of 95. Medicaid Program DME Fee Schedule 2021. CMN. Rental expiration Purchase PA& Rental Purchase HCPCS Description date for PA & CMN Limits Rental Date updated CMN Price Price purchase required required or rental indwelling catheter, specialty type; coude, A4340 NO NO $ mushroom, wing, etc, each Y/12 month per 07/02/2007 limit change Catheter indwelling , foley type, 2 way, all silicone, A4344 if PA YES>31 calendar NO $ each required month Catheter indwelling , foley type, 3 way, for A4346 NO NO $ continuous irrigation, each Male ext.

7 Catheter w or w/o adhesive, disposable, A4349 NO NO $ each Intermittent urinary straight tip urine catheter, with or A4351 NO NO $ without coating Intermittent urinary catheter, Coude tip, with or A4352 NO NO $ without coating Y/12 per 04/02/2007 limit change months if calendar A4353 Intermittent urinary cath sterile catheterization kit YES>124 NO $ PA required month A4354 Insertion tray with drainage bag but without catheter NO NO $ Bladder irrigation tubing set through a three-way A4355 NO NO $ indwelling foley catheter, each Y/12 month 4 per year A4356 Ext ureth clmp or compr dvc if PA YES > 4 NO $ required Y/12 month per A4357 Bedside drainage bag if PA YES > 1 calendar NO $ required month Urinary drainage bag, leg or abdomen, vinyl with or A4358 NO NO $ without tube with straps, each CMS DC 39084. A4359 Urinary suspensory w/o leg bag 1/07. Y/12 month 6 per year rate change 8/1/2007. A4361 Ostomy face plate if PA YES> 6 NO $ required Y/12 month per rate change 8/1/2007.

8 A4362 Solid skin barrier if PA YES > 20 calendar NO $ required month A4363 Ostomy clamp, any type , each NO NO $ rate change 8/1/2007. A4364 Adhesive, liquid or equal, any type, per ounce NO NO $ rate change 8/1/2007. 4 of 95. Medicaid Program DME Fee Schedule 2021. CMN. Rental expiration Purchase PA& Rental Purchase HCPCS Description date for PA & CMN Limits Rental Date updated CMN Price Price purchase required required or rental Y/12 per rate change 8/1/2007. months if calendar A4366 Ostomy vent, any type, each YES>1 NO $ PA required month Y/12 per rate change 8/1/2007. months if calendar A4367 Ostomy belt YES> 1 NO $ PA required month A4368 Ostomy filter NO NO $ rate change 8/1/2007. A4369 Skin barrier liquid per oz NO NO $ rate change 8/1/2007. A4371 Skin barrier powder per oz NO NO $ rate change 8/1/2007. A4372 Ostomy Skin barrier solid 4x4 equiv NO NO $ rate change 8/1/2007. A4373 Skin barrier with flange NO NO $ rate change 8/1/2007.

9 A4375 Drainable plastic pch w fcpl NO NO $ rate change 8/1/2007. A4376 Drainable rubber pch w fcplt NO NO $ rate change 8/1/2007. A4377 Drainable plstic pch w/o fp NO NO $ rate change 8/1/2007. A4378 Drainable rubber pch w/o fp NO NO $ rate change 8/1/2007. A4379 Urinary plastic pouch w fcpl NO NO $ rate change 8/1/2007. A4380 Urinary plastic pouch w/o fp NO NO $ rate change 8/1/2007. Ostomy pouch, urinary, for use on faceplate, plastic, rate change 8/1/2007. A4381 NO NO $ each A4382 Urinary hvy plstc pch w/o fp NO NO $ rate change 8/1/2007. A4383 Urinary rubber pouch w/o fp NO NO $ rate change 8/1/2007. A4384 Ostomy faceplt/silicone ring NO NO $ rate change 8/1/2007. A4385 Ost skn barrier sld ext wear NO NO $ rate change 8/1/2007. A4387 Ost clsd pouch w att st barr NO NO $ Rate updated 01/01/2018. A4388 Drainable pch w ex wear barr NO NO $ rate change 8/1/2007. A4389 Drainable pch w st wear barr NO NO $ rate change 8/1/2007.

10 A4390 Drainable pch ex wear convex NO NO $ rate change 8/1/2007. A4391 Urinary pouch w ex wear barr NO NO $ rate change 8/1/2007. A4392 Urinary pouch w st wear barr NO NO $ rate change 8/1/2007. A4393 Urine pch w ex wear bar conv NO NO $ rate change 8/1/2007. A4394 Ostomy pouch liq deodorant w/wo lubricant NO NO $ rate change 8/1/2007. A4395 Ostomy pouch solid deodorant NO NO $ A4396 Ostomy belt with peristomal hernia support NO NO $ rate change 8/1/2007. Y/12 month per rate change 8/1/2007. A4397 Irrigation supply sleeve if PA YES > 4 calendar NO $ required month 5 of 95. Medicaid Program DME Fee Schedule 2021. CMN. Rental expiration Purchase PA& Rental Purchase HCPCS Description date for PA & CMN Limits Rental Date updated CMN Price Price purchase required required or rental Y/12 month 4 per year rate change 8/1/2007. A4398 Ostomy irrigation bag if PA YES > 4 NO $ required Y/12 month 4 per year rate change 8/1/2007.