Medical Supply Coverage Guide - Minnesota

1 Medical Supply Coverage Guide Updated 2/3/2023 1 HCPCS code Description of code Category 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 A4206 Syringe with needle, sterile, 1cc or less, each Miscellaneous Supplies No Yes Covered for members require medication administration via syringe, diagnosis required.

2 (Insulin syringes are billed under S8490.) Medical necessity Purchase only October 2021 A4207 Syringe with needle, sterile, 2cc, each Miscellaneous Supplies No Yes Covered for members require medication administration via syringe, diagnosis required. (Insulin syringes are billed under S8490.) Medical necessity Purchase only October 2021 A4208 Syringe with needle, sterile, 3cc, each Miscellaneous Supplies No Yes Covered for members require medication administration via syringe, diagnosis required. (Insulin syringes are billed under S8490) Medical necessity Purchase only October 2021 A4209 Syringe with needle, sterile, 5cc or greater, each Miscellaneous Supplies No Yes Covered for members require medication administration via syringe, diagnosis required.

3 (Insulin syringes are billed under S8490.) Medical necessity Purchase only October 2021 A4210 Needle-free injection device, each Miscellaneous Supplies Always Yes 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 1 per 5 years Purchase only October 2021 A4211 Supplies for self-administered injections Equipment and Supplies Over $400 Yes 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.

4 Used for Sharps disposal containers with modifier U3. Medical necessity Purchase only October 2021 Medical Supply Coverage Guide Updated 2/3/2023 2 HCPCS code Description of code Category 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 A4212 Noncoring needle or stylet with or without catheter Miscellaneous Supplies No Y - NF N-ICF/DD Covered when medically necessary.

5 Should not be billed with A4220. Medical necessity Purchase only October 2021 A4213 Syringe, sterile, 20cc or greater, each Miscellaneous Supplies No Yes Covered for members who require medication administration via syringe (Insulin syringes are billed with S8490) Medical necessity Purchase only October 2021 A4215 Needle, sterile, any size, each Miscellaneous Supplies No Yes Covered when needles are dispensed without syringes, or when dispensed with a syringe code that does not include needles when medically necessary. Medical necessity Purchase only October 2021 A4216 Sterile water, saline or dextrose, diluent/flush, 10 ml Miscellaneous Supplies For excess quantities Y - NF N-ICF/DD Covered when medically necessary.

6 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. 300 units per month Purchase only October 2017 A4217 Sterile water or saline, 500 ml Miscellaneous Supplies For excess quantities Y - NF N-ICF/DD 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.

7 100 units per month Purchase only January 2008 Medical Supply Coverage Guide Updated 2/3/2023 3 HCPCS code Description of code Category 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 A4218 Sterile Saline or water, metered dose dispenser, 10 ml Miscellaneous Supplies For excess quantities Y - NF N-ICF/DD Covered when medically necessary for use with inhaled solutions.

8 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. 300 units per month Purchase only January 2008 A4220 Refill kit for implantable infusion pump Drug Infusion Supplies For excess quantities No 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. 5 per month Purchase only January 2008 A4221 Supplies for maintenance of non-insulin drug infusion catheter, per week (list drug separately) Drug Infusion Supplies For excess quantities Y - NF N-ICF/DD Covered for members with drug infusion catheters.

9 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. 4 per month Purchase only November 2016 A4222 Infusion supplies for external drug infusion pump, per cassette or bag (list drugs separately) Drug Infusion Supplies For excess quantities Y - NF N-ICF/DD 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.

10 60 per month Purchase only January 2008 Medical Supply Coverage Guide Updated 2/3/2023 4 HCPCS code Description of code Category 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 A4223 Infusion supplies not used with external infusion pump, per cassette or bag (list drugs separately) Drug Infusion Supplies For excess quantities Y - NF N-ICF/DD Covered when medically necessary.