SPECIAL BULLETIN COVID-19 #69: Clarification to Bulletin #15 Medicaid and NC Health Choice Temporary Flexibilities - 1135 Waiver Provisions and Replace Effective Dates Stated in Bulletins #2, #10 & #11

Monday, April 27, 2020

This Bulletin:

  • Clarifies which specific Prior Authorizations are being lifted on the March 1, 2020, effective date stated in SPECIAL BULLETIN COVID-19 #15: Medicaid and NC Health Choice Temporary Flexibilities - 1135 Waiver Provisions (posted March 24, 2020)
  • References all relevant Prior Authorization information included in other Bulletins
  • Replaces the effective dates originally stated in the following Bulletins: 
    • SPECIAL BULLETIN COVID-19 #2: General Guidance and Policy Modifications (posted Mar 13, 2020)
    • SPECIAL BULLETIN COVID-19 #10: Durable Medical Equipment: Temporary Flexibilities Effective March 23, 2020 (posted Mar 24, 2020)
    • SPECIAL BULLETIN COVID-19 #11: Outpatient Specialized Therapies Temporary Flexibilities (posted Mar 24, 2020)

The Centers for Medicare & Medicaid Services (CMS) has granted NC Medicaid the authority to temporarily modify Medicaid and NC Health Choice policies including reimbursement for Medically Necessary Services without Prior Authorizations. These temporary flexibilities will be effective through the end of the federal emergency declaration or when the flexibility is ended by NC Medicaid or CMS, whichever is first, unless otherwise indicated (such as PACE). 

Reimbursement for Medically Necessary Services without Prior Authorization

  • Durable Medical Equipment (effective retroactive to March 1, 2020)
    • PA suspended for oxygen equipment, ventilators, CPAPs, respiratory assist devices, nebulizers and related supplies (originally effective March 13, 2020)
    • PA suspended to override quantity limits for sterile/non-sterile Gloves and incontinence supplies (originally effective March 13, 2020)
    • PA suspended for six additional oxygen equipment and supply codes (originally effective March 23, 2020)
    • PA suspended for non-preferred brand blood glucose testing supplies and for reauthorizations of continuous glucose monitors and supplies (originally effective March 23, 2020)
    • PA suspended to override quantity limits on 41 respiratory equipment and supply codes (originally effective March 23, 2020)
    • PA suspended to override quantity limits on nursing equipment and supplies including urinary catheters, ostomy supplies, gastrostomy and nasogastric tubes, enteral formula, and blood glucose testing supplies (originally effective March 23, 2020)
  • PA suspended for outpatient Respiratory Therapy provided through the Independent Practitioner Provider (IPP) program (effective retroactive to March 1, 2020; originally effective March 23, 2020)
  • Chest Computed Tomography (CT) Auto-Approval (effective March 24, 2020)
  • Pharmacy: Temporary Flexibilities (effective March 13, 2020)
  • Private Duty Nursing (PDN) (effective March 1, 2020)
    • PA is temporarily lifted for additional PDN hours needed to cover unscheduled school closures for beneficiaries under age 21 with a current PA certification 
    • All beneficiaries: PA is temporarily lifted for short- term increase (STI) hours for any beneficiaries with a current PA certification 
  • Home Health (effective March 1, 2020). PA is temporarily lifted for annual visit limits for home health aides and nursing 
  • Program for All-Inclusive Care for the Elderly (PACE) (effective March 1-Dec. 31, 2020). Prior approval is temporarily lifted for PACE enrollment, including annual prior approvals. Prior approvals in place March 1 through Dec. 31, 2020, will remain in effect until the next scheduled due date in 2021. For example, an updated prior approval due March 2020 will be waived, and the next prior approval will be due March 2021  

For the above categories, the effective dates are retroactive to the system changes made by the NC Medicaid. If a Provider submitted a claim for the above services after the effective date but received a denial, NC Medicaid encourages the provider to resubmit that claim.

Please see below for the details related to the categories above. These details have been covered by previous Bulletins released by NC Medicaid as noted.

Outpatient Specialized Therapies Temporary Flexibilities

This information is from SPECIAL BULLETIN COVID-19 #11: Outpatient Specialized Therapies Temporary Flexibilities (posted Mar 24, 2020). Update: The effective date originally listed in #11 is replaced by this bulletin. 

Effective March 1, 2020, if medically necessary, outpatient Respiratory Therapy (RT) services provided through the Independent Practitioner Provider (IPP) program that typically require prior authorization (PA), may be provided to NC Medicaid and NC Health Choice beneficiaries without PA. All other aspects of Clinical Coverage Policy 10D, Respiratory Therapy Services by Independent Practitioner Provider will remain applicable. 

Chest Computed Tomography (CT) Auto-Approval

This information is from SPECIAL BULLETIN COVID-19 #13: EviCore Chest Computed Tomography (CT) Auto-Approval  (posted Mar 24). 

Effective March 24, 2020, EviCore, NC Medicaid’s contracted vendor for imaging services, will auto-approve the following chest CT codes: 

  • 71250 – Computed tomography, thorax; without contrast material
  • 71260 – Computed tomography, thorax; with contrast material(s)
  • 71270 – Computed tomography, thorax; without contrast material, followed by contrast material(s) and further sections

A provider questionnaire will ask if the test is being requested due to COVID-19; if the answer is yes, the test will be automatically approved, regardless of diagnosis. If the answer is no, the request will process as usual.

As a reminder, if the CT is ordered by an urgent care facility or emergency department, the U2 modifier should be appended to the claim indicating that the test was performed emergently, and prior approval is not required.

Pharmacy: Temporary Flexibilities Effective March 13, 2020

This information is from SPECIAL BULLETIN COVID-19 #2: General Guidance and Policy Modifications (posted Mar 13, 2020).

Recommendations for social distancing in response to the COVID-19 present situations where Medicaid and Health Choice beneficiaries may benefit from an early refill or expanded quantity of their prescription medications.

Effective March 13, 2020 NC Medicaid enrolled pharmacy providers should resubmit these claims with “09” (Emergency Preparedness) in the PA Type Code field and a valid value for an E.R. override in the Reason for Service, Professional Service and Result of Service fields to override a denial for an early refill. Do not place any values in the Submission Clarification Code field.

This override code will allow for early refills and will also allow for coverage of up to a 90-day supply of the medication. Be aware that NC Medicaid policy allows a 90-day supply for brand and generics to be filled when the prescription is either written for a 90-day supply or has enough refills remaining to fill for up to 90 days.

  • Note that these edit changes do not apply to controlled substances. Additionally, providers are encouraged to follow all applicable state and federal laws and regulations for controlled substances.
  • If necessary, up to a 14-day emergency supply can be billed for any pharmacy claim requiring prior approval when no active prior approval is showing in NCTracks. The pharmacy provider should resubmit these claims with “09” (Emergency Preparedness) in the PA Type Code field and “03” in the Level of Service Field.
  • For beneficiaries in the Pharmacy Lock-in Program needing emergency supplies of Lock-In program-related medications, up to a 14-day emergency supply can be billed with “09” (Emergency Preparedness) in the PA Type Code field and “03” in the Level of Service Field. This override is only valid once per beneficiary per year. Beneficiaries and providers may also contact the NCTracks call center to change either the preferred Lock-In pharmacy or preferred Lock-In prescriber on an emergency basis.
  • Copay requirements are still applicable to these pharmacy claims.

Private Duty Nursing (PDN) – Beneficiaries Under 21 Years of Age

This information is from SPECIAL BULLETIN COVID-19 #5: Private Duty Nursing and Home Health Updates (posted Mar 19, 2020). 

Clinical Coverage Policy 3G-2, Private Duty Nursing for Beneficiaries Under 21 Years of Age, allows for State Plan PDN services to be authorized whenever a beneficiary receiving nursing services through Local Education Agencies (LEAs) has an unscheduled school absence. 

  • A parent or caregiver signed notification explaining any unscheduled school absences is required for PDN agency reimbursement of hours worked in the home. 
  • Once required documentation has been received by NC Medicaid, the Prior Authorization (PA) for the affected time frame is adjusted to document the hours provided at the primary private residence.

Effective 3/1/2020, with the direction of Governor Cooper to close school systems state-wide due to COVID-19, NC Medicaid is temporarily lifting the requirement for PA to be obtained when additional PDN hours are needed to cover unscheduled school closures for beneficiaries that have a current PDN PA certification. Claims submitted may be subject to audit for each program. 

Private Duty Nursing (PDN) – All Beneficiaries

Clinical Coverage Policy 3G-1, Private Duty Nursing for Beneficiaries Age 21 and Older, Section 3.4.1 and Clinical Coverage Policy 3G-2, Private Duty Nursing for Beneficiaries Under 21 Years of Age, Section 3.4.3, include coverage for a short- term increase (STI) in PDN services up to four (4) calendar weeks for a significant change in a beneficiary’s condition. 

  • Refer to the policies addressed above for the qualifying conditions. 
  • The amount and duration of the short-term increase is based on medical necessity and approved by NC Medicaid’s PDN Nurse Consultant.  

Effective March 1, 2020, to avoid delays in beneficiaries receiving needed PDN STI services, NC Medicaid is temporarily lifting the requirement for PA to be obtained for STI hours for any PDN beneficiary that has a current PDN PA certification. 

Home Health – All Beneficiaries

This information is from SPECIAL BULLETIN COVID-19 #5: Private Duty Nursing and Home Health Updates (posted Mar 19, 2020). 

Clinical Coverage Policy 3A, Home Health Services, limits a beneficiary’s annual nursing visits to 75 per year and home health aide visits to 100 annually. Effective 3/1/2020, to support Home Health beneficiaries remaining in their residence and to lift the administrative burden for the providers during the COVID-19 outbreak, the visit limit is temporarily being lifted. 

PACE Organizations

This information is from SPECIAL BULLETIN COVID-19 #27: Update for PACE Organizations (posted Mar 30, 2020). 

PACE organizations should follow the guidance of the local, state and federal officials and thoroughly document reasoning for making decisions which may fall outside of the PACE program model. NC Medicaid will provide flexibilities in the following areas:

  • Enrollments – Effective April 1, 2020, PACE organizations have the option to temporarily suspend new enrollments. The PACE organization’s decision to temporarily suspend new enrollments should be communicated to NC Medicaid via memorandum. The communication should include the new enrollment suspension effective date as well as the timeframe for the suspension. 
  • Initial Health and Safety Assessments – The Health and Safety assessment is conducted as a means of ensuring that the applicant’s health, safety or welfare will not be jeopardized by living in the community. The assessment requires an on-site evaluation. Due to COVID-19, effective March 1, 2020, the PACE organization has the option of delaying enrollment in the event the PACE organization cannot complete a Health and Safety assessment which considers all the following: 
    • An evaluation of the applicant’s residence either onsite or via remote technology;
    • An evaluation of the applicant’s social support system, including the willingness and capabilities of all informal caregivers; and
    • An evaluation of whether the applicant can be safely transported to the PACE Center.

The reason for the delay should be clearly documented and the local DSS notified about the delay by checking the revision box in section 2, page 2 of the 5106 form. The PACE organization should note the enrollment has been delayed and the proposed date of enrollment.

  • Annual Health and Safety Assessments – Effective March 1, 2020 – Dec. 31, 2020, annual Health and Safety assessments for currently enrolled participants may be completed either at the participant’s residence or via remote technology. 
  • PACE Center Closures – PACE organizations have the option to close the Adult Day Health portion of its PACE Center to assist with promoting social distancing and preventing the spread of COVID-19 while maintaining the operation of the clinics and delivery of therapy services. The PACE organization should ensure the needs of participants normally addressed at the Adult Day Health portion of its PACE Center are able to be met in the participants’ homes.
  • PACE Center Attendance – As communicated by CMS, NC Medicaid supports limiting PACE participants from attending the PACE Center as a means of minimizing the potential for exposure to COVID-19. The attendance limit of a participant as a result of COVID-19 precautions will not be viewed by NC Medicaid as a service reduction and therefore will not be appealable by the participant. Participants should, however, be informed of their right to file a grievance. The PACE organization must discuss with and provide to the participant in writing the specific steps, including timeframes for response, that will be taken to resolve the participant’s grievance.
  • Annual FL2s – Clinical Policy 3B, Section 5.5.2 requires the PACE organization to submit an FL2 each calendar year to verify the enrollee continues to meet nursing facility level of care requirements. The submission of annual FL2s, for current participants will be waived beginning March 1, 2020 – Dec. 31, 2020. PACE participants will be deemed to meet nursing home level of care and deemed eligible for the PACE program until their next scheduled annual level of care review due in 2021 (e.g. if an annual FL2 is due in March 2020, the submission requirement of the March 2020 annual FL2 will be waived and the next annual FL2 will be due March 2021).   
  • Prior Approvals – Clinical Policy 3B, Section 5.1 requires prior approval for PACE enrollment. The submission of annual prior approvals will be waived between March 1, 2020 – Dec. 31, 2020.  Prior approvals in place during March 1, 2020 – Dec. 31, 2020, will remain in effect until the next scheduled due date in 2021 (e.g. if an updated prior approval is due March 2020, the submission requirement of the March 2020 prior approval will be waived and the next prior approval will be due March 2021).  
  • Assessments/Reassessments – As communicated by CMS, NC Medicaid supports the use of remote technology as appropriate to complete scheduled and unscheduled participant assessments, care planning monitoring, communication and other related activities that would normally occur on an in-person basis. All assessment and reassessment timelines should be followed.

Durable Medical Equipment Temporary Flexibilities

The following information is from SPECIAL BULLETIN COVID-19 #10: Durable Medical Equipment: Temporary Flexibilities Effective March 23, 2020 (posted Mar 24, 2020) and SPECIAL BULLETIN COVID-19 #2: General Guidance and Policy Modifications  (posted Mar 13, 2020). Update: The effective date originally listed in #2 and #10 is replaced by this bulletin. 

Now Effective March 1, 2020, if medically necessary, the respiratory equipment and supplies listed below that typically require PA may be provided to beneficiaries with respiratory infections without first seeking PA.

HCPCS Code

Description

E0424

Stationary compressed gaseous oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask and tubing.

E0431

Portable gaseous oxygen system, rental; includes portable container, regulator, flowmeter, humidifier, cannula or mask and tubing

E0433

Portable liquid oxygen system, rental; home liquefier used to fill portable liquid oxygen containers, includes portable containers, regulator, flowmeter, humidifier, cannula or mask and tubing, with or without supply reservoir and contents gauge

E0434

Portable liquid oxygen system, rental; includes portable container, supply reservoir, humidifier, flowmeter, refill adaptor, contents gauge, cannula or mask, and tubing

E0439

Stationary liquid oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask & tubing

E0445

Oximeter device for measuring blood oxygen levels non-invasively

E0465

Home ventilator, any type, used with invasive interface, (e.g., tracheostomy tube)

E0466

Home ventilator, any type, used with noninvasive interface, (e.g., mask, chest shell)

E0470

Respiratory assist device, bi-level pressure capability, without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device

E0471

Respiratory assist device, bi-level pressure capability, with back-up rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)

E0500

IPPB machine, all types, with built-in nebulization; manual or automatic valves; internal or external power source

E0565

Compressor, air power source for equipment which is not self-contained, or cylinder driven

E0575

Nebulizer, ultrasonic, large volume

E0601

Continuous airway pressure (CPAP) device

E1356

Oxygen accessory, battery pack/cartridge for portable concentrator, any type, replacement only, each

E1357

Oxygen accessory, battery charger for portable concentrator, any type, replacement only, each

E1358

Oxygen accessory, DC power adapter for portable concentrator, any type, replacement only, each

E1390

Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate

E1392

Portable oxygen concentrator, rental

K0738

Portable gaseous oxygen system, rental; home compressor used to fill portable oxygen cylinders; includes portable containers, regulator, flowmeter, humidifier, cannula or mask, and tubing

W4001

CO2 saturation monitor with accessories, probes

W4670

Sterile saline, 3 cc vial, each

W4678

Replacement battery for portable suction pump

Effective March 1, 2020, if medically necessary, quantity limits on the following supplies may be exceeded when provided to beneficiaries with respiratory infections without first seeking PA:

HCPCS Code

Description

A4927

Gloves, non-sterile, per 100

A4930

Gloves, sterile, per pair

A4554

Disposable under pads, all sizes

T4521

Adult sized disposable incontinence product, brief/diaper, small, each

T4522

Adult sized disposable incontinence product, brief/diaper, medium, each

T4523

Adult sized disposable incontinence product, brief/diaper, large, each

T4524

Adult sized disposable incontinence product, brief/diaper, extra-large, each

T4525

Adult sized disposable incontinence product, protective underwear/pull on, small size, each

T4526

Adult sized disposable incontinence product, protective underwear/pull on, medium size, each

T4527

Adult sized disposable incontinence product, protective underwear/pull on, large size, each

T4528

Adult sized disposable incontinence product, protective underwear/pull on, extra-large size, each

T4529

Pediatric sized disposable incontinence product, brief/diaper, small/ medium size, each

T4530

Pediatric sized disposable incontinence product, brief/diaper, large size, each

T4531

Pediatric sized disposable incontinence product, protective underwear/pull on, small/medium size, each

T4532

Pediatric sized disposable incontinence product, protective underwear/pull on, large size, each

T4533

Youth sized disposable incontinence product, brief/diaper, each

T4534

Youth-sized disposable incontinence product, protective underwear/pull on, each

T4543

Disposable incontinence product, brief/diaper, bariatric, each

T4544

Adult sized disposable incontinence product, protective underwear/pull-on, above extra large, each

Effective March 1, 2020, if medically necessary, the following additional respiratory equipment and supplies that typically require PA may be provided to beneficiaries without first seeking PA:

HCPCS Code

Description

E0480

Percussor, electric or pneumatic, home model

E0482

Cough stimulating device, alternating positive and negative airway pressure

E0619

Apnea monitor, with recording feature

W4002

Manual ventilation bag (e.g., Ambu bag)

W4120

Disposable bags for Inspirease inhaler system, set of 3

W4153

Tracheostomy ties, twill

Now effective March 1, 2020, if medically necessary, the following nursing equipment and supplies that typically require PA may be provided to beneficiaries without first seeking PA:

HCPCS Code

Description

A4253

*Non-Preferred Brand: Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips

A4256

*Non-Preferred Brand: Normal, low and high calibrator solution/chips

A4258

*Non-Preferred Brand: Spring-powered device for lancet, each

A4259

*Non-Preferred Brand: Lancets, per box of 100

A9276

**Sensor; invasive (e.g. subcutaneous), disposable, for use with interstitial continuous glucose monitoring system, one unit = 1-day supply

A9277

**Transmitter; external, for use with interstitial continuous glucose monitoring system

A9278

**Receiver (monitor); external, for use with interstitial continuous glucose monitoring system

E2100

Blood glucose monitor with integrated voice synthesizer

K0739

Repair or nonroutine service for durable medical equipment other than oxygen equipment requiring the skill of a technician, labor component, per 15 minutes

*Preferred Roche brand blood glucose testing products do not require PA. See DME fee schedule for appropriate NDCs.
**Reauthorizations suspended for continuous glucose monitors and supplies. Initial PA still required.

Effective March 1, 2020, if medically necessary, quantity limits on the following respiratory equipment and supplies may be exceeded when provided to beneficiaries without first seeking PA:

HCPCS Code

Description

A4556

Electrodes (e.g., apnea monitor), per pair

A4557

Lead wires (e.g., apnea monitor), per pair

A4614

Peak expiratory flow rate meter, hand held

A4624

Tracheal suction catheter, any type, other than closed system, each

A4625

Tracheostomy care kit for new tracheostomy

A4627

Spacer, bag or reservoir, with or without mask, for use with metered dose inhaler

A4628

Oropharyngeal suction catheter, each

A4629

Tracheostomy care kit for established tracheostomy

A7000

Canister, disposable, used with suction pump, each

A7001

Canister, non-disposable, used with suction pump, each

A7002

Tubing, used with suction pump, each

A7003

Administration set, with small volume nonfiltered pneumatic nebulizer, disposable

A7004

Small volume nonfiltered pneumatic nebulizer, disposable

A7005

Administration set, with small volume nonfiltered pneumatic nebulizer, non-disposable

A7006

Administration set, with small volume filtered pneumatic nebulizer

A7007

Large volume nebulizer, disposable, unfilled, used with aerosol compressor

A7010

Corrugated tubing, disposable, used with large volume nebulizer, 100 feet

A7012

Water collection device, used with large volume nebulizer

A7013

Filter, disposable, used with aerosol compressor or ultrasonic generator

A7015

Aerosol mask, used with DME nebulizer

A7020

Interface for cough stimulating device, includes all components, replacement only

A7027

Combination oral/nasal mask, used with continuous positive airway pressure device, each

A7028

Oral cushion for combination oral/nasal mask, replacement only, each

A7029

Nasal pillows for combination oral/nasal mask, replacement only, pair

A7030

Full face mask used with positive airway pressure device, each

A7031

Face mask interface, replacement for full face mask, each

A7032

Cushion for use on nasal mask interface, replacement only, each

A7033

Pillow for use on nasal cannula type interface, replacement only, pair

A7034

Nasal interface (mask or cannula type) used with positive airway pressure device with or without head strap

A7035

Headgear used with positive airway pressure device

A7036

Chinstrap used with positive airway pressure device

A7037

Tubing used with positive airway pressure device

A7038

Filter, disposable, used with positive airway pressure device

A7039

Filter, non-disposable, used with positive airway pressure device

A7526

Tracheostomy tube collar/holder, each

A9284

Spirometer, non-electronic, includes all accessories

E0484

Oscillatory positive expiratory pressure device, non-electric, any type, each

L8501

Tracheostomy speaking valve

S8185

Flutter device

W4120

Disposable bags for Inspirease inhaler system, set of 3

W4153

Tracheostomy ties, twill


Effective March 1, 2020, if medically necessary,
quantity limits on the following nursing equipment and supplies may be exceeded when provided to beneficiaries without first seeking PA:

HCPCS Code

Description

A4213

Syringe, sterile, 20cc or greater, each

A4215

Needle, sterile, any size, each

A4230

Infusion set for external insulin pump, non-needle cannula type

A4231

Infusion set for external insulin pump, needle type 

A4233

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

A4234

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

A4235

Replacement battery, lithium, 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

A4246

Betadine or pHisoHex solution, per pint

A4250

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

A4252

Blood Ketone test or reagent strip, each

A4253

Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips

A4256

Normal, low and high calibrator solution/chips

A4258

Spring-powered device for lancet, each

A4259

Lancets, per box of 100

A4310

Insertion tray without drainage bag and without catheter (accessories only)

A4311

Insertion tray without drainage bag with indwelling catheter, Foley type, two-way latex with coating (Teflon, silicone, silicone elastomer, or hydrophilic, etc.)

A4313

Insertion tray without drainage bag with indwelling catheter, Foley type, three-way, for continuous irrigation

A4314

Insertion tray with drainage bag with indwelling catheter, Foley type, two-way latex with coating (Teflon, silicone, silicone elastomer, or hydrophilic, etc.)

A4316

Insertion tray with drainage bag with indwelling catheter, Foley type, three-way, for continuous irrigation

A4320

Irrigation tray with bulb or piston syringe, any purpose

A4321

Therapeutic agent for urinary catheter irrigation

A4322

Irrigation syringe, bulb or piston, each

A4328

Female external urinary collection device; pouch, each

A4331

Extension drainage tubing, any type, any length, with connector/adapter, for use with urinary leg bag or urostomy pouch, each

A4334

Urinary catheter anchoring device, leg strap, each

A4335

Incontinence supply; miscellaneous

A4338

Indwelling catheter; Foley type, two-way latex with coating (Teflon, silicone, silicone elastomer, or hydrophilic, etc.), each

A4340

Indwelling catheter; specialty type (e.g., coude, mushroom, wing, etc.), each

A4344

Indwelling catheter, Foley type, two-way, all silicone, each

A4349

Male external catheter, with or without adhesive, disposable, each

A4351

Intermittent urinary catheter; straight tip, with or without coating (Teflon, silicone, silicone elastomer, or hydrophilic, etc.), each

A4352

Intermittent urinary catheter; coude (curved) tip, with or without coating (Teflon, silicone, silicone elastomer, or hydrophilic, etc.), each

A4353

Intermittent urinary catheter, with insertion supplies

A4354

Insertion tray with drainage bag but without catheter

A4357

Bedside drainage bag, day or night, with or without anti-reflux device, with or without tube, each

A4358

Urinary drainage bag, leg or abdomen, vinyl, with or without tube, with straps, each

A4361

Ostomy faceplate, each

A4362

Skin barrier; solid, 4X4 or equivalent; each

A4364

Adhesive, liquid or equal, any type, per oz.

A4367

Ostomy belt, each

A4368

Ostomy filter, any type, each

A4369

Ostomy skin barrier, liquid (spray, brush, etc.), per oz.

A4371

Ostomy skin barrier, powder, per oz.

A4372

Ostomy skin barrier, solid 4X4 or equivalent, standard wear, with built-in convexity, each

A4373

Ostomy skin barrier, with flange (solid, flexible, or accordion), with built-in convexity, any size, each

A4375

Ostomy pouch, drainable, with faceplate attached, plastic, each

A4376

Ostomy pouch, drainable, with faceplate attached, rubber, each

A4377

Ostomy pouch, drainable, for use on faceplate, plastic each

A4378

Ostomy pouch, drainable, for use on faceplate, rubber, each

A4379

Ostomy pouch, urinary, with faceplate attached, plastic, each

A4380

Ostomy pouch, urinary, with faceplate attached, rubber, each

A4381

Ostomy pouch, urinary, for use on faceplate, plastic each

A4382

Ostomy pouch, urinary, for use on faceplate, heavy plastic, each

A4383

Ostomy pouch, urinary, for use on faceplate, rubber, each

A4384

Ostomy faceplate equivalent, silicone ring, each

A4385

Ostomy skin barrier, solid 4X4 or equivalent, extended wear, without built-in convexity, each

A4388

Ostomy pouch, drainable, with extended wear barrier attached (1 piece), each

A4389

Ostomy pouch, drainable, with barrier attached, with built-in convexity (1 piece), each

A4390

Ostomy pouch, drainable, with extended wear barrier attached, with built-in convexity (1 piece), each

A4391

Ostomy pouch, urinary, with extended wear barrier attached (1 piece), each

A4392

Ostomy pouch, urinary, with standard wear barrier attached, with built-in convexity (1 piece), each

A4393

Ostomy pouch, urinary, with extended wear barrier attached, with built-in convexity (1 piece), each

A4394

Ostomy deodorant, with or without lubricant, for use in ostomy pouch, per fluid ounce

A4395

Ostomy deodorant, for use in ostomy pouch, solid, per tablet

A4397

Irrigation supply; sleeve, each

A4398

Ostomy irrigation supply; bag, each

A4399

Ostomy irrigation supply; cone/catheter, with or without brush

A4400

Ostomy irrigation set

A4402

Lubricant, per ounce

A4404

Ostomy ring, each

A4405

Ostomy skin barrier, non-pectin based, paste, per ounce

A4406

Ostomy skin barrier, pectin-based, paste, per ounce

A4407

Ostomy skin barrier, with flange (solid, flexible, or accordion), extended wear, with built-in convexity, 4X4 inches or smaller, each

A4408

Ostomy skin barrier, with flange (solid, flexible, or accordion), extended wear, with built-in convexity, larger than 4X4 inches, each

A4409

Ostomy skin barrier, with flange (solid, flexible, or accordion), extended wear, without built-in convexity, 4X4 inches or smaller, each

A4410

Ostomy skin barrier, with flange (solid, flexible, or accordion), extended wear, without built-in convexity, larger than 4X4 inches, each

A4411

Ostomy skin barrier, solid 4X4 or equivalent, extended wear, with built-in convexity, each

A4414

Ostomy skin barrier, with flange (solid, flexible, or accordion), without built-in convexity, 4X4 inches or smaller, each

A4415

Ostomy skin barrier, with flange (solid, flexible, or accordion), without built-in convexity, larger than 4X4 inches, each

A4416

Ostomy pouch, closed, with barrier attached, with filter (1 piece), each

A4417

Ostomy pouch, closed, with barrier attached, with built-in convexity, with filter (1 piece), each

A4418

Ostomy pouch, closed, without barrier attached, with filter (1 piece), each

A4419

Ostomy pouch, closed; for use on barrier with non-locking flange, with filter (2 piece), each

A4423

Ostomy pouch, closed; for use on barrier with locking flange, with filter (2 piece), each

A4424

Ostomy pouch, drainable, with barrier attached, with filter (1 piece), each

A4425

Ostomy pouch, drainable; for use on barrier with non-locking flange, with filter (2 piece system), each

A4426

Ostomy pouch, drainable; for use on barrier with locking flange (2 piece system), each

A4427

Ostomy pouch, drainable; for use on barrier with locking flange, with filter (2 piece system), each

A4428

Ostomy pouch, urinary, with extended wear barrier attached, with faucet-type tap with valve (1 piece), each

A4429

Ostomy pouch, urinary, with barrier attached, with built-in convexity, with faucet-type tap with valve (1 piece), each

A4430

Ostomy pouch, urinary, with extended wear barrier attached, with built-in convexity, with faucet-type tap with valve (1 piece), each

A4431

Ostomy pouch, urinary; with barrier attached, with faucet-type tap with valve (1 piece), each

A4432

Ostomy pouch, urinary; for use on barrier with non-locking flange, with faucet-type tap with valve (2 piece), each

A4433

Ostomy pouch, urinary; for use on barrier with locking flange (2 piece), each

A4435

Ostomy pouch, drainable, high output, with extended wear barrier (one-piece system), with or without filter, each

A4450

Tape, non-waterproof, per 18 square inches

A4452

Tape, waterproof, per 18 square inches

A4455

Adhesive remover or solvent (for tape, cement or other adhesive), per ounce

A4456

Adhesive remover, wipes, any type, each

A4554

Disposable underpads, all sizes

A5051

Ostomy pouch, closed; with barrier attached (1 piece), each

A5052

Ostomy pouch, closed; without barrier attached (1 piece), each

A5053

Ostomy pouch, closed; for use on faceplate, each

A5054

Ostomy pouch, closed; for use on barrier with flange (2 piece), each

A5055

Stoma cap

A5056

Ostomy pouch, drainable, with extended wear barrier attached, with filter, (1 piece), each

A5057

Ostomy pouch, drainable, with extended wear barrier attached, with built in convexity, with filter, (1 piece), each

A5061

Ostomy pouch, drainable; with barrier attached, (1 piece), each

A5062

Ostomy pouch, drainable; without barrier attached (1 piece), each

A5063

Ostomy pouch, drainable; for use on barrier with flange (2 piece system), each

A5071

Ostomy pouch, urinary; with barrier attached (1 piece), each

A5072

Ostomy pouch, urinary; without barrier attached (1 piece), each

A5073

Ostomy pouch, urinary; for use on barrier with flange (2 piece), each

A5093

Ostomy accessory; convex insert

A5102

Bedside drainage bottle with or without tubing, rigid or expandable, each

A5120

Skin barrier, wipes, or swabs, each

A5121

Skin barrier; solid, 6X6 or equivalent, each

A5122

Skin barrier; solid, 8X8 or equivalent, each

A5126

Adhesive or non-adhesive; disk or foam pad

A5131

Appliance cleaner, incontinence and ostomy appliances, per 16 oz.

A6216

Gauze, non-impregnated, non-sterile, pad size 16 sq. in or less, without adhesive boarder, each dressing

A6257

Transparent film, sterile, 16 sq. in. or less, each dressing

A6258

Transparent film, sterile, more than 16 sq. in. but less than or equal to 48 sq. in., each dressing

A7048

Vacuum drainage collection unit and tubing kit, including all supplies needed for collection unit change, for use with implanted catheter, each

A9274

External ambulatory insulin delivery system, disposable, each, includes all supplies and accessories

A9276

Sensor; invasive (e.g. subcutaneous), disposable, for use with interstitial continuous glucose monitoring system, one unit = 1-day supply

A9999

Miscellaneous DME supply or accessory, not otherwise specified (For use with Farrell Valve only)

B4034

Enteral feeding supply kit; syringe fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape

B4035

Enteral feeding supply kit; pump fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape

B4036

Enteral feeding supply kit; gravity fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape

B4081

Nasogastric tubing with stylet

B4082

Nasogastric tubing without stylet

B4083

Stomach tube—Levine type

B4087

Gastrostomy/jejunostomy tube, standard, any material, any type, each

B4088

Gastrostomy/jejunostomy tube, low-profile, any material, any type, each

B4103

Enteral formula, for pediatrics, used to replace fluids and electrolytes (e.g., clear liquids), 500 ml = 1 unit

B4149

Enteral formula, manufactured blenderized natural foods with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories=1 unit

B4150

Enteral formulae, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins, and minerals, may include fiber, administered through an enteral feeding tube, 100 calories= 1 unit

B4152

Enteral formula, nutritionally complete, calorically dense (equal to or greater than 1.5 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories=1 unit

B4153

Enteral formula, nutritionally complete, hydrolyzed proteins (amino acids and peptide chain), includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories=1 unit

B4154

Enteral formula, nutritionally complete, for special metabolic needs, excludes inherited disease of metabolism, includes altered composition of proteins, fats, carbohydrates, vitamins and/or minerals, may include fiber, administered through an enteral feeding tube, 100 calories=1 unit

B4155

Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g. glucose polymers), proteins/amino acids (e.g. glutamine, arginine), fat (e.g. medium chain triglycerides) or combination, administered through an enteral feeding tube, 100 calories= 1unit

B4157

Enteral formula, nutritionally complete, for special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit

B4158

Enteral formula, for pediatric nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 cal = 1 unit

B4159

Enteral formula, for pediatrics, nutritionally complete soy based with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 Cal = 1 unit

B4160

Enteral formula, for pediatrics, nutritionally complete calorically dense (equal to or greater than 0.7 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 Cal = 1 unit

B4161

Enteral formula, for pediatrics, hydrolyzed/amino acids and peptide chain proteins, includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 Cal = 1 unit

B4162

Enteral formula, for pediatrics, special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 Cal = 1 unit

K0552

Supplies for external drug infusion pump, syringe type cartridge, sterile, each

K0601

Replacement battery for external infusion pump owned by patient, silver oxide, 1.5 volt, each

K0602

Replacement battery for external infusion pump owned by patient, silver oxide, 3 volt, each

K0603

Replacement battery for external infusion pump owned by patient, alkaline, 1.5 volt, each

K0604

Replacement battery for external infusion pump owned by patient, lithium, 3.6 volt, each

K0605

Replacement battery for external infusion pump owned by patient, lithium, 4.5 volt, each

S8490

Insulin syringes (100 syringes, any size)

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NCTracks Contact Center: 800-688-6696