All temporary Durable Medical Equipment (DME) policy flexibilities outlined in COVID-19 Special Bulletins remain in effect as of this publication date. See COVID-19 Special Bulletins for details.
An updated version of Clinical Coverage Policy 5A-3, Nursing Equipment and Supplies, with an amended date of May 15, 2022, was posted to the NC Medicaid Clinical Coverage Policy web page. Following is a summary of updates:
In Subsection 5.3.4 Phototherapy, prior approval was removed from phototherapy (bilirubin) light with photometer (HCPCS code E0202) when clinical coverage guidelines are met. And coverage for the treatment of hyperbilirubinemia within the first 30 calendar days of life was updated to allow for coverage during the first 31 calendar days of life. These revisions are effective retroactively to Nov 1, 2021.
New coverage was added for manual pump operated enema systems (HCPCS codes A4453, A4459) with new Subsection 5.3.9 Manual Pump-Operated Enema System, and the following medical necessity criteria. This revision is effective retroactively to Oct 1, 2021:
A manual pump-operated enema system, such as the Peristeen® Anal Irrigation System, may be considered medically necessary when all the following coverage criteria are met:
a. Beneficiary has a diagnosis of neurogenic bowel dysfunction. Refer to Attachment A, Section B for the required ICD-10 diagnosis code;
b. Beneficiary is two years of age and older;
c. Beneficiary suffers from fecal incontinence, chronic constipation, and time-consuming bowel management procedures; and
d. Initial management involving diet, bowel habit, laxatives, or constipating medication has failed.
Note: If the above medical necessity criteria are met, then prior authorization is not required
In Attachment A: Claims-Related Information, Section B, ICD-10-CM Diagnosis Code K59.2 (neurogenic bowel, not elsewhere classified) was added as an acceptable diagnosis for the manual pump-operated enema system.
In Attachment A: Claims-Related Information, Section C: Procedure Code(s), the following updates were made:
Coverage and quantity limits were added for HCPCS codes A4453 (Rectal catheter for use with the manual pump-operated enema system, replacement only) and A4459 (Manual pump-operated enema system, includes balloon, catheter and all accessories, reusable, any type).
Per the CMS annual update, HCPCS code A4397 (Irrigation supply; sleeve, each) was end-dated Dec 31, 2021, and replaced with HCPCS codes A4436 (Irrigation supply; sleeve, reusable, per month) and A4437 (Irrigation supply; sleeve, disposable, per month), effective Jan 1, 2022.
Added language to clarify that the quantity limit for HCPCS codes A4450 (Tape, non-waterproof, per 18 square inches) and A4452 (Tape, waterproof, per 18 square inches) is 80 units per month.
In Attachment B: Provision of DME and Medical Supplies on the Date of Discharge from Specified Facilities, the asterisk indicating that an item requires prior approval was removed. The BOLD indicating Medicare is the primary payer for an item was also removed.
In Attachment C: Completing a Claim for DME or EN Services, NCHC was removed from block one.
Additional Resources
The DME fee schedule and full text of Clinical Coverage Policy 5A-2, Respiratory Equipment and Supplies is available at North Carolina Medicaid’s Durable Medical Equipment (DME) web page. All COVID-19 Special Bulletins are available here.
Contact
NC Medicaid Contact Center, 888-245-0179