An amended version of Clinical Coverage Policy 5A-3, Nursing Equipment and Supplies with an effective date of March 1, 2025, was posted to the NC Medicaid Clinical Coverage Policy web page.
Summary of Updates
In the table Related Clinical Coverage Policies, added reference to clinical coverage policy 3D, Hospice Services.
The terms ‘approval,’ ‘authorization’ and ‘prior authorization’ were changed to ‘prior approval’ for consistency throughout.
In Subsection 1.1 Description of the Procedure, Product, or Service, removed headings and added clarifying language.
In Subsection 4.2.1 Specific Criteria Not Covered by Medicaid, added clarifying language.
In Subsection 5.3.4 Phototherapy, updated ‘block 24’ to ‘block 29’ to align with CMN/PA form.
In Subsection 5.8 Servicing and Repairing Medical Equipment, updated ‘block 25’ to ‘block 30’ to align with CMN/PA form.
In Subsection 6.2 Federal Laws, outdated references to Federal Laws were removed.
In Attachment A, Section B, as part of the CMS annual ICD-10 update, added diagnosis codes E10A0 (type 1 diabetes mellitus, presymptomatic, unspecified), E10A1 (type 1 diabetes mellitus, presymptomatic, stage 1), and E10A2 (type 1 diabetes mellitus, presymptomatic, stage 2) to the ICD-10 code table associated with blood glucose monitors and external insulin pumps, effective Oct. 1, 2024.
In Attachment A: Claims-Related Information, Section C: Procedure Code(s), the following updates were made:
- Removed HCPCS codes A9276, A9277, A9278 and end dated coverage Jan. 31, 2025, as adjunctive (non-therapeutic) continuous glucose monitors and supplies are now described by A4238 and E2102.
- Added age limit 0 to 20 for HCPCS code B4100 to match medical necessity criteria in subsection 5.3.6, and S8265 to align with NCTracks.
Added coverage, lifetime expectancy/quantity limitations for the following HCPCS codes:
| HCPCS code | Description | Lifetime Expectancy or Quantity Limitation |
|---|---|---|
| A4271 | Integrated lancing and blood sample testing cartridges for home blood glucose monitor, per month | 1 per month |
| E2104 | Home blood glucose monitor for use with integrated lancing/blood sample testing cartridge | Per manufacturer’s warranty |
| A4332 | Lubricant, individual sterile packet, each | 200 per month |
In Attachment A: Claims-Related Information, Section D: Modifiers, added routine instructions: NU for items purchased new, UE for items purchased used, RR for rental items.
In Attachment C: Completing a Claim for DME or EN Services, instructions for completing a CMS-1500 claim form were updated, and outdated sample claim forms were removed.
The note about when to submit an invoice with a claim for a manually priced item was updated to read:
“Note: For manually priced items requiring PA, if the maximum allowable reimbursement was based on a quote or estimate, then the invoice must be submitted with the claim. If the invoice was submitted with the PA request, then it is not required again with claim.”
Additional Resources
The Durable Medical Equipment (DME) fee schedule and full text of Clinical Coverage Policy 5A-3, Nursing Equipment and Supplies is available at North Carolina Medicaid’s Durable Medical Equipment web page.
Contact
NC Medicaid Contact Center, 888-245-0179
Please contact the managed care health plans by leveraging the information on the Health Plan Contacts and Resources page.