Gloves

Revised: 07-29 2011

Overview

Non-sterile gloves are used by a recipient or caregiver when performing non-sterile medical procedures for the recipient. Sterile gloves are used by a recipient or caregiver when performing sterile medical procedures for the recipient.

Eligible Providers

The following providers may provide sterile or non-sterile gloves:

TPL and Medicare

Providers must meet any provider criteria, including accreditation, for third party insurance or for Medicare in order to assist recipients for whom MHCP is not the primary payer.

Eligible Recipients

Non-sterile and sterile gloves are covered for eligible MHCP recipients.

Covered Services

Codes: A4927 (1 unit = 100 non-sterile gloves), A4930 (1 unit = 1 pair of sterile gloves)

Documentation

The supplier must maintain the dispensing order including:

MHCP pays for non-sterile gloves for use by the recipient or caregiver when ordered by the prescribing provider for use in performing non-sterile medical procedures for the recipient. MHCP pays for sterile gloves for use by the recipient or caregiver when ordered by the prescribing provider for use during sterile medical procedures.

Non-sterile gloves are medically necessary for clean procedures including but not limited to most wound care/dressing changes, application of topical medications, clean catheterization, tracheostomy cares, gastrostomy tube/jejunostomy tube cares, and all tube feedings.

Non-sterile gloves are medically necessary for hygiene cares only if the recipient has open sores, diarrhea, a diagnosed infection or a compromised immune system. If a recipient has a history of frequent diarrhea, the provider may dispense gloves to be kept on hand.

Sterile gloves are medically necessary for sterile procedures including sterile catheterization, sterile wound care and other procedures a prescribing provider determines cannot be safely done using clean techniques.

Noncovered Services

Authorization

Authorization may be requested for recipients requiring more than the allowed number of units of non-sterile or sterile gloves per month. Clearly document the cares or procedures requiring gloves, and the frequency of the cares or procedures required.

Submit authorization requests and required documentation to the authorization medical review agent.

Billing

Non-Sterile

Sterile

If gloves are ordered for cares or procedures where no resolution is expected for the recipient, the order may be written without an expiration date and does not need to be annually renewed.

If gloves are ordered for cares or procedures with reasonable expectations of resolution (i.e. wound care), the order may not exceed 12 months.

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