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Minnesota Department of Human Services Provider Manual
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Gloves

Revised: 07-29 2011

  • Overview
  • Eligible Providers
  • Eligible Recipients
  • Covered Services
  • Noncovered Services
  • Authorization
  • Billing
  • 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:

  • • Federally Qualified Health Center
  • • Home health agencies
  • • Indian Health Services
  • • Medical suppliers
  • • Pharmacies
  • • Rural Health Clinic
  • 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:

  • • Description of item (non-sterile or sterile gloves)
  • • Quantity ordered
  • • Medical procedures requiring gloves
  • • Duration of the order
  • • Name of recipient
  • • Name of physician
  • • Date of order
  • 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

  • • Gloves for use while performing hygiene cares, including routine incontinence care
  • • Sterile gloves for use for non-sterile procedures
  • • Non-sterile or sterile gloves for recipients living in nursing facilities or intermediate care facilities for persons with developmental disabilities
  • 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

  • • Bill the correct HCPCS code with the NU modifier
  • • Bill in units, not quantity of gloves (1 unit equals 100 gloves)
  • • If billing 50 gloves, bill 1 unit with the 52 modifier (reduced services)
  • Sterile

  • • Bill using the correct HCPCS code with the NU modifier
  • • Bill in units, not quantity of gloves (1 unit equals 2 gloves or one pair)
  • 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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