Gloves

Revised: November 26, 2019

· Overview

· Eligible Providers

· Eligible Recipients

· Covered Services

· Noncovered Services

· Authorization

· Billing

Overview

Non-sterile gloves are used for clean procedures. These are suitable for procedures where a member is not at high risk for infection.

Sterile gloves must meet FDA standards. They are required for procedures where a member is at higher risk for infection.

Eligible Providers

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

· Federally Qualified Health Centers

· Home health agencies

· Indian Health Services

· Medical suppliers

· Pharmacies

· Rural Health Clinics

TPL and Medicare

Providers must meet any provider criteria, including accreditation, for third-party insurance or for Medicare in order to assist members for whom Minnesota Health Care Programs (MHCP) is not the primary payer.

Eligible Recipients

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

Covered Services

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

Coverage Criteria

MHCP covers non-sterile gloves for use by a member or the member’s caregiver for procedures which could include the following:

· Most wound care or dressing changes

· Application of topical medications

· Clean catheterization

· Tracheostomy cares

· Gastrostomy tube or jejunostomy tube cares

· Tube feedings

· Other procedures a prescriber deems medically necessary

MHCP covers non-sterile gloves for use by the member or the member’s caregiver for hygiene care when the following conditions are present:

· Open sores

· Diarrhea (If a member has a history of frequent diarrhea, the medical supply provider may dispense gloves to keep on hand)

· A diagnosed infection

· A compromised immune system

· Other conditions a prescriber deems medically necessary

MHCP covers sterile gloves for use by the member or the member’s caregiver when ordered by the prescribing provider for use during sterile medical procedures, which could include the following:

· Sterile catheterization

· Sterile wound care

· Other procedures which the prescriber determines infection concerns require the use 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

Noncovered Services

· Gloves for use while performing routine hygiene and incontinence care

· Sterile gloves for use for non-sterile procedures

· Non-sterile or sterile gloves for members living in nursing facilities or intermediate care facilities (this is included in the per diem).

Authorization

Authorization may be requested for members requiring more than the allowed number of units of non-sterile or sterile gloves per month. Clearly document the cares or procedures requiring gloves including their frequency.

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

Billing

· Use MN–ITS 837P Professional or X12 Batch

· Shipping and delivery costs are included in the MHCP maximum allowable payment. Do not bill either MHCP or the member separately for these costs.

· If gloves are ordered for cares or procedures where no resolution is expected for the member, 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.

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)