Notice of Instruction 5905 Breckenridge Parkway, Suite F Tampa, Florida (813) (800) (FL) Fax (813)

Transcription

1 Notice of Instruction 5905 Breckenridge Parkway, Suite F Tampa, Florida (813) (800) (FL) Fax (813) Notice of Instruction Number: # Aged and Disabled Adult Waiver Disposable Incontinence Medical Supplies Fee Schedule - lc TO: FROM: All Aged and Disabled Adult Medicaid Waiver Providers Lauren Cury DATE: August 23, 2012 SUBJECT: Aged and Disabled Adult Waiver Disposable Incontinence Medical Supplies Fee Schedule The purpose of this Notice of Instruction is to inform you that on July 23, 2012, the West Central Florida Area Agency on Aging (WCFAAA) received notification from the Department of Elder Affairs (DOEA), that all Aged and Disabled Adult Medicaid Waiver (ADA) providers are now able to bill Florida Medicaid using new ADA disposable incontinence medical supplies billing codes. Effectively immediately all ADA Providers should begin the transition to using the new ADA disposable incontinence medical supplies billing codes. The new ADA disposable medical supplies billing codes can be found in the attached document entitled, "Aged and Disabled Adult Waiver Disposable Incontinence Medical Supplies Fee Schedule". Provider billing should coincide with the recipients' routine Quarterly Care Plan Reviews, as formed by the ADA Case Manager. The WCFAAA is concurrently notifying the case management agencies of the need to update ADA recipient care plans in accordance with the Aged and Disabled Adult Waiver Disposable Incontinence Medical Supplies Fee Schedule (see attached).

2 For further clarification, please visit to our website, to access the documents, Incontinence Billing Guidelines and Incontinence Frequently Asked Question. Further clarification will be provided as it is received from the DOEA and/or the Agency for Health Care Administration (AHCA). The WCFAAA appreciates your cooation in regards to this directive. Thank you for your continued commitment to Florida s elders. Should you require additional program information, please contact your WCFAAA Medicaid Waiver Specialist.

3 AGED AND DISABLED ADULT WAIVER DISPOSABLE INCONTINENCE MEDICAL SUPPLIES FEE SCHEDULE The codes listed below are billable under the Durable Medical Equipment (DME) and Medical Supplies State Plan Program for recipients under 21 years of age. For recipients under age 21, providers must bill the DME State Plan Program up to the maximum limit before billing the waiver for these codes. For recipients over age 21, the provider may bill the waiver for these codes using the code plus the waiver modifier. Reimbursement for these codes under the waiver is counted towards the total allowable reimbursement for medical supplies established under the waiver. A4310 A4314 A4315 A4316 A4320 INSERTION TRAY WITHOUT DRAINAGE BAG AND WITHOUT CATHETER (ACCESSORIES ONLY) INSERTION TRAY WITH DRAINAGE BAG WITH INDWELLING CATHETER, FOLEY TYPE, TWO-WAY LATEX WITH COATING (TEFLON, SILICONE, SILICONE ELASTOMER OR HYDROPHILIC, ETC.) INSERTION TRAY WITH DRAINAGE BAG WITH INDWELLING CATHETER, FOLEY TYPE, TWO-WAY, ALL SILICONE INSERTION TRAY WITH DRAINAGE BAG WITH INDWELLING CATHETER, FOLEY TYPE, THREE-WAY, FOR CONTINUOUS IRRIGATION IRRIGATION TRAY WITH BULB OR PISTON SYRINGE, ANY PURPOSE MAX PMTS. $ $ year $ $ year $ $ year $ $ year $ $1, year A4322 IRRIGATION TRAY WITH BULB OR PISTON SYRINGE, $ $ year A4326 A4327 A4328 A4330 MALE EXTERNAL CATHETER SPECIALTY TYPE WITH INTEGRAL COLLECTION CHAMBER, FEMALE EXTERNAL URINARY COLLECTION DEVICE; METAL CUP, FEMALE EXTERNAL URINARY COLLECTION DEVICE; POUCH, IANAL FECAL COLLECTION POUCH WITH ADHESIVE, $ $3, year $ $ year $ $ year $ $1, year *Enter 1 only when billing the waiver. Do not enter 1 when billing state plan Durable Medical Equipment and Medical Supply Program services. Note: = Date of Service Page 1 of 16

4 Plan Program for recipients under 21 years of age. For recipients under age 21, providers must bill the DME State Plan Program up to the maximum limit before billing the waiver for these codes. For recipients over age 21, the provider may bill the waiver for these codes using the code plus the waiver modifier. Reimbursement for these codes under the waiver is counted towards the total allowable reimbursement for medical supplies established under the waiver. MAX PMTS. A4335 INCONTINENCE SUPPLY; MISCELLANEOUS $ $ year A4338 A4340 A4344 A4346 A4354 A4355 A4356 INDWELLING CATHETER; FOLEY TYPE, TWO-WAY LATEX WITH COATING (TEFLON, SILICONE, SILICONE ELASTOMER, OR HYDROPHILIC, ETC.), INDWELLING CATHETER; SPECIALTY TYPE, EG., COUDE, MUSHROOM, WING, ETC., INDWELLING CATHETER, FOLEY TYPE, TWO-WAY, ALL SILICONE, INDWELLING CATHETER; FOLEY TYPE, THREE WAY FOR CONTINUOUS IRRIGATION, INSERTION TRAY WITH DRAINAGE BAG BUT WITHOUT CATHETER IRRIGATION TUBING SET FOR CONTINUOUS BLADDER IRRIGATION THROUGH A THREE-WAY INDWELLING FOLEY CATHETER, EXTERNAL URETHRAL CLAMP OR COMPRESSION DEVICE (NOT TO BE USED FOR CATHETER CLAMP), $ $ year $ $ year $ $ year $ $ year $ $ year $ $ year $ $ year A4554 DISPOSABLE UNDERPADS, ALL SIZES, (E.G., CHUXS) $ $ year A5102 BEDSIDE DRAINAGE BOTTLE WITH OR WITHOUT TUBING, RIGID OR EXPANDABLE, $ $ year A5105 URINARY SUSPENSORY; WITH LEG BAG, WITH OR WITHOUT TUBE $ $ year *Enter 1 only when billing the waiver. Do not enter 1 when billing state plan Durable Medical Equipment and Medical Supply Program services. Page 2 of 16

5 Plan Program for recipients under 21 years of age. For recipients under age 21, providers must bill the DME State Plan Program up to the maximum limit before billing the waiver for these codes. For recipients over age 21, the provider may bill the waiver for these codes using the code plus the waiver modifier. Reimbursement for these codes under the waiver is counted towards the total allowable reimbursement for medical supplies established under the waiver. MAX PMTS. A5113 LEG STRAP; LATEX, REPLACEMENT ONLY, SET $ $ year A5114 LEG STRAP; FOAM OR FABRIC, REPLACEMENT ONLY, SET $ $ year A5126 ADHESIVE OR NON-ADHESIVE; DISK OR FOAM PAD $ $ year A5200 CUTANEOUS CATHETER/TUBE ANCHORING DEVICE, ADHESIVE SKIN ATTACHMENT $ $ year Page 3 of 16

6 The codes listed below are billable under the Durable Medical Equipment (DME) and Medical Supplies State Plan Program for recipients 4 to 20 years of age. For recipients under age 21, providers must bill the DME State Plan Program up to the maximum limit before billing the waiver for these codes. Reimbursement for these codes under the waiver is counted towards the total allowable reimbursement for medical supplies established under the waiver. T4521 BRIEF/DIA, SMALL, MAX PMTS. 1 $ $1, T4522 BRIEF/DIA, MEDIUM, $ $1, T4523 BRIEF/DIA, LARGE, $ $1, T4524 BRIEF/DIA, EXTRA LARGE, $ $2, T4525 PROTECTIVE UNDERWEAR/PULL-ON, SMALL SIZE, $ $1, T4526 PROTECTIVE UNDERWEAR/PULL-ON, MEDIUM SIZE, $ $2, T4527 PROTECTIVE UNDERWEAR/PULL-ON, LARGE SIZE, $ $2, T4528 PROTECTIVE UNDERWEAR/PULL-ON, EXTRA LARGE SIZE, $ $2, T4529 PEDIATRIC SIZED DISPOSABLE INCONTINENCE PRODUCT, BRIEF/DIA, SMALL/MEDIUM SIZE, $ $1, T4530 PEDIATRIC SIZED DISPOSABLE INCONTINENCE PRODUCT, BRIEF/DIA, LARGE SIZE, $ $1, Page 4 of 16

7 Plan Program for recipients 4 to 20 years of age. For recipients under age 21, providers must bill the DME State Plan Program up to the maximum limit before billing the waiver for these codes. Reimbursement for these codes under the waiver is counted towards the total allowable reimbursement for medical supplies established under the waiver. MAX PMTS. 1 T4531 PEDIATRIC SIZED DISPOSABLE INCONTINENCE PRODUCT, PROTECTIVE UNDERWEAR/PULL- ON, SMALL/MEDIUM SIZE, $ $1, T4532 PEDIATRIC SIZED DISPOSABLE INCONTINENCE PRODUCT, PROTECTIVE UNDERWEAR/PULL-ON, LARGE SIZE, $ $1, T4533 YOUTH SIZED DISPOSABLE INCONTINENCE PRODUCT, BRIEF/DIA, $ $1, T4534 YOUTH SIZED DISPOSABLE INCONTINENCE PRODUCT, PROTECTIVE UNDERWEAR/PULL-ON, $ $2, T4535 DISPOSABLE LINER/SHIELD/GUARD/PAD/ UNDERGARMENT, FOR INCONTINENCE, $ $1, T4543 DISPOSABLE INCONTINENCE PRODUCT, BRIEF/DIA, BARIATRIC, $ $3, *Enter 1 only when billing the waiver. Do not enter 1 when billing state plan Durable Medical Equipment and Medical Supply Program services. 1. The 200 units limit is for ANY COMBINATION of DISPOSABLE INCONTINENCE PRODUCT (T-Codes) Page 5 of 16

8 The codes listed below are billable under the Durable Medical Equipment (DME) and Medical Supplies State Plan Program for all recipients. Providers must bill the DME State Plan Program up to the maximum limit before billing the waiver for these codes. Reimbursement for these codes under the waiver is counted towards the total allowable reimbursement for medical supplies established under the waiver. A4311 A4312 A4313 A4331 A4332 A4333 A4349 A4351 A4352 INSERTION TRAY WITHOUT DRAINAGE BAG WITH INDWELLING CATHETER, FOLEY TYPE, TWO-WAY LATEX WITH COATING (TEFLON, SILICONE, SILICONE ELASTOMER OR HYDROPHILIC, ETC.) INSERTION TRAY WITHOUT DRAINAGE BAG WITH INDWELLING CATHETER, FOLEY TYPE, TWO-WAY, ALL SILICONE INSERTION TRAY WITHOUT DRAINAGE BAG WITH INDWELLING CATHETER, FOLEY TYPE, THREE-WAY, FOR CONTINUOUS IRRIGATION EXTENSION DRAINAGE TUBING, ANY TYPE, ANY LENGTH, WITH CONNECTOR/ADAPTOR, FOR USE WITH URINARY LEG BAG OR UROSTOMY POUCH, LUBRICANT, INDIVIDUAL STERILE PACKET, FOR INSERTION OF URINARY CATHETER, URINARY CATHETER ANCHORING DEVICE, ADHESIVE SKIN ATTACHMENT, MALE EXTERNAL CATHETER, WITH OR WITHOUT ADHESIVE, DISPOSABLE, INTERMITTENT URINARY CATHETER; STRAIGHT TIP, WITH OR WITHOUT COATING (TEFLON, SILICONE, SILICONE ELASTOMER, OR HYDROPHILIC, ETC.), INTERMITTENT URINARY CATHETER; COUDE (CURVED) TIP, WITH OR WITHOUT COATING (TEFLON, SILICONE, SILICONE ELASTOMERIC, OR HYDROPHILIC, ETC.), MAX PMTS. $ $ year $ $ year $ $ year $ $ year $ $ $ $ $ $ $ $ 3, $ $4, *Enter 1 only when billing the waiver. Do not enter 1 when billing state plan Durable Medical Equipment and Medical Supply Program services. Page 6 of 16

9 Plan Program for all recipients. Providers must bill the DME State Plan Program up to the maximum limit before billing the waiver for these codes. Reimbursement for these codes under the waiver is counted towards the total allowable reimbursement for medical supplies established under the waiver. A4353 A4357 A4358 INTERMITTENT URINARY CATHERTER, WITH INSERTION SUPPLIES (Note: Medicaid's coverage is for a sterile intermittent catheter kit, packaged by the product manufacturer, to be used for self-catheterization) BEDSIDE DRAINAGE BAG, DAY OR NIGHT, WITH OR WITHOUT ANTI-REFLUX DEVICE, WITH OR WITHOUT TUBE, URINARY DRAINAGE BAG, LEG OR ABDOMEN, VINYL, WITH OR WITHOUT TUBE, WITH STRAPS, MAX PMTS. $ $11, $ $ year $ $ year A4361 OSTOMY FACEPLATE, $ $ year A4362 SKIN BARRIER; SOLID, 4 X 4 OR EQUIVALENT; $ $ year A4363 SKIN BARRIER; LIQUID (SPRAY, BRUSH, ETC.) POWDER OR PASTE; 0Z. $ $ year A4364 ADHESIVE, LIQUID OR EQUAL, ANY TYPE, OZ $ $ year A4365 ADHESIVE REMOVER WIPES, ANY TYPE, 50 $ $ A4367 OSTOMY BELT, $ $ year A4368 OSTOMY FILTER, ANY TYPE, $ $ A4369 OSTOMY SKIN BARRIER, LIQUID (SPRAY, BRUSH, ETC.), OZ $ $ year A4371 OSTOMY SKIN BARRIER, POWDER, OZ $ $ year *Enter 1 only when billing the waiver. Do not enter 1 when billing state plan Durable Medical Equipment and Medical Supply Program services. Page 7 of 16

10 Plan Program for all recipients. Providers must bill the DME State Plan Program up to the maximum limit before billing the waiver for these codes. Reimbursement for these codes under the waiver is counted towards the total allowable reimbursement for medical supplies established under the waiver. A4372 A4373 A4375 A4376 A4377 A4378 A4379 A4380 A4381 A4382 A4383 A4384 A4385 OSTOMY SKIN BARRIER, SOLID 4 X 4 OR EQUIVALENT, WITH BUILT-IN CONVEXITY, OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE OR ACCORDIAN), WITH BUILT-IN CONVEXITY, ANY SIZE, OSTOMY POUCH, DRAINABLE, WITH FACEPLATE ATTACHED, PLASTIC, OSTOMY POUCH, DRAINABLE, WITH FACEPLATE ATTACHED, RUBBER, OSTOMY POUCH, DRAINABLE, FOR USE ON FACEPLATE, PLASTIC, OSTOMY POUCH, DRAINABLE, FOR USE ON FACEPLATE, RUBBER, OSTOMY POUCH, URINARY, WITH FACEPLATE ATTACHED, PLASTIC, OSTOMY POUCH, URINARY, WITH FACEPLATE ATTACHED, RUBBER, OSTOMY POUCH, URINARY, FOR USE ON FACEPLATE, PLASTIC, OSTOMY POUCH, URINARY, FOR USE ON FACEPLATE, HEAVY PLASTIC, OSTOMY POUCH, URINARY, FOR USE ON FACEPLATE, RUBBER, OSTOMY FACEPLATE EQUIVALENT, SILICONE RING, OSTOMY SKIN BARRIER, SOLID 4 X 4 OR EQUIVALENT, EXTENDED WEAR, WITHOUT BUILT-IN CONVEXITY, MAX PMTS. $ $ year $ $1, year $ $1, $ $4, $ $ $ $2, $ $1, $ $6, year $ $ $ $2, $ $2, $ $ $ $ *Enter 1 only when billing the waiver. Do not enter 1 when billing state plan Durable Medical Equipment and Medical Supply Program services. Page 8 of 16

11 Plan Program for all recipients. Providers must bill the DME State Plan Program up to the maximum limit before billing the waiver for these codes. Reimbursement for these codes under the waiver is counted towards the total allowable reimbursement for medical supplies established under the waiver. A4387 A4388 A4389 A4390 A4391 A4392 A4393 A4394 A4395 OSTOMY POUCH, CLOSED, WITH BARRIER ATTACHED, WITH BUILT-IN CONVEXITY (1 PIECE), OSTOMY POUCH, DRAINABLE, WITH EXTENDED WEAR BARRIER ATTACHED, (1 PIECE), OSTOMY POUCH, DRAINABLE, WITH BARRIER ATTACHED, WITH BUILT-IN CONVEXITY (1 PIECE), OSTOMY POUCH, DRAINABLE, WITH EXTENDED WEAR BARRIER ATTACHED, WITH BUILT-IN CONVEXITY (1 PIECE), OSTOMY POUCH, URINARY, WITH EXTENDED WEAR BARRIER ATTACHED (1 PIECE), OSTOMY POUCH, URINARY, WITH STANDARD WEAR BARRIER ATTACHED, WITH BUILT-IN CONVEXITY (1 PIECE), OSTOMY POUCH, URINARY, WITH EXTENDED WEAR BARRIER ATTACHED, WITH BUILT-IN CONVEXITY (1 PIECE), OSTOMY DEODORANT FOR USE IN OSTOMY POUCH, LIQUID, FLUID OUNCE OSTOMY DEODORANT FOR USE IN OSTOMY POUCH, SOLID, TABLET MAX PMTS. $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ A4396 OSTOMY BELT WITH ISTOMAL HERNIA SUPPORT $ $ A4397 IRRIGATION SUPPLY; SLEEVE, $ $ year *Enter 1 only when billing the waiver. Do not enter 1 when billing state plan Durable Medical Equipment and Medical Supply Program services. Page 9 of 16

12 Plan Program for all recipients. Providers must bill the DME State Plan Program up to the maximum limit before billing the waiver for these codes. Reimbursement for these codes under the waiver is counted towards the total allowable reimbursement for medical supplies established under the waiver. MAX PMTS. A4398 OSTOMY IRRIGATION SUPPLY; BAG, $ $ year A4399 OSTOMY IRRIGATION SUPPLY; CONE/CATHETER, INCLUDING BRUSH $ $ year A4400 OSTOMY IRRIGATION SET $ $ year A4402 LUBRICANT, OUNCE $ $ year A4404 OSTOMY RING, $ $ year A4405 A4406 A4407 A4408 A4409 A4410 OSTOMY SKIN BARRIER, NONPECTIN-BASED, PASTE, OUNCE OSTOMY SKIN BARRIER, PECTIN-BASED, PASTE, OUNCE OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE, OR ACCORDION), EXTENDED WEAR, WITH BUILT-IN CONVEXITY, 4 X 4 INCHES OR SMALLER, OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE OR ACCORDION), EXTENDED WEAR, WITH BUILT-IN CONVEXITY, LARGER THAN 4 X 4 INCHES, OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE OR ACCORDION), EXTENDED WEAR, WITHOUT BUILT-IN CONVEXITY, 4 X 4 INCHES OR SMALLER, OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE OR ACCORDION), EXTENDED WEAR, WITHOUT BUILT-IN CONVEXITY, LARGER THAN 4 X 4 INCHES, $ $ year $ $ year $ $2, year $ $2, year $ $1, year $ $2, year *Enter 1 only when billing the waiver. Do not enter 1 when billing state plan Durable Medical Equipment and Medical Supply Program services. Page 10 of 16

13 Plan Program for all recipients. Providers must bill the DME State Plan Program up to the maximum limit before billing the waiver for these codes. Reimbursement for these codes under the waiver is counted towards the total allowable reimbursement for medical supplies established under the waiver. A4411 A4412 A4413 A4414 A4415 A4416 A4417 A4418 A4420 OSTOMY SKIN BARRIER, SOLID 4X4 OR EQUIVALENT, EXTENDED WEAR, WITH BUILT-IN CONVEXITY, OSTOMY POUCH, DRAINABLE, HIGH OUTPUT, FOR USE ON A BARRIER WITH FLANGE (2 PIECE SYSTEM), WITHOUT FILTER, OSTOMY POUCH, DRAINABLE, HIGH OUTPUT, FOR USE ON A BARRIER WITH FLANGE (2 PIECE SYSTEM), WITH FILTER, OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE OR ACCORDION), WITHOUT BUILT-IN CONVEXITY, 4 X 4 INCHES OR SMALLER, OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE OR ACCORDION), WITHOUT BUILT-IN CONVEXITY, LARGER THAN 4X4 INCHES, OSTOMY POUCH, CLOSED, WITH BARRIER ATTACHED, WITH FILTER (1 PIECE), OSTOMY POUCH, CLOSED, WITH BARRIER ATTACHED, WITH BUILT-IN CONVEXITY, WITH FILTER (1 PIECE), OSTOMY POUCH, CLOSED; WITHOUT BARRIER ATTACHED, WITH FILTER (1 PIECE), OSTOMY POUCH, CLOSED; FOR USE ON BARRIER WITH LOCKING FLANGE (2 PIECE), MAX PMTS. $ $1, year $ $1, $ $ $ $1, year $ $1, year $ $ $ $ $ $ $ $ A4421 OSTOMY SUPPLY; MISCELLANEOUS $ $ year A4423 A4424 OSTOMY POUCH, CLOSED; FOR USE ON BARRIER WITH LOCKING FLANGE, WITH FILTER (2 PIECE), OSTOMY POUCH, DRAINABLE, WITH BARRIER ATTACHED, WITH FILTER (1 PIECE), $ $ $ $1, *Enter 1 only when billing the waiver. Do not enter 1 when billing state plan Durable Medical Equipment and Medical Supply Program services. Page 11 of 16

14 Plan Program for all recipients. Providers must bill the DME State Plan Program up to the maximum limit before billing the waiver for these codes. Reimbursement for these codes under the waiver is counted towards the total allowable reimbursement for medical supplies established under the waiver. A4425 A4426 A4427 A4428 A4429 A4430 A4431 A4432 A4433 A4434 OSTOMY POUCH, DRAINABLE; FOR USE ON BARRIER WITH NON-LOCKING FLANGE, WITH FILTER (2 PIECE SYSTEM), OSTOMY POUCH, DRAINABLE; FOR USE ON BARRIER WITH LOCKING FLANGE (2 PIECE SYSTEM), OSTOMY POUCH, DRAINABLE; FOR USE ON BARRIER WITH LOCKING FLANGE, WITH FILTER (2 PIECE SYSTEM), OSTOMY POUCH, URINARY, WITH EXTENDED WEAR BARRIER ATTACHED, WITH FAUCET-TYPE TAP WITH VALVE (1 PIECE), OSTOMY POUCH, URINARY, WITH BARRIER ATTACHED, WITH BUILT-IN CONVEXITY, WITH FAUCET-TYPE TAP WITH VALVE (1 PIECE), OSTOMY POUCH, URINARY, WITH EXTENDED WEAR BARRIER ATTACHED, WITH BUILT-IN CONVEXITY, WITH FAUCET-TYPE TAP WITH VALVE (1 PIECE), OSTOMY POUCH, URINARY; WITH BARRIER ATTACHED, WITH FAUCET-TYPE TAP WITH VALVE (1 PIECE), OSTOMY POUCH, URINARY; FOR USE ON BARRIER WITH NON-LOCKING FLANGE, WITH FAUCET-TYPE TAP WITH VALVE (2 PIECE), OSTOMY POUCH, URINARY; FOR USE ON BARRIER WITH LOCKING FLANGE (2 PIECE), OSTOMY POUCH, URINARY; FOR USE ON BARRIER WITH LOCKING FLANGE, WITH FAUCET-TYPE TAP WITH VALVE (2 PIECE), MAX PMTS. $ $ year $ $ year $ $ year $ $1, year $ $1, year $ $2, year $ $1, $ $ $ $ $ $ year *Enter 1 only when billing the waiver. Do not enter 1 when billing state plan Durable Medical Equipment and Medical Supply Program services. Page 12 of 16

15 Plan Program for all recipients. Providers must bill the DME State Plan Program up to the maximum limit before billing the waiver for these codes. Reimbursement for these codes under the waiver is counted towards the total allowable reimbursement for medical supplies established under the waiver. MAX PMTS. A4450 TAPE, NON-WATERPROOF, 18 SQUARE INCHES $ $ year A4452 TAPE, WATERPROOF, 18 SQUARE INCHES $ $ year A4455 ADHESIVE REMOVER OR SOLVENT (FOR TAPE, CEMENT OR OTHER ADHESIVE), OUNCE $ $ year A4927 GLOVES, NON-STERILE, 100 $ $ year A4930 GLOVES, STERILE, PAIR $ $ year A5051 A5052 A5053 A5054 OSTOMY POUCH, CLOSED; WITH BARRIER ATTACHED (1 PIECE), OSTOMY POUCH, CLOSED; WITHOUT BARRIER ATTACHED (1 PIECE), OSTOMY POUCH, CLOSED; FOR USE ON FACEPLATE, OSTOMY POUCH, CLOSED; FOR USE ON BARRIER WITH FLANGE (2 PIECE), $ $ year $ $ year $ $ year $ $ year A5055 STOMA CAP $ $ A5061 A5062 A5063 A5071 OSTOMY POUCH, DRAINABLE; WITH BARRIER ATTACHED, (1 PIECE), OSTOMY POUCH, DRAINABLE; WITHOUT BARRIER ATTACHED (1 PIECE), OSTOMY POUCH, DRAINABLE; FOR USE ON BARRIER WITH FLANGE (2 PIECE SYSTEM), OSTOMY POUCH, URINARY; WITH BARRIER ATTACHED (1 PIECE), $ $ year $ $ year $ $ year $ $1, year *Enter 1 only when billing the waiver. Do not enter 1 when billing state plan Durable Medical Equipment and Medical Supply Program services. Page 13 of 16

16 Plan Program for all recipients. Providers must bill the DME State Plan Program up to the maximum limit before billing the waiver for these codes. Reimbursement for these codes under the waiver is counted towards the total allowable reimbursement for medical supplies established under the waiver. MAX PMTS. A5072 OSTOMY POUCH, URINARY; WITHOUT BARRIER ATTACHED (1 PIECE), $ $ year A5073 OSTOMY POUCH, URINARY; FOR USE ON BARRIER WITH FLANGE (2 PIECE), $ $ year A5081 CONTINENT DEVICE; PLUG FOR CONTINENT STOMA $ $ year A5082 CONTINENT DEVICE; CATHETER FOR CONTINENT STOMA $ $ year A5093 OSTOMY ACCESSORY; CONVEX INSERT $ $ year A5112 URINARY LEG BAG; LATEX $ $ year A5120 SKIN BARRIER, WIPES OR SWABS, $ $ year A5121 SKIN BARRIER; SOLID, 6 X 6 OR EQUIVALENT, $ $ year A5122 SKIN BARRIER; SOLID, 8 X 8 OR EQUIVALENT, $ $1, year A5131 APPLIANCE CLEANER, INCONTINENCE AND OSTOMY APPLIANCES, 16 OZ. $ $ year *Enter 1 only when billing the waiver. Do not enter 1 when billing state plan Durable Medical Equipment and Medical Supply Program services. Page 14 of 16

17 The codes listed below are billable under the waiver for recipients of all ages. The codes are not billable under the Medicaid Durable Medical Equipment (DME) and Medical Supplies State Plan Program. Reimbursement for these codes under the waiver is counted towards the total allowable reimbursement for medical supplies established under the waiver. A4419 OSTOMY POUCH, CLOSED; FOR USE ON BARRIER WITH NON-LOCKING FLANGE, WITH FILTER MAX PMTS. $ $ S5199 SONAL CARE ITEM, NOS, By Invoice See waiver for policy rules and limits The codes listed below are billable under the waiver for recipients aged 21 and older. The codes are not billable under the Medicaid Durable Medical Equipment (DME) and Medical Supplies State Plan Program. Reimbursement for these codes under the waiver is counted towards the total allowable reimbursement for medical supplies established under the waiver. T4521 BRIEF/DIA, SMALL, MAX PMTS. 1 $ $1, T4522 BRIEF/DIA, MEDIUM, $ $1, T4523 BRIEF/DIA, LARGE, $ $1, T4524 BRIEF/DIA, EXTRA LARGE, $ $2, T4525 PROTECTIVE UNDERWEAR/PULL-ON, SMALL SIZE, $ $1, T4526 PROTECTIVE UNDERWEAR/PULL-ON, MEDIUM SIZE, $ $2, T4527 PROTECTIVE UNDERWEAR/PULL-ON, LARGE SIZE, $ $2, Page 15 of 16

18 Continued: The codes listed below are billable under the waiver for recipients aged 21 and older. The codes are not billable under the Medicaid Durable Medical Equipment (DME) and Medical Supplies State Plan Program. Reimbursement for these codes under the waiver is counted towards the total allowable reimbursement for medical supplies established under the waiver. MAX PMTS. 1 T4528 PROTECTIVE UNDERWEAR/PULL-ON, EXTRA LARGE SIZE, $ $2, T4535 DISPOSABLE LINER/SHIELD/GUARD/PAD/ UNDERGARMENT, FOR INCONTINENCE, $ $1, T4543 DISPOSABLE INCONTINENCE PRODUCT, BRIEF/DIA, BARIATRIC, $ $3, The 200 units limit is for ANY COMBINATION of DISPOSABLE INCONTINENCE PRODUCT (T-Codes) Note: = Date of Service Note to Waiver Providers: Florida Medicaid s state plan durable medical equipment products and services must be accessed before accessing DME through the waiver. To see what items or codes are covered by Medicaid s state plan DME program, please visit Click on Public Information for Providers. Then click on Provider Support. Under provider support, chose Fee Schedules. Select Durable Medical Equipment. Please note there are two fee schedules: one for all ages and one for under 21 only. Page 16 of 16

19 Size Aged and Disabled Adult Waiver Quality Standards Minimum Quality Standards for Briefs and Dias v Minimum Length (2) Minimum Width (3) Waist Range Rate Of Absorbency Rewet Capacity (ROA) < < > inches inches inches seconds grams grams Youth " Small " ,100 Medium " ,400 Regular " ,400 Large " ,700 Extra Large " ,700 Extra Extra Large " ,700 Notes (1) To qualify for reimbursement, products need to meet or exceed two of the three formance standards and be within 15% of the third standard. (2) Measured by cutting leg elastic and stretching flat. (3) Measured at non-tape end. Universal Requirements 1. Designed with wetness indicator visible on the outside of the brief. 2. Designed with a side closure system (if tape tab, minimum of 2 size and width > 5/8"). 3. Designed with multi-elastic leg gathers. 4. Backing is waterproof. Minimum Quality Standards for Pads, Inserts, Shields v Product Performance ROA Rewet Capacity < < > - na - - na The products must have one of the following attributes: 1. Embossed or channeled absorbent mat 2. Elastic gathers 3. Su absorbent polymer 4. Waterproof backing This is the Minimum Quality Standards for Pads, Inserts, Shields; providers must supply products that meet the medical needs of the beneficiary, including moderate and heavy needs. Providers should inquire with the products manufacturer to insure that their products, at a minimum, meet the above quality standards.

20 Aged and Disabled Adult Waiver Quality Standards Minimum Quality Standards for Underpads v Total Capacity (grams) ROA (seconds) Rewet (grams) To qualify for reimbursement, products must meet or exceed 2 standards and be within 15% of the third standard. Size Minimum Quality Standards for Protective Underwear v Product Performance (1) Minimum Inside Width (2) Minimum ROA Rewet Capacity Length (3) < < > inches inches seconds grams grams Small Medium ,000 Large ,100 Extra Large ,200 Universal Requirements 1. Designed with a continuous elasticized waistband and side panels. 2. Designed with multi-elastic leg gathers 3. Backing is waterproof Providers should inquire with the products manufacturer to insure that their products, at a minimum, meet the above quality standards.