`A5120` Skin barrier, wipe or swab

Skin barrier, wipes or swabs, each

Medicare coverage: Special coverage instructions apply
Status: active (October 2026 file)

Medically Unlikely Edits (effective October 1, 2026)

Practitioner: max 150 units per day (clinical), rationale: Published Contractor Policy
Outpatient hospital: max 150 units per day (clinical), rationale: Published Contractor Policy
DME supplier: max 450 units per day (clinical), rationale: Published Contractor Policy

Medicare pricing for A5120

DMEPOS fee schedule, July 2026 (DME26-C)

AU, ostomy, tracheostomy and urological (OS): non-rural $0.30 to $0.35 in the contiguous states; $0.14 to $0.38 in AK, HI, PR and VI; ceiling $0.35, floor $0.30
AV, prosthetics and orthotics (PO): non-rural $0.30 to $0.39 in the contiguous states; $0.16 to $0.36 in AK, HI, PR and VI; ceiling $0.40, floor $0.30

Physician Fee Schedule (CY 2026, RVU26D)

Status X: statutory exclusion, not paid under the PFS.

Payer policies and prior authorization for A5120

Payer coverage policies that name A5120

A5120 appears in 3 coverage policies from Aetna.

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Ostomy Supplies (0906)	covered if criteria are met	Dec 22, 2025	payer document
Aetna	Tracheostomy Supplies (0074)	covered if criteria are met	Mar 18, 2026	payer document
Aetna	Urological Supplies (0533)	not covered	Jul 30, 2026	payer document

Medicaid fee-for-service

Prior authorization required or conditional in KY, LA, MA, OH, VA, WV.

AZ: $0.37 (dme), effective Oct 1, 2026
CO: $0.23 (chp_plus, non-facility), effective Jul 1, 2026
FL: $0.18 (dme), effective Jul 1, 2026
IL: $0.19 (dme), effective Jan 1, 2026
IN: $0.26 (professional, Advanced Practice Nurse (85%), non-facility), effective Feb 1, 2026
KS: $0.28 (default), effective Jul 1, 2026
KY: $0.20 (dme), effective Jan 1, 2026
LA: $0.16 (dme), effective Jul 1, 2012
MD: $0.27 (dme), effective Apr 1, 2026
MS: $0.26 (comprehensive), effective Jul 1, 2026
ND: $0.00 (dme), effective Aug 1, 2026
NE: $0.32 (dme), effective Jul 1, 2026
NY: $0.21 (dme), effective Jul 1, 2026
OH: $0.20 (dme), effective Jan 1, 2024
OK: $0.33 (dme), effective Jan 1, 2026
TX: $0.26 (dmepos_tos_9_e_j_l_and_r, Home Health Dme, non-facility), effective Mar 1, 2012
VA: $0.27 (dme), effective Dec 1, 2026
VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026
WA: $0.25 (medical_equipment_supplies), effective Jul 1, 2026
WY: $0.00 (outpatient_hospital_apc, Children's Hospitals), effective Apr 1, 2026

From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.

A5120 Skin barrier, wipe or swab