mc sup prod ost twoex

Medical Supply Products: Ostomy Two-Piece Extended Wear Skin Barriers1

This section lists the billing codes, manufacturer codes and units for ostomy medical supplies. In this section, “UPN” refers to the Universal Product Number.
For additional help, refer to the Medical Supplies section in this manual. HCPCS codes are for reference only.

Effective DatesAll two-piece ostomy products are effective for dates of service on or after August 1, 2007 unless otherwise noted.

TWO-PIECE OSTOMY PRODUCTS

Description / UPN / HCPCS(reference only) / Billing
Code / Maximum Acquisition Cost (MAC) / Unit of
Measure
TWO-PIECE EXTENDED WEAR SKIN BARRIER WITH CONVEXITY(Limited to no more than 90 in an 81-day period.)
Coloplast – JN
Assura - 2-Pc. Convex Light Extra-Extended Wear Skin Barrier Flange With Belt Loops, Cut-To-Fit
5/8" - 15/16" (15-23 mm) / Green / 0762123047552 / A4407 / 9914WJN / $8.31 / each
Assura - 2-Pc. Convex Light Extra-Extended Wear Skin Barrier Flange With Belt Loops, Cut-To-Fit
5/8" - 1 5/16" (15-33 mm) / Red / 0762123047576 / A4407 / 9914WJN / $8.31 / each
Assura - 2-Pc. Convex Light Extra-Extended Wear Skin Barrier Flange With Belt Loops, Cut-To-Fit
5/8" - 1 11/16" (15-43 mm) / Blue / 0762123047590 / A4407 / 9914WJN / $8.31 / each
Assura - 2-Pc. Convex Light Extra-Extended Wear Skin Barrier Flange With Belt Loops, Pre-cut 3/4" (18 mm) / 0762123047613 / A4407 / 9914WJN / $8.31 / each

2 – Medical Supply Products: Ostomy Two-Piece Extended Wear Skin BarriersJune 2008

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Description / UPN / HCPCS(reference only) / Billing
Code / Maximum Acquisition Cost (MAC) / Unit of
Measure
Coloplast – JN
Assura - 2-Pc. Convex Light Extra-Extended Wear Skin Barrier Flange With Belt Loops, Pre-cut 7/8" (21 mm) / 0762123047637 / A4407 / 9914WJN / $8.31 / each
Assura - 2-Pc. Convex Light Extra-Extended Wear Skin Barrier Flange With Belt Loops, Pre-cut 1" (25 mm) / 0762123047651 / A4407 / 9914WJN / $8.31 / each
Assura - 2-Pc. Convex Light Extra-Extended Wear Skin Barrier Flange With Belt Loops, Pre-cut 1 1/8" (28 mm) / 0762123047675 / A4407 / 9914WJN / $8.31 / each
Assura - 2-Pc. Convex Light Extra-Extended Wear Skin Barrier Flange With Belt Loops, Pre-cut 1 1/4" (31 mm) / 0762123047699 / A4407 / 9914WJN / $8.31 / each
Assura - 2-Pc. Convex Light Extra-Extended Wear Skin Barrier Flange With Belt Loops, Pre-cut 1 3/8" (35 mm) / 0762123047712 / A4407 / 9914WJN / $8.31 / each
Assura - 2-Pc. Convex Light Extra-Extended Wear Skin Barrier Flange With Belt Loops, Pre-cut 1 1/2" (38 mm) / 0762123047736 / A4407 / 9914WJN / $8.31 / each
Assura - 2-Pc. Convex Light Extra-Extended Wear Skin Barrier Flange With Belt Loops, Pre-cut 1 5/8" (41 mm) / 0762123047750 / A4407 / 9914WJN / $8.31 / each
Assura Extra - 2-Pc.Convex Extra-Extended Wear Skin Barrier Flange With Belt Loops, Cut-To-Fit
5/8" - 15/16" (15-23 mm) / Green / 0762123030158 / A4407 / 9914WJN / $8.31 / each

2 – Medical Supply Products: Ostomy Two-Piece Extended Wear Skin BarriersJune 2008

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Description / UPN / HCPCS(reference only) / Billing
Code / Maximum Acquisition Cost (MAC) / Unit of
Measure
Coloplast – JN
Assura Extra - 2-Pc.Convex Extra-Extended Wear Skin Barrier Flange With Belt Loops, Cut-To-Fit
5/8" - 1 5/16" (15-33 mm) / Red / 0762123031704 / A4407 / 9914WJN / $8.31 / each
Assura Extra - 2-Pc.Convex Extra-Extended Wear Skin Barrier Flange With Belt Loops, Cut-To-Fit
5/8" - 1 11/16" (15-43 mm) / Blue / 0762123031728 / A4407 / 9914WJN / $8.31 / each
Assura Extra - 2-Pc. Convex Extra-Extended Wear Skin Barrier Flange With Belt Loops, Pre-Cut 3/4" (18 mm) / Green / 0762123035900 / A4407 / 9914WJN / $8.31 / each
Assura Extra - 2-Pc. Convex Extra-Extended Wear Skin Barrier Flange With Belt Loops, Pre-Cut 7/8" (21 mm) / Green / 0762123035924 / A4407 / 9914WJN / $8.31 / each
Assura Extra - 2-Pc. Convex Extra-Extended Wear Skin Barrier Flange With Belt Loops, Pre-Cut 1" (25 mm) / Red / 0762123035948 / A4407 / 9914WJN / $8.31 / each
Assura Extra - 2-Pc. Convex Extra-Extended Wear Skin Barrier Flange With Belt Loops, Pre-Cut 1 1/8" (28 mm) / Red / 0762123035962 / A4407 / 9914WJN / $8.31 / each
Assura Extra - 2-Pc. Convex Extra-Extended Wear Skin Barrier Flange With Belt Loops, Pre-Cut 1 1/4" (31 mm) / Red / 0762123035986 / A4407 / 9914WJN / $8.31 / each
Assura Extra - 2-Pc. Convex Extra-Extended Wear Skin Barrier Flange With Belt Loops, Pre-Cut 1 3/8" (35 mm) / Blue / 0762123036006 / A4407 / 9914WJN / $8.31 / each

2 – Medical Supply Products: Ostomy Two-Piece Extended Wear Skin BarriersJune 2008

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Description / UPN / HCPCS(reference only) / Billing
Code / Maximum Acquisition Cost (MAC) / Unit of
Measure
Coloplast – JN
Assura Extra - 2-Pc. Convex Extra-Extended Wear Skin Barrier Flange With Belt Loops, Pre-Cut 1 1/2" (38 mm) / Blue / 0762123036020 / A4407 / 9914WJN / $8.31 / each
Assura Extra - 2-Pc. Convex Extra-Extended Wear Skin Barrier Flange With Belt Loops, Pre-Cut 1 5/8" (41 mm) / Blue / 0762123036044 / A4407 / 9914WJN / $8.31 / each
Assura AC Extra-Extended Wear, Convex Light 2-piece Baseplate, Cut-to-fit 35 mm 15-23mm / 0762123050606 / A4407 / 9914WJN / $8.31 / each
Assura AC Extra-Extended Wear, Convex Light 2-piece Baseplate, Cut-to-fit 33 mm 15-33mm / 0762123050620 / A4407 / 9914WJN / $8.31 / each
Assura AC Extra-Extended Wear, Convex Light 2-piece Baseplate, Cut-to-fit 43 mm 15-43mm / 0762123050644 / A4407 / 9914WJN / $8.31 / each
Assura AC Extra-Extended Wear, Convex Light 2-piece Baseplate, Cut-to-fit 70 mm 15-73mm / 0762123050187 / A4408 / 9914XJN / $8.31 / each

2 – Medical Supply Products: Ostomy Two-Piece Extended Wear Skin BarriersJune 2008

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Description / UPN / HCPCS(reference only) / Billing
Code / Maximum Acquisition Cost (MAC) / Unit of
Measure
Convatec – SQ
Esteem Synergy Durahesive moldable convex skin barrier, white flexible collar, small / 30003409268 / A4407 / 9914WSQ / $8.31 / each †
medium / 30003409269 / A4407 / 9914WSQ / $8.31 / each †
large / 30003409270 / A4407 / 9914WSQ / $8.31 / each †
SUR-FIT Natura Durahesive skin barrier with Convex-It
45 mm (1 3/4") flange, tape collar precut 1/2" (13 mm) / 30003413177 / A4407 / 9914WSQ / $8.31 / each †
5/8" (16 mm) / 30003413178 / A4407 / 9914WSQ / $8.31 / each †
3/4" (19 mm) / 30003413179 / A4407 / 9914WSQ / $8.31 / each †
7/8" (22 mm) / 30003413180 / A4407 / 9914WSQ / $8.31 / each †
1 " (25 mm) / 30003413181 / A4407 / 9914WSQ / $8.31 / each †
1 1/8" (28 mm) / 30003413182 / A4407 / 9914WSQ / $8.31 / each †
1 1/4" (32 mm) / 30003413183 / A4407 / 9914WSQ / $8.31 / each †
1 3/8" (35 mm) / 30003413184 / A4407 / 9914WSQ / $8.31 / each †
SUR-FIT Natura Durahesive Moldable convex skin
barrier with 45 mm (1 3/4") flange, mold-to-fit opening,
small 1/2"-7/8" / 30003404592 / A4407 / 9914WSQ / $8.31 / each †
medium 7/8"-1 1/4" / 30003404593 / A4407 / 9914WSQ / $8.31 / each †
SUR-FIT Natura Durahesive Moldable convex skin
barrier with 57 mm (2 1/4") flange, mold-to-fit opening,
large 1 1/4"-1 3/4" / 30003404594 / A4407 / 9914WSQ / $8.31 / each †

†Effective June 1, 2008

2 – Medical Supply Products: Ostomy Two-Piece Extended Wear Skin BarriersJune 2008

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Description / UPN / HCPCS(reference only) / Billing
Code / Maximum Acquisition Cost (MAC) / Unit of
Measure
Hollister – HS
Premier 2pc convex barr 5/8" / 10610075087317 / A4407 / 9914WHS / $8.31 / each
Premier 2pc convex barr 3/4" / 10610075087324 / A4407 / 9914WHS / $8.31 / each
Premier 2pc convex barr 7/8" / 10610075087331 / A4407 / 9914WHS / $8.31 / each
Premier 2pc convex barr 1" / 10610075087348 / A4407 / 9914WHS / $8.31 / each
Premier 2pc convex barr 1 1/8" / 10610075087355 / A4407 / 9914WHS / $8.31 / each
Premier 2pc convex barr 1 1/4" / 10610075087362 / A4407 / 9914WHS / $8.31 / each
Premier 2pc convex barr 1 3/8" / 10610075087379 / A4407 / 9914WHS / $8.31 / each
Premier 2pc convex barr 1 1/2" / 10610075087386 / A4407 / 9914WHS / $8.31 / each
Premier 2pc cnvx ctf bar 1" / 10610075087744 / A4407 / 9914WHS / $8.31 / each
Premier 2pc cnvx ctf bar 1 1/2" / 10610075087782 / A4407 / 9914WHS / $8.31 / each
Ni cnvx ft ctf float tape 44 mm 1 3/4" / 10610075148025 / A4407 / 9914WHS / $8.31 / each
Ni cnvx ft ctf float tape 57 mm 2 1/4" / 10610075148032 / A4407 / 9914WHS / $8.31 / each
Ni cnvx ft ctf float tape 70 mm 2 3/4" / 10610075148049 / A4407 / 9914WHS / $8.31 / each
Ni cvxft tp 44 mm 1 3/4" flg 16 mm 5/8" ps / 10610075118271 / A4407 / 9914WHS / $8.31 / each
Ni cvxft tp 44 mm 1 3/4" flg 19 mm 3/4" ps / 10610075118288 / A4407 / 9914WHS / $8.31 / each
Ni cnvx ft ps 22 mm 7/8 ff tape 44 m 1 3/4” / 10610075149039 / A4407 / 9914WHS / $8.31 / each
Ni cnvx ft ps 25mm 1" ff tape 44 m 1 3/4” / 10610075149046 / A4407 / 9914WHS / $8.31 / each
Ni cvx ft ps 29m 1 1/8 ff tape 57 m 2 1/4” / 10610075149053 / A4407 / 9914WHS / $8.31 / each
Ni cvx ft ps 32m 1 1/4 ff tape 57 m 2 1/4” / 10610075149060 / A4407 / 9914WHS / $8.31 / each

2 – Medical Supply Products: Ostomy Two-Piece Extended Wear Skin BarriersJune 2008

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Description / UPN / HCPCS(reference only) / Billing
Code / Maximum Acquisition Cost (MAC) / Unit of
Measure
Hollister – HS
Ni cvxft tp 57mm 2 1/4" flg 35 mm 1 3/8"ps / 10610075118295 / A4407 / 9914WHS / $8.31 / each
Ni cvxft tp 57mm 2 1/4" flg 38 mm 1 1/2"ps / 10610075118301 / A4407 / 9914WHS / $8.31 / each
Ni cvxft tp 70mm 2 3/4" flg 41 mm 1 5/8"ps / 10610075118318 / A4407 / 9914WHS / $8.31 / each
Ni cvxft tp 70mm 2 3/4" flg 44 mm 1 3/4"ps / 10610075118325 / A4407 / 9914WHS / $8.31 / each
Ni cvxft tp 70mm 2 3/4" flg 51 mm 2" ps / 10610075118332 / A4407 / 9914WHS / $8.31 / each
New image convex ft ctf 1" / 10610075158024 / A4407 / 9914WHS / $8.31 / each
New image convex ft ctf 1.5" / 10610075158031 / A4407 / 9914WHS / $8.31 / each
New image convex ft 7/8" / 10610075159038 / A4407 / 9914WHS / $8.31 / each
New image convex ft 1" / 10610075159045 / A4407 / 9914WHS / $8.31 / each
New image convex ft 1 1/8" / 10610075159052 / A4407 / 9914WHS / $8.31 / each
New image convex ft 1 1/4" / 10610075159069 / A4407 / 9914WHS / $8.31 / each
Premier 2pc cnvx ctf bar 2" / 10610075877116 / A4407 / 9914WHS / $8.31 / each
New image convex ft ctf 2" / 10610075158048 / A4408 / 9914XHS / $8.31 / each

2 – Medical Supply Products: Ostomy Two-Piece Extended Wear Skin BarriersJune 2008

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Description / UPN / HCPCS(reference only) / Billing
Code / Maximum Acquisition Cost (MAC) / Unit of
Measure
TWO-PIECE EXTENDED WEAR SKIN BARRIER WITHOUT CONVEXITY(Limited to no more than 90 in an 81-day period.)
Coloplast – JN
Assura AC - Non-Convex Extra-Extended Wear Baseplate, Cut-To-Fit, Small Coupling 3/8"-1 5/16" (10-33 mm) / green / 0762123040492 / A4409 / 9914YJN / $6.74 / each
Assura AC - Non-Convex Extra-Extended Wear Baseplate, Cut-To-Fit, Medium Coupling 3/8"- 1 7/8" (10-48 mm) / red / 0762123040515 / A4409 / 9914YJN / $6.74 / each
Assura Extra - 2-Pc. Non-Convex Extra-Extended Wear Skin Barrier Flange With Belt Loops, Cut-To-Fit
3/8" - 1 3/8" (10-35 mm) / Green / 0762123031841 / A4409 / 9914YJN / $6.74 / each
Assura Extra - 2-Pc. Non-Convex Extra-Extended Wear Skin Barrier Flange With Belt Loops, Cut-To-Fit
3/8" - 1 3/4" (10-45 mm) / Red / 0762123031865 / A4409 / 9914YJN / $6.74 / each
Assura Extra - 2-Pc. Non-Convex Extra-Extended Wear Skin Barrier Flange With Belt Loops, Cut-To-Fit
3/8" - 2 1/8" (10-55 mm) / Blue / 0762123031889 / A4409 / 9914YJN / $6.74 / each
Assura Extra - 2-Pc. Non-Convex Extra-Extended Wear Skin Barrier Flange With Belt Loops, Pre-Cut 5/8" (15 mm) / Green / 0762123036747 / A4409 / 9914YJN / $6.74 / each
Assura Extra - 2-Pc. Non-Convex Extra-Extended Wear Skin Barrier Flange With Belt Loops, Pre-Cut 3/16" (20 mm) / Green / 0762123036754 / A4409 / 9914YJN / $6.74 / each
Assura Extra - 2-Pc. Non-Convex Extra-Extended Wear Skin Barrier Flange With Belt Loops, Pre-Cut 1" (25 mm) / Green / 0762123036761 / A4409 / 9914YJN / $6.74 / each
Assura Extra - 2-Pc. Non-Convex Extra-Extended Wear Skin Barrier Flange With Belt Loops, Pre-Cut 1 3/16" (30 mm) / Red / 0762123036778 / A4409 / 9914YJN / $6.74 / each

2 – Medical Supply Products: Ostomy Two-Piece Extended Wear Skin BarriersJune 2008

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Description / UPN / HCPCS(reference only) / Billing
Code / Maximum Acquisition Cost (MAC) / Unit of
Measure
Coloplast – JN
Assura Extra - 2-Pc. Non-Convex Extra-Extended Wear Skin Barrier Flange With Belt Loops, Pre-Cut 1 3/8" (35 mm) / Red / 0762123036785 / A4409 / 9914YJN / $6.74 / each
Assura Extra - 2-Pc. Non-Convex Extra-Extended Wear Skin Barrier Flange With Belt Loops, Pre-Cut 1 9/16" (40 mm) / Blue / 0762123036792 / A4409 / 9914YJN / $6.74 / each
Assura Extra - 2-Pc. Non-Convex Extra-Extended Wear Skin Barrier Flange With Belt Loops, Pre-Cut 1 3/4" (45 mm) / Blue / 0762123036808 / A4409 / 9914YJN / $6.74 / each
Assura AC - Non-Convex Extra-Extended Wear Baseplate, Cut-To-Fit, Large Coupling 3/8"-2 3/4" (10-68 mm) / yellow / 0762123040539 / A4410 / 9914ZJN / $6.74 / each
Convatec – SQ
SUR-FIT Natura, Durahesive Skin Barrier w/flange (overall dimension 4" x 4") w/o tape collar 1 1/4" (32 mm) / 30003413153 / A4409 / 9914YSQ / $6.74 / each
SUR-FIT Natura, Durahesive Skin Barrier w/flange (overall dimension 4" x 4") w/o tape collar 1 1/2" (38 mm) / 30003413154 / A4409 / 9914YSQ / $6.74 / each
SUR-FIT Natura, Durahesive Skin Barrier w/flange (overall dimension 4" x 4") w/o tape collar 1 3/4" (45 mm) / 30003413155 / A4409 / 9914YSQ / $6.74 / each
SUR-FIT Natura, Durahesive Skin Barrier w/flange (overall dimension 4" x 4") w/o tape collar 2 1/4" (57 mm) / 30003413156 / A4409 / 9914YSQ / $6.74 / each
SUR-FIT Natura, Durahesive Flexible Skin Barrier w/flange (overall dimension 4" x 4") TAN, w/tape collar 1 1/4" (32 mm) / 30003413164 / A4409 / 9914YSQ / $6.74 / each
SUR-FIT Natura, Durahesive, Flexible Skin Barrier w/flange (overall dimension 4" x 4") TAN, w/tape collar 1 1/2" (38 mm) / 30003413165 / A4409 / 9914YSQ / $6.74 / each
SUR-FIT Natura, Durahesive Flexible Skin Barrier w/flange (overall dimension 4" x 4") TAN, w/tape collar 1 3/4" (45 mm) / 30003413166 / A4409 / 9914YSQ / $6.74 / each

2 – Medical Supply Products: Ostomy Two-Piece Extended Wear Skin BarriersJune 2008

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Description / UPN / HCPCS(reference only) / Billing
Code / Maximum Acquisition Cost (MAC) / Unit of
Measure
Convatec – SQ
SUR-FIT Natura, Durahesive Flexible Skin Barrier w/flange (overall dimension 5" x 5") TAN, w/tape collar 2 1/4" (57 mm) / 30003413167 / A4409 / 9914YSQ / $6.74 / each
SUR-FIT Natura, Durahesive Flexible Skin Barrier w/flange (overall dimension 5" x 5") TAN w/tape collar 2 3/4" (70 mm) / 30003413168 / A4409 / 9914YSQ / $6.74 / each
SUR-FIT Natura, Durahesive Flexible Skin Barrier w/flange (overall dimension 4" x 4") WHT w/tape collar 1 1/4" (32 mm) / 30003413159 / A4409 / 9914YSQ / $6.74 / each
SUR-FIT Natura, Durahesive Flexible Skin Barrier w/flange (overall dimension 4" x 4") WHT w/tape collar 1 1/2" (38 mm) / 30003413160 / A4409 / 9914YSQ / $6.74 / each
SUR-FIT Natura, Durahesive Flexible Skin Barrier w/flange (overall dimension 4" x 4") WHT w/tape collar 1 3/4" (45 mm) / 30003413161 / A4409 / 9914YSQ / $6.74 / each
SUR-FIT Natura, Durahesive Flexible Skin Barrier w/flange (overall dimension 5" x 5") WHT w/tape collar 2 1/4" / 30003413162 / A4409 / 9914YSQ / $6.74 / each
SUR-FIT Natura, Durahesive Flexible Skin Barrier w/flange (overall dimension 5" x 5") WHT w/tape collar 2 3/4" / 30003413163 / A4409 / 9914YSQ / $6.74 / each
SUR-FIT Natura, Moldable Durahesive Skin Barrier with Hydrocolloid Flexible Collar [45mm (1 3/4") - Small] / 30003411800 / A4409 / 9914YSQ / $6.74 / each
SUR-FIT Natura, Moldable Durahesive Skin Barrier with Hydrocolloid Flexible Collar [45mm (1 3/4") - Medium] / 30003411802 / A4409 / 9914YSQ / $6.74 / each
SUR-FIT Natura, Moldable Durahesive Skin Barrier with Hydrocolloid Flexible Collar [57mm (2 1/4") - Large] / 30003411804 / A4409 / 9914YSQ / $6.74 / each
SUR-FIT Natura, Moldable Durahesive Skin Barrier with Hydrocolloid Flexible Collar [70mm (2 3/4") - X-Large] / 30003411806 / A4409 / 9914YSQ / $6.74 / each
SUR-FIT Natura, Durahesive Skin Barrier w/flange (overall dimension 5" x 5") w/o tape collar 2 3/4" (70 mm) / 30003413157 / A4410 / 9914ZSQ / $6.74 / each

2 – Medical Supply Products: Ostomy Part 3July 2007

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Description / UPN / HCPCS(reference only) / Billing
Code / Maximum Acquisition Cost (MAC) / Unit of
Measure
Cymed – CD
Two-Piece MicroSkin Barrier / Universal Flange1 mm washer cut-to-fit to 1 1/2 inches (38 mm) / (01)00383950580007 / A4409 / 9914YCD / $6.74 / each
Two-Piece MicroSkin Barrier / Universal Flange1 mm washer pre-cut for 7/8 inch stoma (22 mm) / (01)00383950580205 / A4409 / 9914YCD / $6.74 / each
Two-Piece MicroSkin Barrier / Universal Flange1 mm washer pre-cut for 1 inch stoma (25 mm) / (01)00383950580304 / A4409 / 9914YCD / $6.74 / each
Two-Piece MicroSkin Barrier / Universal Flange1 mm washer pre-cut for 1 1/8 inch stoma (29 mm) / (01)00383950580403 / A4409 / 9914YCD / $6.74 / each
Two-Piece MicroSkin Barrier / Universal Flange1 mm washer pre-cut for 1 1/4 inch stoma (32 mm) / (01)00383950580502 / A4409 / 9914YCD / $6.74 / each
Two-Piece MicroSkin Barrier / Universal Flange1 mm washer pre-cut for 1 3/8 inch stoma (35 mm) / (01)00383950580601 / A4409 / 9914YCD / $6.74 / each
Two-Piece MicroSkin Barrier / Universal Flange1 mm washer pre-cut for 1 1/2 inch stoma (38 mm) / (01)00383950580700 / A4409 / 9914YCD / $6.74 / each
Two-Piece MicroSkin Barrier/Platinum Style Universal Flange
2 mm washer cut-to-fit to 1 1/2 inches (38 mm) / (01)00383950780001 / A4409 / 9914YCD / $6.74 / each
Two-Piece MicroSkin Barrier/Platinum Style Universal Flange
2 mm washer pre-cut for 7/8 inch stoma (22 mm) / (01)00383950780209 / A4409 / 9914YCD / $6.74 / each
Two-Piece MicroSkin Barrier/Platinum Style Universal Flange
2 mm washer pre-cut for 1 inch stoma (25 mm) / (01)00383950780308 / A4409 / 9914YCD / $6.74 / each
Two-Piece MicroSkin Barrier/Platinum Style Universal Flange
2 mm washer pre-cut for 1 1/8 inch stoma (29 mm) / (01)00383950780407 / A4409 / 9914YCD / $6.74 / each
Two-Piece MicroSkin Barrier/Platinum Style Universal Flange
2 mm washer pre-cut for 1 1/4 inch stoma (32 mm) / (01)00383950780506 / A4409 / 9914YCD / $6.74 / each
Two-Piece MicroSkin Barrier/Platinum Style Universal Flange
2 mm washer pre-cut for 1 3/8 inch stoma (35 mm) / (01)00383950780605 / A4409 / 9914YCD / $6.74 / each

2 – Medical Supply Products: Ostomy Two-Piece Extended Wear Skin BarriersJune 2008

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Description / UPN / HCPCS(reference only) / Billing
Code / Maximum Acquisition Cost (MAC) / Unit of
Measure
Cymed – CD
Two-Piece MicroSkin Barrier/Platinum Style Universal Flange
2 mm washer pre-cut for 1 1/2 inch stoma (38 mm) / (01)00383950780704 / A4409 / 9914YCD / $6.74 / each
Two-Piece MicroSkin Barrier/Plain Style Universal Flange
No washer cut-to-fit to 1 3/4 inches (45 mm) / (01)00383950581004 / A4409 / 9914YCD / $6.74 / each
Hollister – HS
Premier 2pc barrier flg 1 3/4" / 10610075087225 / A4409 / 9914YHS / $6.74 / each
Premier 2pc barrier flg 2 1/4" / 10610075087232 / A4409 / 9914YHS / $6.74 / each
Premier 2pc barrier flg 2 3/4" / 10610075087249 / A4409 / 9914YHS / $6.74 / each
Premier 2pc barrier flg 1 1/2" / 10610075087270 / A4409 / 9914YHS / $6.74 / each
Prm cpl 2pc ps barr 22 mm / 10610075087430 / A4409 / 9914YHS / $6.74 / each
1.25 cpl 2pc ps barr 25 mm / 10610075087447 / A4409 / 9914YHS / $6.74 / each
Prm cpl 2pc ps barr 29 mm / 10610075087454 / A4409 / 9914YHS / $6.74 / each
Prm cpl 2pc ps barr 32 mm / 10610075087461 / A4409 / 9914YHS / $6.74 / each
Prm cpl 2pc ps barr 35 mm / 10610075087478 / A4409 / 9914YHS / $6.74 / each
Prm cpl 2pc ps barr 38 mm / 10610075087485 / A4409 / 9914YHS / $6.74 / each
Cut-to-fit skin barrier 1 3/4" / 10610075087522 / A4409 / 9914YHS / $6.74 / each
Cut-to-fit skin barrier 2 1/4" / 10610075087539 / A4409 / 9914YHS / $6.74 / each
Ni flat ft ctf float tape 44 mm (1 3/4") / 10610075146021 / A4409 / 9914YHS / $6.74 / each
Ni flat ft ctf float tape 57 mm (2 1/4") / 10610075146038 / A4409 / 9914YHS / $6.74 / each
Ni flat ft ctf float tape 70 mm (2 3/4") / 10610075146045 / A4409 / 9914YHS / $6.74 / each

2 – Medical Supply Products: Ostomy Two-Piece Extended Wear Skin BarriersJune 2008

mc sup prod ost twoex

1

Description / UPN / HCPCS(reference only) / Billing
Code / Maximum Acquisition Cost (MAC) / Unit of
Measure
Hollister – HS
Ni flat ft pre-sz ff tape 16 mm (5/8") / 10610075112828 / A4409 / 9914YHS / $6.74 / each
Ni flat ft pre-sz ff tape 19 mm (3/4") / 10610075112835 / A4409 / 9914YHS / $6.74 / each
Ni flat ft pre-sz ff tape 22 mm (7/8") / 10610075112842 / A4409 / 9914YHS / $6.74 / each
Ni flat ft pre-sz ff tape 25 mm (1") / 10610075112859 / A4409 / 9914YHS / $6.74 / each
Ni flat ft pre-sz ff tape 29 mm (1 1/8") / 10610075112866 / A4409 / 9914YHS / $6.74 / each
Ni flat ft pre-sz ff tape 32 mm (1 1/4") / 10610075112873 / A4409 / 9914YHS / $6.74 / each
Ni flat ft pre-sz ff tape 35 mm (1 3/8") / 10610075112880 / A4409 / 9914YHS / $6.74 / each
Ni flat ft pre-sz ff tape 38 mm (1 1/2") / 10610075112897 / A4409 / 9914YHS / $6.74 / each
Ni ft tp 57 mm 2 1/4" flg 44 mm 1 3/4" ps / 10610075118257 / A4409 / 9914YHS / $6.74 / each
New image flextend ctf ff 1 3/4” / 10610075156020 / A4409 / 9914YHS / $6.74 / each
New image flextend ctf ff 2 1/4” / 10610075156037 / A4409 / 9914YHS / $6.74 / each
Ni flat ft pre-sz ff 16 mm (5/8") / 10610075112903 / A4409 / 9914YHS / $6.74 / each
Ni flat ft pre-sz ff 19 mm (3/4") / 10610075112910 / A4409 / 9914YHS / $6.74 / each
Ni flat ft pre-sz ff 22 mm (7/8") / 10610075112927 / A4409 / 9914YHS / $6.74 / each
Ni flat ft pre-sz ff 25 mm(1") / 10610075112934 / A4409 / 9914YHS / $6.74 / each
Ni flat ft pre-sz ff 29 mm (1 1/8") / 10610075112941 / A4409 / 9914YHS / $6.74 / each
Ni flat ft pre-sz ff 32 mm (1 1/4") / 10610075112958 / A4409 / 9914YHS / $6.74 / each
Ni flat ft pre-sz ff 35 mm (1 3/8") / 10610075112965 / A4409 / 9914YHS / $6.74 / each
Ni flat ft pre-sz ff 38 mm (1 1/2") / 10610075112972 / A4409 / 9914YHS / $6.74 / each
New image flextend ctf ff 2 3/4” / 10610075156044 / A4410 / 9914ZHS / $6.74 / each

2 – Medical Supply Products: Ostomy Two-Piece Extended Wear Skin BarriersJune 2008