mc sup prod ost twodr

Medical Supply Products: Ostomy Two-Piece Drainable/Closed Pouches1

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 DRAINABLE POUCHES(Limited to no more than 90 pouches in an 81-day period.)

Coloplast – JN

Assura AC - Easiclose™ Drainable Pouch Maxi, Opaque
Small Coupling, matches green baseplates / 0762123041208 / A4425 / 9914TJN / $2.82 / each
Assura AC - Easiclose™ Drainable Pouch Maxi, Opaque
Medium Coupling, matches red baseplates / 0762123041307 / A4425 / 9914TJN / $2.82 / each
Assura AC - Easiclose™ Drainable Pouch Maxi, Opaque
Medium/Custom Peel Coupling, matches red baseplates / 0762123041314 / A4425 / 9914TJN / $2.82 / each
Assura AC - Easiclose™ Drainable Pouch Maxi, Opaque
Large Coupling, matches yellow baseplates / 0762123041444 / A4425 / 9914TJN / $2.82 / each
Assura AC - 2-Pc. Easiclose™ Pouch XL, (750 ml) Opaque
X-Large Coupling 90 mm, 3 1/2" / 0762123046869 / A4425 / 9914TJN / $2.82 / each
Assura AC - Easiclose™ Drainable Pouch Maxi, Transparent Small Coupling, matches green baseplates / 0762123041192 / A4425 / 9914TJN / $2.82 / each
Assura AC - Easiclose™ Drainable Pouch Maxi, Transparent Medium Coupling, matches red baseplates / 0762123041284 / A4425 / 9914TJN / $2.82 / each
Assura AC - Easiclose™ Drainable Pouch Maxi, Transparent Medium/Custom Peel Coupling, matches red baseplates / 0762123041291 / A4425 / 9914TJN / $2.82 / each

2 – Medical Supply Products: Ostomy Two-Piece Drainable/Closed PouchesJune 2008

mc sup prod ost

Medical Supply Products: Ostomy1

Coloplast – JN

Assura AC - Easiclose™ Drainable Pouch Maxi, Transparent Large Coupling, matches yellow baseplates / 0762123041437 / A4425 / 9914TJN / $2.82 / each
Assura AC - Easiclose™ Drainable Pouch Midi, Opaque
Small Coupling, matches green baseplates / 0762123041185 / A4425 / 9914TJN / $2.82 / each
Assura AC - Easiclose™ Drainable Pouch Midi, Opaque
Medium Coupling, matches red baseplates / 0762123041280 / A4425 / 9914TJN / $2.82 / each
Assura AC - Easiclose™ Drainable Pouch Midi, Opaque
Medium/Custom Peel, matches red baseplates Coupling / 0762123041277 / A4425 / 9914TJN / $2.82 / each
Assura AC - Easiclose™ Drainable Pouch Midi, Opaque
Large Coupling, matches yellow baseplates / 0762123041406 / A4425 / 9914TJN / $2.82 / each
Assura AC - Easiclose™ Drainable Pouch Midi, Transparent
Small Coupling, matches green baseplates / 0762123041178 / A4425 / 9914TJN / $2.82 / each
Assura AC - Easiclose™ Drainable Pouch Midi, Transparent Medium Coupling, matches red baseplates / 0762123041253 / A4425 / 9914TJN / $2.82 / each
Assura AC - Easiclose™ Drainable Pouch Midi, Transparent
Large Coupling, matches yellow baseplates / 0762123041390 / A4425 / 9914TJN / $2.82 / each
Assura - 2-Pc. Drainable Pouch, Opaque Standard 12" (30 cm), matches green flange sizes / 0762123018545 / A4426 / 9906QJN / $2.54 / each
Assura - 2-Pc. Drainable Pouch, Opaque Standard 12" (30 cm), matches red flange sizes / 0762123018569 / A4426 / 9906QJN / $2.54 / each
Assura - 2-Pc. Drainable Pouch, Opaque Standard 12" (30 cm), matches blue flange sizes / 0762123018583 / A4426 / 9906QJN / $2.54 / each

2 – Medical Supply Products: Ostomy Two-Piece Drainable/Closed PouchesJune 2008

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Description / UPN / HCPCS(reference only) / Billing
Code / Maximum Acquisition Cost (MAC) / Unit of
Measure

Coloplast – JN

Assura - 2-Pc. Drainable Pouch, Transparent Standard
12" (30 cm), matches green flange sizes / 0762123018606 / A4426 / 9906QJN / $2.54 / each
Assura - 2-Pc. Drainable Pouch, Transparent Standard
12" (30 cm), matches red flange sizes / 0762123018620 / A4426 / 9906QJN / $2.54 / each
Assura - 2-Pc. Drainable Pouch, Transparent Standard
12" (30 cm), matches blue flange sizes / 0762123018644 / A4426 / 9906QJN / $2.54 / each
Assura - 2-Pc. Drainable Pouch, Opaque Small 10" (25 cm), matches green flange sizes / 0762123018682 / A4426 / 9906QJN / $2.54 / each
Assura - 2-Pc. Drainable Pouch, Opaque Small 10" (25 cm), matches red flange sizes / 0762123018507 / A4426 / 9906QJN / $2.54 / each
Assura - 2-Pc. Drainable Pouch, Opaque Small 10" (25 cm), matches blue flange sizes / 0762123018521 / A4426 / 9906QJN / $2.54 / each
Assura - 2-Pc. Pediatric Drainable Pouch, Transparent
8" (21 cm), 8 1/2" (21 cm) / 0762123018668 / A4426 / 9906QJN / $2.54 / each
Assura - 2-Pc. Easiclose™ WIDE Outlet - Maxi, Opaque
40 mm, matches green flange sizes / 0762123046487 / A4427 / 9906QJN / $2.54 / each
Assura - 2-Pc. Easiclose™ WIDE Outlet - Maxi, Opaque
50 mm, matches red flange sizes / 0762123046548 / A4427 / 9906QJN / $2.54 / each
Assura - 2-Pc. Easiclose™ WIDE Outlet - Maxi, Opaque
60 mm, matches blue flange sizes / 0762123046609 / A4427 / 9906QJN / $2.54 / each

2 – Medical Supply Products: Ostomy Two-Piece Drainable/Closed PouchesJune 2008

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Description / UPN / HCPCS(reference only) / Billing
Code / Maximum Acquisition Cost (MAC) / Unit of
Measure

Coloplast – JN

Assura - 2-Pc. Easiclose™ WIDE Outlet - Maxi, Transparent
40 mm, matches green flange sizes / 0762123046463 / A4427 / 9906QJN / $2.54 / each
Assura - 2-Pc. Easiclose™ WIDE Outlet - Maxi, Transparent
50 mm, matches red flange sizes / 0762123046524 / A4427 / 9906QJN / $2.54 / each
Assura - 2-Pc. Easiclose™ WIDE Outlet - Maxi, Transparent
60 mm, matches blue flange sizes / 0762123046586 / A4427 / 9906QJN / $2.54 / each
Assura - 2-Pc. Easiclose™ WIDE Outlet - Midi, Opaque 40 mm, matches green flange sizes / 0762123046449 / A4427 / 9906QJN / $2.54 / each
Assura - 2-Pc. Easiclose™ WIDE Outlet - Midi, Opaque 50 mm, matches red flange sizes / 0762123046500 / A4427 / 9906QJN / $2.54 / each
Assura - 2-Pc. Easiclose™ WIDE Outlet - Midi, Opaque 60 mm, matches blue flange sizes / 0762123046562 / A4427 / 9906QJN / $2.54 / each
Assura - 2-Pc. Easiclose™ Drainable Pouch, Cut-To-Fit,
Maxi Soft Front Opaque, matches green flange sizes / 0762123029909 / A4427 / 9906QJN / $2.54 / each
Assura - 2-Pc. Easiclose™ Drainable Pouch, Cut-To-Fit,
Maxi Soft Front Opaque, matches red flange sizes / 0762123029947 / A4427 / 9906QJN / $2.54 / each
Assura - 2-Pc. Easiclose™ Drainable Pouch, Cut-To-Fit,
Maxi Soft Front Opaque, matches blue flange sizes / 0762123029985 / A4427 / 9906QJN / $2.54 / each
Assura - 2-Pc. Easiclose™ Drainable Pouch, Cut-To-Fit,
Maxi Transparent, matches green flange sizes / 0762123029893 / A4427 / 9906QJN / $2.54 / each
Assura - 2-Pc. Easiclose™ Drainable Pouch, Cut-To-Fit,
Maxi Transparent, matches red flange sizes / 0762123029930 / A4427 / 9906QJN / $2.54 / each
Assura - 2-Pc. Easiclose™ Drainable Pouch, Cut-To-Fit,
Maxi Transparent, matches blue flange sizes / 0762123029978 / A4427 / 9906QJN / $2.54 / each

2 – Medical Supply Products: Ostomy Two-Piece Drainable/Closed PouchesJune 2008

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Description / UPN / HCPCS(reference only) / Billing
Code / Maximum Acquisition Cost (MAC) / Unit of
Measure

Coloplast – JN

Assura - 2-Pc. Easiclose™ Drainable Pouch, Cut-To-Fit,
Midi Graphic, matches green flange sizes / 0762123029886 / A4427 / 9906QJN / $2.54 / each
Assura - 2-Pc. Easiclose™ Drainable Pouch, Cut-To-Fit,
Midi Graphic, matches red flange sizes / 0762123029923 / A4427 / 9906QJN / $2.54 / each
Assura - 2-Pc. Easiclose™ Drainable Pouch, Cut-To-Fit,
Midi Graphic, matches blue flange sizes / 0762123029961 / A4427 / 9906QJN / $2.54 / each
Assura - 2-Pc. Easiclose™ Drainable Pouch, Cut-To-Fit,
Mini Soft Front Opaque, matches green flange sizes / 0762123029879 / A4427 / 9906QJN / $2.54 / each
Assura - 2-Pc. Easiclose™ Drainable Pouch, Cut-To-Fit,
Mini Soft Front Opaque, matches red flange sizes / 0762123029916 / A4427 / 9906QJN / $2.54 / each
Assura - 2-Pc. Easiclose™ Drainable Pouch, Cut-To-Fit,
Mini Soft Front Opaque, matches blue flange sizes / 0762123029954 / A4427 / 9906QJN / $2.54 / each
Assura AC - 2-Pc. Easiclose™ Pediatric Pouch, Opaque
17 mm / 0762123046982 / A4427 / 9906QJN / $2.54 / each
Assura AC - 2-Pc. Easiclose™ Pediatric Pouch, Opaque
27 mm / 0762123047026 / A4427 / 9906QJN / $2.54 / each
Assura AC - 2-Pc. Easiclose™ Pediatric Pouch, Transparent
17 mm / 0762123046968 / A4427 / 9906QJN / $2.54 / each
Assura AC - 2-Pc. Easiclose™ Pediatric Pouch, Transparent
27 mm / 0762123047002 / A4427 / 9906QJN / $2.54 / each
SenSura 2-Pc. Midi drainable pouch, opaque with filter
40mm (green) / 1170193101 / A4427 / 9906QJN / $2.54 / each †
SenSura 2-Pc. Midi drainable pouch, opaque with filter
50mm (red) / 1170193102 / A4427 / 9906QJN / $2.54 / each †
SenSura 2-Pc. Midi drainable pouch, opaque with filter
60mm (blue) / 1170193103 / A4427 / 9906QJN / $2.54 / each †

†Effective September 1, 2008

2 – Medical Supply Products: Ostomy Two-Piece Drainable/Closed PouchesAugust 2008

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Description / UPN / HCPCS(reference only) / Billing
Code / Maximum Acquisition Cost (MAC) / Unit of
Measure

Coloplast – JN

SenSura 2-Pc. Maxi drainable pouch, opaque with filter
40mm (green) / 1170193104 / A4427 / 9906QJN / $2.54 / each †
SenSura 2-Pc. Maxi drainable pouch, opaque with filter
50mm (red) / 1170193105 / A4427 / 9906QJN / $2.54 / each †
SenSura 2-Pc. Maxi drainable pouch, opaque with filter
60mm (blue) / 1170193106 / A4427 / 9906QJN / $2.54 / each †
SenSura 2-Pc. Maxi drainable pouch, transparent with filter
40mm (green) / 1170193108 / A4427 / 9906QJN / $2.54 / each †
SenSura 2-Pc. Maxi drainable pouch, transparent with filter
50mm (red) / 1170193109 / A4427 / 9906QJN / $2.54 / each †
SenSura 2-Pc. Maxi drainable pouch, transparent with filter
60mm (blue) / 1170193110 / A4427 / 9906QJN / $2.54 / each †
Assura AC - Easiclose™ Non-Filter Drainable Pouch Maxi, Opaque, matches red baseplates / 0762123047774 / A5063 / 9906QJN / $2.54 / each
Assura AC - 2-Pc. Easiclose™ Pouch XL, (750 ml) Transparent, X-Large Coupling 90 mm, 3 1/2" / 0762123047101 / A5063 / 9906QJN / $2.54 / each
Assura AC - Easiclose™ Non-Filter Drainable Pouch Maxi, Opaque, matches yellow baseplates / 0762123047811 / A5063 / 9906QJN / $2.54 / each
Assura AC - Easiclose™ Non-Filter Drainable Pouch Maxi, Transparent, matches red baseplates / 0762123047798 / A5063 / 9906QJN / $2.54 / each
Assura AC - Easiclose™ Non-Filter Drainable Pouch Maxi, Transparent, matches yellow baseplates / 0762123047835 / A5063 / 9906QJN / $2.54 / each
Assura - 2-Pc. Easiclose™ WIDE Outlet - Maxi, Non-Filter, Red, Transparent, matches red flange sizes / 0762123048191 / A5063 / 9906QJN / $2.54 / each
Assura - 2-Pc. Easiclose™ WIDE Outlet - Maxi, Non-Filter, Blue, Transparent, matches blue flange sizes / 0762123048238 / A5063 / 9906QJN / $2.54 / each
Assura - 2-Pc. Easiclose™ WIDE Outlet - Maxi, Non-Filter, Red, Opaque, matches red flange sizes / 0762123048214 / A5063 / 9906QJN / $2.54 / each

†Effective September 1, 2008

2 – Medical Supply Products: Ostomy Part 1July 2007

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Description / UPN / HCPCS(reference only) / Billing
Code / Maximum Acquisition Cost (MAC) / Unit of
Measure

Coloplast – JN

Assura - 2-Pc. Easiclose™ WIDE Outlet - Maxi, Non-Filter,
Blue Opaque, matches blue flange sizes / 0762123048252 / A5063 / 9906QJN / $2.54 / each
Coloplast - 2-Pc. Drainable Pouch, Opaque Standard 11"
(28 cm), matches green Coloplast flange / 0762123000793 / A5063 / 9906QJN / $2.54 / each
Coloplast - 2-Pc. Drainable Pouch, Opaque Standard 11"
(28 cm), matches red Coloplast flange / 0762123000816 / A5063 / 9906QJN / $2.54 / each
Coloplast - 2-Pc. Drainable Pouch, Opaque Standard 11"
(28 cm), matches blue Coloplast flange / 0762123000830 / A5063 / 9906QJN / $2.54 / each
Coloplast - 2-Pc. Drainable Pouch, Transparent Standard
11" (28 cm), matches green Coloplast flange / 0762123000762 / A5063 / 9906QJN / $2.54 / each
Coloplast - 2-Pc. Drainable Pouch, Transparent Standard
11" (28 cm), matches red Coloplast flange / 0762123000779 / A5063 / 9906QJN / $2.54 / each
Coloplast - 2-Pc. Drainable Pouch, Transparent Standard
11" (28 cm), matches blue Coloplast flange / 0762123000786 / A5063 / 9906QJN / $2.54 / each
Coloplast - 2-Pc. Drainable Pouch, Opaque Small 10" (25 cm), matches green Coloplast flange / 0762123000809 / A5063 / 9906QJN / $2.54 / each
Coloplast - 2-Pc. Drainable Pouch, Opaque Small 10" (25 cm), matches red Coloplast flange / 0762123000823 / A5063 / 9906QJN / $2.54 / each
Coloplast - 2-Pc. Drainable Pouch, Opaque Small 10" (25 cm), matches blue Coloplast flange / 0762123000847 / A5063 / 9906QJN / $2.54 / each
Coloplast - 2-Pc. Non-Convex Post-Op Drainable Pouch,
Cut-To-Fit, Transparent 1/2" - 2 3/4" (13-70 mm) / 0762123001981 / A5063 / 9906QJN / $2.54 / each
Coloplast - 2-Pc. Non-Convex Post-Op Drainable Pouch,
Cut-To-Fit, Transparent 1/2" - 3 7/8" (13-100 mm) / 0762123000953 / A5063 / 9906QJN / $2.54 / each
SenSura 2-Pc. Maxi drainable pouch, opaque Non-filter 50mm (red) / 1170193112 / A5063 / 9906QJN / $2.54 / each †
SenSura 2-Pc. Maxi drainable pouch, opaque Non-filter 60mm (blue) / 1170193113 / A5063 / 9906QJN / $2.54 / each †

†Effective September 1, 2008

2 – Medical Supply Products: Ostomy Two-Piece Drainable/Closed PouchesAugust 2008

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Description / UPN / HCPCS(reference only) / Billing
Code / Maximum Acquisition Cost (MAC) / Unit of
Measure

Coloplast – JN

SenSura 2-Pc. Maxi drainable pouch, transparent Non-filter
50mm (red) / 1170193114 / A5063 / 9906QJN / $2.54 / each †
SenSura 2-Pc. Maxi drainable pouch, transparent Non-filter
60mm (blue) / 1170193115 / A5063 / 9906QJN / $2.54 / each †
Convatec – SQ
Esteem Synergy 12" Drainable Pouch with filter, one-sided comfort panel, 2 tail closures, transparent, left side, small / 30003405400 / A4425 / 9914TSQ / $2.82 / each
medium / 30003405401 / A4425 / 9914TSQ / $2.82 / each
large / 30003405402 / A4425 / 9914TSQ / $2.82 / each
Esteem Synergy 12" Drainable Pouch with filter, one-sided comfort panel, 2 tail closures, transparent, right side, small / 30003405403 / A4425 / 9914TSQ / $2.82 / each
medium / 30003405404 / A4425 / 9914TSQ / $2.82 / each
large / 30003405405 / A4425 / 9914TSQ / $2.82 / each
Esteem Synergy 12" Drainable Pouch with filter, one-sided comfort panel, 2 tail closures, opaque, right side, small / 30003410800 / A4425 / 9914TSQ / $2.82 / each
medium / 30003410801 / A4425 / 9914TSQ / $2.82 / each
large / 30003410802 / A4425 / 9914TSQ / $2.82 / each
Esteem Synergy 12" Drainable Pouch with filter, one-sided comfort panel, 2 tail closures, opaque, left side, small / 30003410803 / A4425 / 9914TSQ / $2.82 / each
medium / 30003410804 / A4425 / 9914TSQ / $2.82 / each
large / 30003410805 / A4425 / 9914TSQ / $2.82 / each

†Effective September 1, 2008

2 – Medical Supply Products: Ostomy Two-Piece Drainable/Closed PouchesAugust 2008

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Description / UPN / HCPCS(reference only) / Billing
Code / Maximum Acquisition Cost (MAC) / Unit of
Measure
Convatec – SQ
Esteem Synergy 10" Drainable Pouch with filter, one-sided comfort panel, 2 tail closures, opaque, right side, small / 30003410806 / A4425 / 9914TSQ / $2.82 / each †
medium / 30003410807 / A4425 / 9914TSQ / $2.82 / each †
Esteem Synergy 10" Drainable Pouch with filter, one-sided comfort panel, 2 tail closures, opaque, left side, small / 30003410808 / A4425 / 9914TSQ / $2.82 / each †
medium / 30003410809 / A4425 / 9914TSQ / $2.82 / each †
Esteem Synergy 12" Drainable Pouch with InvisiClose outlet and filter, one-sided comfort panel, opaque,
right side, small / 30003410810 / A4425 / 9914TSQ / $2.82 / each †
medium / 30003410811 / A4425 / 9914TSQ / $2.82 / each †
large / 30003410812 / A4425 / 9914TSQ / $2.82 / each †
Esteem Synergy 12" Drainable Pouch with InvisiClose outlet and filter, one-sided comfort panel, opaque,
left side, small / 30003410813 / A4425 / 9914TSQ / $2.82 / each †
medium / 30003410814 / A4425 / 9914TSQ / $2.82 / each †
large / 30003410815 / A4425 / 9914TSQ / $2.82 / each †

†Effective June 1, 2008

2 – Medical Supply Products: Ostomy Two-Piece Drainable/Closed PouchesJune 2008

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Description / UPN / HCPCS(reference only) / Billing
Code / Maximum Acquisition Cost (MAC) / Unit of
Measure
Convatec – SQ
Esteem Synergy 12" Drainable Pouch with InvisiClose outlet and filter, one-sided comfort panel, transparent,
right side, medium / 30003413353 / A4425 / 9914TSQ / $2.82 / each †
large / 30003413354 / A4425 / 9914TSQ / $2.82 / each †
Little Ones 2-piece adhesive coupling technology drainable pouch with InvisiClose outlet and filter, transparent, for children over 10 lbs / 30003411637 / A4425 / 9914TSQ / $2.82 / each †
opaque / 30003411638 / A4425 / 9914TSQ / $2.82 / each †
SUR-FIT Natura Drainable Pouch, 12" Transparent,
one-side flocking, with filter 1 1/4" / 30003411263 / A4425 / 9914TSQ / $2.82 / each †
1 1/2" / 30003411264 / A4425 / 9914TSQ / $2.82 / each †
3/4" / 30003411265 / A4425 / 9914TSQ / $2.82 / each †
2 1/4" / 30003411266 / A4425 / 9914TSQ / $2.82 / each †
2 3/4" / 30003411267 / A4425 / 9914TSQ / $2.82 / each †
Esteem Synergy 12" Drainable Pouch, one-sided comfort panel, transparent, straight, small / 30003403997 / A5063 / 9906QSQ / $2.54 / each †
large / 30003403995 / A5063 / 9906QSQ / $2.54 / each †

†Effective June 1, 2008

2 – Medical Supply Products: Ostomy Two-Piece Drainable/Closed PouchesJune 2008

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Description / UPN / HCPCS(reference only) / Billing
Code / Maximum Acquisition Cost (MAC) / Unit of
Measure
Convatec – SQ
Esteem Synergy 14" Drainable Pouch, one-sided comfort panel, transparent, straight, extra large / 30003405406 / A5063 / 9906QSQ / $2.54 / each †
Little Ones 2-piece adhesive coupling technology drainable pouch with InvisiClose outlet, transparent, for children under 10 lbs / 30003411631 / A5063 / 9906QSQ / $2.54 / each †
SUR-FIT Natura Drainable Pouch, 10" Opaque w/2-sided comfort panel, 1 1/4" (32 mm), 20/box / 30003404030 / A5063 / 9906QSQ / $2.54 / each
10/box / 30003401505 / A5063 / 9906QSQ / $2.54 / each †
SUR-FIT Natura Drainable Pouch, 10" Opaque w/2-sided comfort panel, 1 1/2" (38 mm), 20/box / 30003404031 / A5063 / 9906QSQ / $2.54 / each
10/box / 30003401506 / A5063 / 9906QSQ / $2.54 / each †
SUR-FIT Natura Drainable Pouch, 10" Opaque w/2-sided comfort panel, 1 3/4" (45 mm), 20/box / 30003404032 / A5063 / 9906QSQ / $2.54 / each
10/box / 30003401507 / A5063 / 9906QSQ / $2.54 / each

†Effective June 1, 2008

2 – Medical Supply Products: Ostomy Two-Piece Drainable/Closed PouchesJune 2008

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Description / UPN / HCPCS(reference only) / Billing
Code / Maximum Acquisition Cost (MAC) / Unit of
Measure
Convatec – SQ
SUR-FIT Natura Drainable Pouch, 10" Opaque w/2-sided comfort panel, 2 1/4" (57 mm), 20/box / 30003404033 / A5063 / 9906QSQ / $2.54 / each
10 /box / 30003401508 / A5063 / 9906QSQ / $2.54 / each †
SUR-FIT Natura Drainable Pouch, 10" Opaque w/2-sided comfort panel, 2 3/4" (70 mm), 20/box / 30003404034 / A5063 / 9906QSQ / $2.54 / each
10/box / 30003401509 / A5063 / 9906QSQ / $2.54 / each †
SUR-FIT Natura Drainable Pouch 12" Opaque w/1-sided comfort panel, 1 1/4" (32 mm), 20/box / 30003404014 / A5063 / 9906QSQ / $2.54 / each
10/box / 30003401932 / A5063 / 9906QSQ / $2.54 / each †
SUR-FIT Natura Drainable Pouch 12" Opaque w/1-sided comfort panel, 1 1/2" (38 mm), 20/box / 30003404015 / A5063 / 9906QSQ / $2.54 / each
10/box / 30003401933 / A5063 / 9906QSQ / $2.54 / each †

†Effective June 1, 2008

2 – Medical Supply Products: Ostomy Two-Piece Drainable/Closed PouchesJune 2008

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Description / UPN / HCPCS(reference only) / Billing
Code / Maximum Acquisition Cost (MAC) / Unit of
Measure
Convatec – SQ
SUR-FIT Natura Drainable Pouch 12" Opaque w/1-sided comfort panel, 1 3/4" (45 mm), 20/box / 30003404016 / A5063 / 9906QSQ / $2.54 / each
10/box / 30003401934 / A5063 / 9906QSQ / $2.54 / each †
SUR-FIT Natura Drainable Pouch 12" Opaque w/1-sided comfort panel, 2 1/4" (57 mm), 20/box / 30003404017 / A5063 / 9906QSQ / $2.54 / each
10/box / 30003401935 / A5063 / 9906QSQ / $2.54 / each †
SUR-FIT Natura Drainable Pouch 12" Opaque w/1-sided comfort panel, 2 3/4" (70 mm), 20/box / 30003404018 / A5063 / 9906QSQ / $2.54 / each
10/box / 30003401936 / A5063 / 9906QSQ / $2.54 / each †
SUR-FIT Natura Drainable Pouch, 12" Opaque w/2-sided comfort panel, 1 1/4" (32 mm), 20/box / 30003404025 / A5063 / 9906QSQ / $2.54 / each
10/box / 30003401500 / A5063 / 9906QSQ / $2.54 / each †
SUR-FIT Natura Drainable Pouch, 12" Opaque w/2-sided comfort panel, 1 1/2" (38 mm), 20/box / 30003404026 / A5063 / 9906QSQ / $2.54 / each
10/box / 30003401501 / A5063 / 9906QSQ / $2.54 / each †

†Effective June 1, 2008

2 – Medical Supply Products: Ostomy Two-Piece Drainable/Closed PouchesJune 2008

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Description / UPN / HCPCS(reference only) / Billing
Code / Maximum Acquisition Cost (MAC) / Unit of
Measure
Convatec – SQ
SUR-FIT Natura Drainable Pouch, 12" Opaque w/2-sided comfort panel, 1 3/4" (45 mm), 20/box / 30003404027 / A5063 / 9906QSQ / $2.54 / each
10/box / 30003401502 / A5063 / 9906QSQ / $2.54 / each †
SUR-FIT Natura Drainable Pouch, 12" Opaque w/2-sided comfort panel, 2 1/4" (57 mm), 20/box / 30003404028 / A5063 / 9906QSQ / $2.54 / each
10/box / 30003401503 / A5063 / 9906QSQ / $2.54 / each †
SUR-FIT Natura Drainable Pouch, 12" Opaque w/2-sided comfort panel, 2 3/4" (70 mm), 20/box / 30003404029 / A5063 / 9906QSQ / $2.54 / each
10/box / 30003401504 / A5063 / 9906QSQ / $2.54 / each †
SUR-FIT Natura Drainable Pouch w/ Invisiclose Outlet,
12" Opaque, w/1-sided comfort panel, no filter, 1 3/4" / 30003413334 / A5063 / 9906QSQ / $2.54 / each
SUR-FIT Natura Drainable Pouch w/ Invisiclose Outlet,
12" Opaque, w/1-sided comfort panel, no filter, 2 1/4" / 30003413335 / A5063 / 9906QSQ / $2.54 / each

†Effective June 1, 2008

2 – Medical Supply Products: Ostomy Two-Piece Drainable/Closed PouchesJune 2008

mc sup prod ost twodr

1

Description / UPN / HCPCS(reference only) / Billing
Code / Maximum Acquisition Cost (MAC) / Unit of
Measure
Convatec – SQ
SUR-FIT Natura Drainable Pouch w/ Invisiclose Outlet,
12" Opaque, w/1-sided comfort panel, no filter, 2 3/4" / 30003413336 / A5063 / 9906QSQ / $2.54 / each
SUR-FIT Natura Little Ones Drainable Pouch w/1-sided comfort panel, 6" transparent, 1 1/4" / 30003401927 / A5063 / 9906QSQ / $2.54 / each †
SUR-FIT Natura Little Ones Drainable Pouch w/1 sided comfort panel, 6" Transparent, 1 3/4" / 30003401928 / A5063 / 9906QSQ / $2.54 / each
SUR-FIT Natura Drainable Pouch, 12" transparent
w/1-sided comfort panel, 1 1/4" / 30003401510 / A5063 / 9906QSQ / $2.54 / each †
SUR-FIT Natura Drainable Pouch, 12" transparent
w/1-sided comfort panel, 1 1/2" / 30003401511 / A5063 / 9906QSQ / $2.54 / each †
SUR-FIT Natura Drainable Pouch, 12" Transparent
w/1-sided comfort panel, 1 3/4" (45mm.) / 30003401512 / A5063 / 9906QSQ / $2.54 / each
SUR-FIT Natura Drainable Pouch, 12" transparent
w/1-sided comfort panel, 2 1/4" / 30003401513 / A5063 / 9906QSQ / $2.54 / each †
SUR-FIT Natura Drainable Pouch, 12" Transparent
w/1-sided comfort panel, 2 3/4" (70mm.) / 30003401514 / A5063 / 9906QSQ / $2.54 / each
SUR-FIT Natura Drainable Pouch, 14" transparent
w/1-sided comfort panel, 4" / 30003401515 / A5063 / 9906QSQ / $2.54 / each †

†Effective June 1, 2008

2 – Medical Supply Products: Ostomy Two-Piece Drainable/Closed PouchesJune 2008

mc sup prod ost twodr

1

Description / UPN / HCPCS(reference only) / Billing
Code / Maximum Acquisition Cost (MAC) / Unit of
Measure
Cymed – CD
11” drainable pouch, clear. Use with any two-piece MicroSkin Barrier (except 68100) / (01)00383950513906 / A5063 / 9906QCD / $2.54 / each
11” drainable pouch, opaque. Use with any two-piece MicroSkin Barrier (except 68100) / (01)00383950514903 / A5063 / 9906QCD / $2.54 / each
11” drainable pouch, clear (tapered). Use with any two-piece MicroSkin Barrier (except 68100) / (01)00383950783903 / A5063 / 9906QCD / $2.54 / each
11” drainable pouch, opaque (tapered). Use with any two-piece MicroSkin Barrier (except 68100) / (01)00383950784900 / A5063 / 9906QCD / $2.54 / each
9” drainable pouch, clear. Use with any two-piece MicroSkin Barrier (except 68100) / (01)00383950413909 / A5063 / 9906QCD / $2.54 / each
9” drainable pouch, opaque. Use with any two-piece MicroSkin Barrier (except 68100) / (01)00383950414906 / A5063 / 9906QCD / $2.54 / each

2 – Medical Supply Products: Ostomy Two-Piece Drainable/Closed Pouches___ 2008

mc sup prod ost twodr

1

Description / UPN / HCPCS(reference only) / Billing
Code / Maximum Acquisition Cost (MAC) / Unit of
Measure
Hollister – HS
New Image Drain Beige, w/fil, 44 mm, 1 3/4” / 10610075181428 / A4425 / 9914THS / $2.82 / each
New Image Drain Beige, w/fil, 57 mm, 2 1/4” / 10610075181435 / A4425 / 9914THS / $2.82 / each
New Image Drain Beige, w/fil, 70 mm, 2 3/4” / 10610075181442 / A4425 / 9914THS / $2.82 / each
New Image Drain Trans, w/fil, 44 mm, 1 3/4” / 10610075181626 / A4425 / 9914THS / $2.82 / each
New Image Drain Trans, w/fil, 57 mm, 2 1/4” / 10610075181633 / A4425 / 9914THS / $2.82 / each
New Image Drain Trans, w/fil, 70 mm, 2 3/4” / 10610075181640 / A4425 / 9914THS / $2.82 / each
Ni Maxi Opq Sym Drn Lnr Flt 44 mm / 10610075181824 / A4425 / 9914THS / $2.82 / each
Ni Maxi Opq Sym Drn Lnr Flt 57 mm / 10610075181831 / A4425 / 9914THS / $2.82 / each
Ni Maxi Opq Sym Drn Lnr Flt 70 mm / 10610075181848 / A4425 / 9914THS / $2.82 / each
Ni Maxi Trnsp Sym Drn Lnr Flt 44 mm / 10610075181923 / A4425 / 9914THS / $2.82 / each
Ni Maxi Trnsp Sym Drn Lnr Flt 57 mm / 10610075181930 / A4425 / 9914THS / $2.82 / each
Ni Maxi Trnsp Sym Drn Lnr Flt 70 mm / 10610075181947 / A4425 / 9914THS / $2.82 / each
Ni Mini Beig Drain Lnr Fltr 44 mm, 1 3/4” / 15390166080063 / A4425 / 9914THS / $2.82 / each
Ni Mini Beig Drain Lnr Fltr 57 mm, 2 1/4” / 15390166080087 / A4425 / 9914THS / $2.82 / each
Ni Mini Beig Drain Lnr Fltr 70 mm, 2 3/4” / 15390166080100 / A4425 / 9914THS / $2.82 / each
Ni Mini Trnsp Drain Lnr Fltr 44 mm, 1 3/4” / 15390166080001 / A4425 / 9914THS / $2.82 / each
Ni Mini Trnsp Drain Lnr Fltr 57 mm, 2 1/4” / 15390166080025 / A4425 / 9914THS / $2.82 / each
Ni Mini Trnsp Drain Lnr Fltr 70 mm, 2 3/4” / 15390166080049 / A4425 / 9914THS / $2.82 / each

2 – Medical Supply Products: Ostomy Two-Piece Drainable/Closed PouchesJune 2008