mc sup lst3
Medical Supplies List 3 (N through S)1
This section lists the billing codes and units for medical supplies. For additional help, refer to the Medical Supplies section of this manual. Refer to the Incontinence Supplies Product List section in this manual
for ostomy and incontinence creams and washes codes. For ostomy products, refer to the Medical Supply Products: Ostomy sections of this manual.
Bill Quantity
BillingIn Total
DescriptionCodeNumber of:
NEBULIZER, BULB TYPE
Pocket and Standard Nebulizer are limited to a cumulative total of no more than one in a
365-day period, per recipient, without prior authorization.
Pocket Nebulizer (plastic) – Specify
manufacturer, catalog number and item
supplied9944Aeach
Standard Nebulizer (glass) – Specify
manufacturer, catalog number and item
supplied9944Beach
Nebulizer replacement parts
Bulb – Specify manufacturer catalog
number and item supplied9944Cbulbs
NEEDLES, HYPODERMIC
Disposable – Specify manufacturer
catalog number and item supplied9926Aneedles
Limited to no more than 100 in a 27-day period, per recipient, without prior authorization.
Reusable – Specify manufacturer,
catalog number and item supplied9932Aneedles
Limited to no more than one in a 27-day period, per recipient, without prior authorization.
OSTOMY SUPPLIES
Colostomy, Fistula, Ileostomy and Urostomy Supplies
Ostomy Adhesives (Nontape) and Adhesive Discs are limited to a cumulative total of no more than 10 in a 27-day period, per recipient, without prior authorization.
Adhesives (Nontape)
Specify manufacturer, catalog number
and item supplied9981Tcontainers
*Code 1. See A(3) of the Medical Supplies: Introduction to List section in this manual regarding prior authorization and prescription documentation requirements.
**See A(6) of the Medical Supplies: Introduction to List section in this manual regarding coverage for inpatients receiving skilled nursing facility services or intermediate care facility services.
2 – Medical Supplies List 3 (N through S)
July 2007
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Bill Quantity
BillingIn Total
DescriptionCodeNumber of:
OSTOMY SUPPLIES
Colostomy, Fistula, Ileostomy and Urostomy Supplies (continued)
Ostomy Adhesives (Nontape) and Adhesive Discs are limited to a cumulative total of no more than 10 in a 27-day period, per recipient, without prior authorization.
Adhesive Discs
ReliaSeal9913Ydiscs
Others – Specify manufacturer, catalog
number and item supplied9915Ldiscs
Adhesive Remover
Specify manufacturer, catalog number
and item supplied9913J
Bags
Bard’s (Including Former Davol & Diamond Shamrock Products) †
Numbers:
13099959Pbags
13229959Rbags
13239959Sbags
13259959Tbags
13269959Ybags
13279959Wbags
13329973Abags
13349973Bbags
13359973Cbags
13369973Dbags
13379973Ebags
13389973Fbags
16609973Hbags
22029973Jbags
22039973Kbags
22529973Lbags
22539973Mbags
†Effective August 1, 2007
*Code 1. See A(3) of the Medical Supplies: Introduction to List section in this manual regarding prior authorization and prescription documentation requirements.
**See A(6) of the Medical Supplies: Introduction to List section in this manual regarding coverage for inpatients receiving skilled nursing facility services or intermediate care facility services.
2 – Medical Supplies List 3 (N through S)
July 2007
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Bill Quantity
BillingIn Total
DescriptionCodeNumber of:
OSTOMY SUPPLIES (continued)
Colostomy, Fistula, Ileostomy and Urostomy Supplies (continued)
Bags
Bard’s (Including Former Davol & Diamond Shamrock Products) (continued) †
Numbers:
2272 – 22779973Nbags
2285 – 22889973Pbags
23529973Rbags
2372 – 23779973Sbags
2385 – 23889973Tbags
2472 – 24779973Ybags
2485 – 24889973Wbags
29739974Abags
29749974Bbags
2603 – 26099974Cbags
2643 – 26499974Dbags
2703 – 27099974Ebags
2743 – 27499974Fbags
41409974Hbags
41419974Jbags
4262 – 42649974Kbags
4272 – 42779974Lbags
4284 – 42889974Mbags
4321 – 43229974Nbags
4362 – 43649974Pbags
4372 – 43779974Rbags
4384 – 43889974Sbags
4462 – 44649974Tbags
4472 – 44779974Ybags
4484 – 44889974Wbags
†Effective August 1, 2007
*Code 1. See A(3) of the Medical Supplies: Introduction to List section in this manual regarding prior authorization and prescription documentation requirements.
**See A(6) of the Medical Supplies: Introduction to List section in this manual regarding coverage for inpatients receiving skilled nursing facility services or intermediate care facility services.
2 – Medical Supplies List 3 (N through S)
July 2007
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Bill Quantity
BillingIn Total
DescriptionCodeNumber of:
OSTOMY SUPPLIES (continued)
Colostomy, Fistula, Ileostomy and Urostomy Supplies (continued)
Bags (continued)
Bard’s (Including Former Davol & Diamond Shamrock Products) (continued)†
Numbers:
74009975Abags
7440 – 74419975Bbags
74429975Cbags
9600019913Kbags
9600029913Lbags
9600039913Mbags
9600049913Nbags
9601019913Abags
9601029913Bbags
9601039913Cbags
9602019975Dbags
9602029913Dbags
9603019975Ebags
9603029913Ebags
9604019975Fbags
960403 – 9604049975Hbags
9604059975Jbags
9604069975Kbags
9610029975Lbags
9610059959Abags
9610069959Bbags
9610079959Cbags
961008 – 9610099975Mbags
9610139975Nbags
9610209975Pbags
9629009975Rbags
†Effective August 1, 2007
*Code 1. See A(3) of the Medical Supplies: Introduction to List section in this manual regarding prior authorization and prescription documentation requirements.
**See A(6) of the Medical Supplies: Introduction to List section in this manual regarding coverage for inpatients receiving skilled nursing facility services or intermediate care facility services.
2 – Medical Supplies List 3 (N through S)
July 2007
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Bill Quantity
BillingIn Total
DescriptionCodeNumber of:
OSTOMY SUPPLIES (continued)
Colostomy, Fistula, Ileostomy and Urostomy Supplies (continued)
Bags (continued)
Bard’s (Including Former Davol & Diamond Shamrock Products) (continued)†
Numbers:
9629019975Sbags
9629049975Tbags
9629059975Ybags
9630029913Fbags
9630039913Hbags
9710059975Wbags
Greer’s Numbers:†
50079976Abags
50089976Bbags
50099976Cbags
50109976Dbags
50179976Ebags
50189976Fbags
50199976Hbags
70359976Jbags
70369976Kbags
90409976Lbags
90419976Mbags
90459976Nbags
90469981Wbags
†Effective August 1, 2007
*Code 1. See A(3) of the Medical Supplies: Introduction to List section in this manual regarding prior authorization and prescription documentation requirements.
**See A(6) of the Medical Supplies: Introduction to List section in this manual regarding coverage for inpatients receiving skilled nursing facility services or intermediate care facility services.
2 – Medical Supplies List 3 (N through S)
July 2007
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Bill Quantity
BillingIn Total
DescriptionCodeNumber of:
OSTOMY SUPPLIES (continued)
Colostomy, Fistula, Ileostomy and Urostomy Supplies (continued)
Bags (continued)
Hollister’s Series:
1439976Sbags
3149915Bbags
3189976Tbags
3229915Cbags
3239915Dbags
3279915Ebags
3329915Fbags
3609976Wbags
7169915Nbags
No. 97759977Dbags
*Code 1. See A(3) of the Medical Supplies: Introduction to List section in this manual regarding prior authorization and prescription documentation requirements.
**See A(6) of the Medical Supplies: Introduction to List section in this manual regarding coverage for inpatients receiving skilled nursing facility services or intermediate care facility services.
2 – Medical Supplies List 3 (N through S)
June 2001
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Bill Quantity
BillingIn Total
DescriptionCodeNumber of:
OSTOMY SUPPLIES (continued)
Colostomy, Fistula, Ileostomy and Urostomy Supplies (continued)
Bags (continued)
Kay’s Numbers:†
125-50259977Ebags
126-14129977Fbags
126-15129977Hbags
126-15169977Jbags
126-16129977Kbags
126-16169977Lbags
126-24129977Mbags
126-25129977Nbags
126-25169977Pbags
126-26129977Rbags
126-26169977Sbags
†Effective August 1, 2007
*Code 1. See A(3) of the Medical Supplies: Introduction to List section in this manual regarding prior authorization and prescription documentation requirements.
**See A(6) of the Medical Supplies: Introduction to List section in this manual regarding coverage for inpatients receiving skilled nursing facility services or intermediate care facility services.
2 – Medical Supplies List 3 (N through S)
July 2007
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Bill Quantity
BillingIn Total
DescriptionCodeNumber of:
OSTOMY SUPPLIES (continued)
Colostomy, Fistula, Ileostomy and Urostomy Supplies (continued)
Bags (continued)
Nu Hope’s Numbers:
8100 – 811110’s9919Bbags
8100 CI Series10’s9919Cbags
8150 – 816110’s9962Abags
8150 CI Series10’s9962Bbags
8200 – 822410’s9919Hbags
8200 CI Series10’s9919Kbags
8250 – 827410’s9962Dbags
8250CI; 8450CI; 8550CI Series10’s9962Ebags
8400CI; 8500CI Series10’s9919Fbags
Shield’s Numbers:
06089977Tbags
06099977Wbags
14129977Ybags
14139978Abags
15129978Bbags
15139978Cbags
15169978Ebags
15179978Fbags
16129978Hbags
16139978Jbags
16169978Kbags
50259978Dbags
*Code 1. See A(3) of the Medical Supplies: Introduction to List section in this manual regarding prior authorization and prescription documentation requirements.
**See A(6) of the Medical Supplies: Introduction to List section in this manual regarding coverage for inpatients receiving skilled nursing facility services or intermediate care facility services.
2 – Medical Supplies List 3 (N through S)
July 2007
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Bill Quantity
BillingIn Total
DescriptionCodeNumber of:
OSTOMY SUPPLIES (continued)
Colostomy, Fistula, Ileostomy and Urostomy Supplies (continued)
Bags (continued)
Convatec’s (formerly know as Squibb, E.R. and Sons, Inc.) Numbers:
0223-(10-13)1’s9978Lbags
0223-(20-23)1’s9978Mbags
0242-(30-33)10’s9978Nbags
0242-(34-37)10’s9978Pbags
0242-(60-62)25’s9978Rbags
0256-(20-23)30’s9978Sbags
0256-(30-33,39)10’s9978Tbags
0256-(40-43,49)10’s9978Wbags
0256-(90-93,99)10’s9978Ybags
0257-(75-78)20’s9979Abags
*Code 1. See A(3) of the Medical Supplies: Introduction to List section in this manual regarding prior authorization and prescription documentation requirements.
**See A(6) of the Medical Supplies: Introduction to List section in this manual regarding coverage for inpatients receiving skilled nursing facility services or intermediate care facility services.
2 – Medical Supplies List 3 (N through S)
July 2007
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Bill Quantity
BillingIn Total
DescriptionCodeNumber of:
OSTOMY SUPPLIES (continued)
Colostomy, Fistula, Ileostomy and Urostomy Supplies (continued)
Bags (continued)
Colostomy, fistula and ileostomy bags
not specifically listed under manufacturers
above – Specify manufacturer, catalog number
and item supplied9913Pbags
Billing code 9913P can only be used to bill for ONE-PIECE colostomy, fistula and ileostomy pouches.†
Urostomy bags not specifically listed
under manufacturers above – Specify
manufacturer, catalog number and
item supplied9959Mbags
Billing code 9959M can only be used to bill for ONE-PIECE urostomy pouches. †
Irrigation Kits
Specify manufacturer, catalog
number and item supplied9915Yeach
†Effective October 1, 2007
*Code 1. See A(3) of the Medical Supplies: Introduction to List section in this manual regarding prior authorization and prescription documentation requirements.
**See A(6) of the Medical Supplies: Introduction to List section in this manual regarding coverage for inpatients receiving skilled nursing facility services or intermediate care facility services.
2 – Medical Supplies List 3 (N through S)
July 2007
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Bill Quantity
BillingIn Total
DescriptionCodeNumber of:
OSTOMY SUPPLIES (continued)
Irrigation Sleeves and Accessories
Limited to no more than two in a 27-day period, per recipient, without prior authorization.
Specify manufacturer, catalog
number and item supplied9919Jeach
Skin Protectives
Barrier Films
Karaya Gum Powder, Karaya Paste and Stomahesive Paste/Powder is limited to a cumulative total of no more than 12 ounces in a 27-day period, per recipient, without prior authorization.
Karaya Paste2 oz/tube9919Lounces
4.5 oz/tube9919Nounces
**Karaya PowderSee KARAYA GUM POWDER
Karaya Wafers – Specify manufacturer,
catalog number and item supplied9919Pwafers
Op-Site DressingSee BANDAGES, Dressing
Type (Nonmedicated)
Peristomal Coverings (No Flange)
Nonsterile4” x 4”9913Seach
8” x 8”9913Teach
Sterile4” x 4”9919Reach
8” x 8”9919Seach
Peristomal Coverings (With Flange)
Nonsterile4” x 4”9919Teach†
Peristomal coverings not specifically
listed above – Specify manufacturer,
catalog number and item supplied9919Weach
†Effective August 1, 2007
*Code 1. See A(3) of the Medical Supplies: Introduction to List section in this manual regarding prior authorization and prescription documentation requirements.
**See A(6) of the Medical Supplies: Introduction to List section in this manual regarding coverage for inpatients receiving skilled nursing facility services or intermediate care facility services.
2 – Medical Supplies List 3 (N through S)
July 2007
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Bill Quantity
BillingIn Total
DescriptionCodeNumber of:
OSTOMY SUPPLIES (continued)
Karaya Gum Powder, Karaya Paste and Stomahesive Paste/Powder is limited to a cumulative total of no more than 12 ounces in a 27-day period, per recipient, without prior authorization.
Stomahesive Paste2 oz.9980Sounces
Powder1 oz.9980Tounces
Tincture of Benzoin
Specify manufacturer, catalog
number and item supplied9919Yeach
Vigilon DressingSee BANDAGES; Dressing Type (Non-medicated)
Skin Protectives, Barrier films
Barrier films other than those specifically
listed – Specify manufacturer, catalog
number and item supplied9913Rcontainers
Tubes, Clamps, Connectors, and Etc. are limited to no more than five in a 27-day period, per recipient, without prior authorization.
Tubes, Clamps, Connectors, Etc. – Specify
manufacturer, catalog number and item supplied9959Neach
Ostomy Supplies other than those specifically
listed above – Specify manufacturer, catalog
number and item supplied (Note: The following9913Weach
items are not a benefit: spray and pump
deodorants; protective ointments; body lotions or
powders; skin conditioners; emollients or
moisturizers; skin cleansers or shampoos;
bathing cleansers or shampoos; cleansing wipes
and pads.)
*Code 1. See A(3) of the Medical Supplies: Introduction to List section in this manual regarding prior authorization and prescription documentation requirements.
**See A(6) of the Medical Supplies: Introduction to List section in this manual regarding coverage for inpatients receiving skilled nursing facility services or intermediate care facility services.
2 – Medical Supplies List 3 (N through S)
July 2007
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Bill Quantity
BillingIn Total
DescriptionCodeNumber of:
OSTOMY SUPPLIES (continued)
Tracheostomy Supplies
Care Trays (Kits) limited to no more than 31 in a 27-day period, per recipient, without prior authorization.
Care Trays (Kits) – Specify manufacturer, catalog number and item supplied9981Etrays
Catheters, Suction – Specify manufacturer, catalog number and item supplied9981Fcatheters
Cleaners (Solvent & Mechanical Types) – Specify manufacturer, catalog number and item supplied 9981H each
Tubes (All Types) – Specify manufacturer, catalog number, and item supplied9981Jtubes
Other tracheostomy supplies – Specify manufacturer, catalog number and item supplied9981Keach
Note: Suction catheter kits are reimbursable under code 9981K, without prior authorization.
Tracheostoma filter, any size, any type, no more than 31 in a 27-day period, without prior authorization 9916L each†
Tracheal suction catheter, closed system, no more than 15 in a 27-day period, without prior authorization 9916M each†
Tracheostoma Cleaning Brush, no more than 2 in a 27-day period, without prior authorization 9916N each†
Tracheostoma Valve, Including diaphragm, no more than 1 in a 27-day period, without prior authorization 9916P each†
†Effective July 1, 2007
*Code 1. See A(3) of the Medical Supplies: Introduction to List section in this manual regarding prior authorization and prescription documentation requirements.
**See A(6) of the Medical Supplies: Introduction to List section in this manual regarding coverage for inpatients receiving skilled nursing facility services or intermediate care facility services.
2 – Medical Supplies List 3 (N through S)
June 2007
mc sup lst3
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Bill Quantity
BillingIn Total
DescriptionCodeNumber of:
OSTOMY SUPPLIES (continued)
Tracheostomy Supplies (continued)
Replacement diaphragm and/or faceplate for Trach Valve, no more than 1 in 27 days, without prior authorization 9916Q each†
HME – Holder or cap, reusuable, no more than 4 a year without prior authorization9916Reach†
HME – Filter (also referred to as a cassette that contains a filter), no more than 372 in a year without prior authorization 9916S each†
HME – Housing, reusable, no more than 12 in a year without prior authorization9916Teach†
HME – Adhesive disc, any type, no more than 31 in a 27-day period, without prior authorization 9916U each†
HME – Filter holder & integrated filter without adhesive, for use in a heat and moisture exchange system, no more than 4 a year, without prior authorization 9916V each†
HME – Exchange system and/ or with a trach valve, no more than 31 in a 27-day period, without prior authorization 9916W each†
Filter holder & integrated filter housing, & adhesive, for use as a heat & moisture exchange system, no more than 4 in a year, without prior authorization 9916X each†
Trach/Laryn Tube, noncuffed, PVC, Silicone, or equal, no more than 2 in a 27-day period, without prior authorization 9916Y each†
†Effective July 1, 2007
*Code 1. See A(3) of the Medical Supplies: Introduction to List section in this manual regarding prior authorization and prescription documentation requirements.
**See A(6) of the Medical Supplies: Introduction to List section in this manual regarding coverage for inpatients receiving skilled nursing facility services or intermediate care facility services.
2 – Medical Supplies List 3 (N through S)
June 2007
mc sup lst3
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Bill Quantity
BillingIn Total
DescriptionCodeNumber of:
OSTOMY SUPPLIES (continued)
Tracheostomy Supplies (continued)
Trach/Laryn Tube, cuffed, PVC, Silicone, or equal, no more than 2 in a 27-day period, without prior authorization 9916Z each†
Trach/Laryn, Tube, Stainless steel or equal, no more than 1 in a 27-day period, without prior authorization 9917P each†
Tracheostoma shower protector, no more than 1 in a 27-day period, without prior authorization 9917Q each†
Tracheostoma stent/stud/button, no more than 5 in a 27-day period, without prior authorization 9917S each†
Trach Mask, no more than 4 in a 27-day period, without prior authorization9917Teach†
Trach, collar/holder, no more than 6 in a 27-day period, without prior authorization9917Ueach†
Trach/Laryn, Tube plug/stop, no more than 1 in a
27-day period without prior authorization9917Veach†
PADS, STERILESee BANDAGES; Pad Type (Sterile)
PEAK FLOW METERS, NON-ELECTRONIC
Meters can be billed by pharmacies only. Peak Flow Meters, Non-electric are limited to no more than one meter in a
365-day period, per recipient, without prior authorization. *Use NDC or UPC codeeach
†Effective July 1, 2007
*Code 1. See A(3) of the Medical Supplies: Introduction to List section in this manual regarding prior authorization and prescription documentation requirements.
**See A(6) of the Medical Supplies: Introduction to List section in this manual regarding coverage for inpatients receiving skilled nursing facility services or intermediate care facility services.
2 – Medical Supplies List 3 (N through S)
June 2007
mc sup lst3
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Bill Quantity
BillingIn Total
DescriptionCodeNumber of:
SANITARY NAPKINS/TAMPONSSee BANDAGES; Sanitary Napkin/Tampon Type
SHEETING, WATERPROOF9947Aeach
Limited to no more than two (2) in a 365-day period, per recipient, without prior authorization.
Note: Waterproof mattress covers are billed using code 9947A and the manufacturer code. Items not listed are not a Medi-Cal benefit and will not be granted prior authorization or a Treatment Authorization Request (TAR). Waterproof sheeting products not listed cannot be billed using a miscellaneous code 9999A.
Note: Waterproof sheeting that is zippered or conforming, such as a fitted sheet, is considered a mattress protector and is billed with code 9999A. Prior authorization is required.
Specify manufacturer, catalog number and item supplied.
Description
/ Stock Number /UPC
/ Maximum Acquisition Cost / Billing CodeG. Hirsch & Company Inc.
Poly/Vinyl Quilted, with
Anchor band, 39” x 75” / SR 832 / 000891832001 / $22.00 / 9947A TI
Cooltex with Bactishield, 36” x 72” / SR 837 / 000891837006 / $22.00 / 9947A TI
Humanicare International, Inc.
Sheeting, Waterproof, Quilted rubber free hypoallergenic
36” x 80” / 36080 / (01)00044156360809 / $22.00 / 9947A VS
Sheeting, Waterproof, Quilted rubber free hypoallergenic
39” x 75” / 39075 / (01)00044156390752 / $22.00 / 9947A VS
*Code 1. See A(3) of the Medical Supplies: Introduction to List section in this manual regarding prior authorization and prescription documentation requirements.
**See A(6) of the Medical Supplies: Introduction to List section in this manual regarding coverage for inpatients receiving skilled nursing facility services or intermediate care facility services.
2 – Medical Supplies List 3 (N through S)
June 2007
mc sup lst3
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Bill Quantity
BillingIn Total
DescriptionCodeNumber of:
SPONGES, STERILESee BANDAGES; Sponge Type
SUSPENSORY
Specify manufacturer, catalog number and item supplied9956Aeach
* SWABSTICKS, SATURATED
70% Isopropyl Alcohol
3-swab sealed package only9955Reach
Povidone-Iodine Scrub
3-swab sealed package only9955Teach
* Restricted to use for cleansing the skin at central or peripheral catheter exit site during dressing changes and for intravenous starts.
SYRINGE, BULB TYPES
Bulb Syringe Catheter Tip, Glass
Bulb Syringes are limited to a cumulative total of no more than one in a 365-day period, per recipient, without prior authorization.
1 ounce9908Asyringes
1½ ounces9908Bsyringes
2 ounces9908Csyringes
3 ounces9908Dsyringes
4 ounces9908Esyringes
Other – Specify manufacturer, catalog
number and item supplied9908Fsyringes
*Code 1. See A(3) of the Medical Supplies: Introduction to List section in this manual regarding prior authorization and prescription documentation requirements.
**See A(6) of the Medical Supplies: Introduction to List section in this manual regarding coverage for inpatients receiving skilled nursing facility services or intermediate care facility services.
2 – Medical Supplies List 3 (N through S)
June 2007
mc sup lst3
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Bill Quantity
BillingIn Total
DescriptionCodeNumber of:
SYRINGE, BULB TYPES (continued)
Ear and Ulcer Syringe
1 ounce9928Asyringes
2 ounces9928Bsyringes
3 ounces9928Csyringes
Infant Nasal Aspirator
1 ounce9928Daspirators
3 ounces9928Easpirators
SYRINGE, HYPODERMIC
Disposable Syringe Only (No Needle)
Disposable Syringes/No Needle are limited to a cumulative total of no more than 100 in
a 27-day period, per recipient, without prior authorization.
1 cc (Insulin)9926Bsyringes
2 cc (Insulin)9926Csyringes
3 cc9926Dsyringes
5 cc9926Esyringes
Others – Specify manufacturer,
catalog number and item supplied9926Fsyringes
*Code 1. See A(3) of the Medical Supplies: Introduction to List section in this manual regarding prior authorization and prescription documentation requirements.
**See A(6) of the Medical Supplies: Introduction to List section in this manual regarding coverage for inpatients receiving skilled nursing facility services or intermediate care facility services.
2 – Medical Supplies List 3 (N through S)
June 2007
mc sup lst3
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Bill Quantity
BillingIn Total
DescriptionCodeNumber of:
SYRINGE, HYPODERMIC (continued)
Reusable Syringe Only, Glass