mc sup prod wou adv con

Medical Supply Products: Wound Care – Advanced Contracted1

This section lists the billing codes, manufacturer codes and units for wound care medical supplies. In this section, “MAC” refers to the maximum acquisition

cost and “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 DateUnless otherwise indicated, advanced wound care products are effective for dates of service on or after July 1, 2007.

ADVANCED WOUND CARE
Description / UPN / HCPCS(reference only) / Billing
Code / MAC / Unit of
Measure
† ALGINATE DRESSINGS (Limited to no more than 30 pads in a 27-day period, with 90 days duration of therapy, per recipient, without authorization.)
Coloplast – JN
SeaSorb Soft Alginate 2" x 2" / 0762123033098 / A6196 / 9908PJN / $1.93 / each
SeaSorb Soft Alginate 4" x 4" / 0762123033128 / A6196 / 9908RJN / $3.85 / each

Derma Sciences – 5S

* Algicell Alginate 2" x 2"

/ 80995808250 / A6196 / 9908P5S / $1.93 / each††

* Algicell Alginate 4" x 4"

/ 80995801860 / A6196 /
9908R5S
/ $3.85 / each††

* Algicell Alginate 4" x 8"

/ 80995808270 / A6197 / 9908S5S / $5.06 / each††
Deroyal – YJ
Kalginate Alginate 2" x 2" / 00749756055208 / A6196 / 9908PYJ / $1.93 / each
Kalginate Alginate 4" x 4" / 00749756055260 / A6196 / 9908RYJ / $3.85 / each
Gentell – 2J
Gentell Alginate 2" x 2" / 06155413202 / A6196 / 9908P2J / $1.93 / each
Gentell Alginate 4" x 4" / 06155413504 / A6196 / 9908R2J / $3.85 / each

††Effective October 1, 2008

†Effective May 1, 2007 unless otherwise noted.

* Code I. See A(3) of the Medical Supplies: Introduction to List section in this manual for authorization and prescription documentation requirements.

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Medical Supply Products: Wound Care – Advanced Contracted1

† ALGINATE DRESSINGS (Limited to no more than 30 pads in a 27-day period, with 90 days duration of therapy, per recipient, without authorization.)
Hartmann-Conco – 2Q
Sorbalgon Alginate 2" x 2" / 0120612553013648 / A6196 / 9908P2Q / $1.93 / each
Sorbalgon Alginate 4" x 4" / 0120612553013655 / A6196 / 9908R2Q / $3.85 / each
Sorbalgon Alginate 4" x 8" / 0120612553017073 / A6197 / 9908S2Q / $5.06 / each

Hollister – HS

Restore CalciCare Alginate 2" x 2" / 610075099382 / A6196 / 9908PHS / $1.93 / each
Restore CalciCare Alginate 4" x 4" / 610075099375 / A6196 / 9908RHS / $3.85 / each
Lohmann & Rauscher – 2U
Suprasorb A, Alginate 5 x 5 cm / 4021447204406 / A6196 / 9908P2U / $1.93 / each
Suprasorb A, Alginate 10 x 10 cm / 4021447204413 / A6196 / 9908R2U / $3.85 / each
Suprasorb A, Alginate 10 x 20 cm / 4021447204420 / A6197 / 9908S2U / $5.06 / each
Medline – ZH
Maxorb Extra CMC Alginate 2" x 2" / 10080196710829 / A6196 / 9908PZH / $1.93 / each
Maxorb Extra CMC Alginate 4" x 4.75" / 10080196771066 / A6197 / 9908RZH / $3.85 / each
Maxorb Extra CMC Alginate 4" x 8" / 10080196710843 / A6197 / 9908SZH / $5.06 / each
MPM Medical – ZX
MPM Excelginate Alginate 2" x 2" / 366977800228 / A6196 / 9908PZX / $1.93 / each
MPM Excelginate Alginate 4" x 4" / 366977800440 / A6196 / 9908RZX / $3.85 / each
MPM Excelginate Alginate 4" x 8" / 366977800488 / A6197 / 9908SZX / $5.06 / each

†Effective May 1, 2007, unless otherwise noted.

* Code I. See A(3) of the Medical Supplies: Introduction to List section in this manual for authorization and prescription documentation requirements.

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Description / UPN / HCPCS(reference only) / Billing
Code / MAC / Unit of
Measure
† ALGINATE WOUND FILLERS (Limited to no more than 180 inches in a 15-day period, with 60 days duration of therapy, per recipient, without authorization.)
Coloplast – JN
SeaSorb Soft Alginate 1" x 17 1/2" Rope / 0762123035863 / A6199 / 9908XJN / $0.3467 / per inch
Derma Sciences – 5S
* Algicell Alginate ¾" x 12" Rope / 80995808290 / A6199 / 9908X5S / $0.3467 / per inch††

Deroyal – YJ

Kalginate Alginate 6" Rope / 00749756468039 / A6199 / 9908XYJ / $0.3467 / per inch
Gentell – 2J
Gentell Alginate 12" Rope / 061554131206 / A6199 / 9908X2J / $0.3467 / per inch
Hartmann-Conco – 2Q
Sorbalgon Alginate 12" Ribbon / 0120612553013662 / A6199 / 9908X2Q / $0.3467 / per inch
Hollister – HS
Restore CalciCare Alginate 12" Rope / 610075099405 / A6199 / 9908XHS / $0.3467 / per inch
Lohmann & Rauscher – 2U
Suprasorb Alginate (30cm/2gm) 12" Rope / 4021447204451 / A6199 / 9908X2U / $0.3467 / per inch
Medline – ZH
Maxorb Extra CMC Alginate (2 gm) 12" Rope / 10080196710812 / A6199 / 9908XZH / $0.3467 / per inch
MPM Medical – ZX
MPM Excelginate Alginate 6" Rope / 366977800068 / A6199 / 9908XZX / $0.3467 / per inch
MPM Excelginate Alginate 12" Rope / 366977800129 / A6199 / 9908XZX / $0.3467 / per inch

†Effective May 1, 2007, unless otherwise noted.

††Effective October 1, 2008

* Code I. See A(3) of the Medical Supplies: Introduction to List section in this manual for authorization and prescription documentation requirements.

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Description / UPN / HCPCS(reference only) / Billing
Code / MAC / Unit of
Measure
† ANTIMICROBIAL ALGINATE DRESSINGS (Limited to no more than 20 pads in a 27-day period, with 30 days duration of therapy, per recipient, without authorization.)
Argentum Medical – 2E
Silverlon CA 2" x 2" / 85727800040 / A6196 / 9908V2E / $3.04 / each
Silverlon CA 4.25" x 4.25" / 85727800041 / A6197 / 9908W2E / $6.08 / each
Coloplast – JN
Seasorb AG Alginate with Silver 2" x 2" / 0762123049259 / A6196 / 9908VJN / $3.04 / each
Seasorb AG Alginate with Silver 4" x 4" / 0762123049280 / A6196 / 9908WJN / $6.08 / each
Derma Sciences – 5S
* Algicell Ag Silver Alginate 2" x 2" / 80995818190 / A6196 / 9908V5S / $3.04 / each ††
* Algicell Ag Silver Alginate 4.25" x 4.25" / 80995818200 / A6196 / 9908WYJ / $6.08 / each ††
Deroyal – YJ
Algidex Ag Thin Sheet 4" x 4" / 00749756590242 / A6196 / 9908WYJ / $6.08 / each
Medline – ZH
Maxorb Extra AG CMC Alginate with Silver 2" x 2" / 10080196759248 / A6196 / 9908VZH / $3.04 / each
Maxorb Extra AG CMC Alginate with Silver 4" x 4.75" / 10080196769117 / A6197 / 9908WZH / $6.08 / each

†Effective May 1, 2007, unless otherwise noted.

††Effective October 1, 2008

* Code I. See A(3) of the Medical Supplies: Introduction to List section in this manual for authorization and prescription documentation requirements.

2 – Medical Supply Products: Wound Care – Advanced ContractedSeptember 2008

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Description / UPN / HCPCS(reference only) / Billing
Code / MAC / Unit of
Measure
† ANTIMICROBIAL ALGINATE WOUND FILLERS (Limited to no more than 180 inches in a 27-day period, with 30 days duration of therapy, per recipient, without authorization.)
Argentum Medical – 2E
Silverlon CA 3/4" x 12" / 85727800043 / A6199 / 9908Z2E / $0.40 / per inch
Coloplast – JN
Seasorb AG Alginate with Silver 1" x 17 1/2" Rope / 0762123049310 / A6199 / 9908ZJN / $0.40 / per inch
Derma Sciences – 5S
*Algicell Ag Silver Alginate 3/4" x 12" Rope / 80995818210 / A6199 / 9908Z5S / $0.40 / per inch ††
Medline – ZH
Maxorb Extra AG CMC Alginate with Silver 12" Rope / 10080196759262 / A6199 / 9908ZZH / $0.40 / per inch
COLLAGEN DRESSING (* Restricted to chronic granulating wounds unresponsive to an alginate, foam or hydrocolloid dressing. Limited to no more than
10 pads in a 27-day period, with 90 days duration of therapy, per recipient, without authorization.)
BioCore Medical Technologies – OD
Skin Temp II 2" x 3" / 757905110109 / A6021 / 9900XOD / $3.50 / each
Skin Temp II 3" x 4" / 757905100209 / A6021 / 9900ZOD / $7.50 / each
Medline – ZH
Puracol Collagen (1 cc) 2" x 2" / 10080196285808 / A6021 / 9900XZH / $3.50 / each
Puracol Collagen (1 cc) 4" x 4.25" / 10080196285815 / A6022 / 9900ZZH / $7.50 / each
Puracol PLUS Collagen (2 cc) 2" x 2.25" / 10080196285822 / A6021 / 9900XZH / $3.50 / each

†Effective October 1, 2007, unless otherwise noted.

††Effective October 1, 2008

* Code I. See A(3) of the Medical Supplies: Introduction to List section in this manual for authorization and prescription documentation requirements.

2 – Medical Supply Products: Wound Care – Advanced ContractedSeptember 2008

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Description / UPN / HCPCS(reference only) / Billing
Code / MAC / Unit of
Measure
COLLAGEN BASED WOUND FILLER, DRY FORM (* Restricted to chronic granulating wounds unresponsive to an alginate, foam or hydrocolloid wound filler. Limited to no more than 10 gm per 15-day period, with 90 days duration of therapy, per recipient, without authorization.)
BioCore Medical Technologies – OD
Medifil Particles II 5 cc or 0.5 gram / 757905010109 / A6010 / 9902ZOD / $14.00 / per gram
Medifil Particles II 10 cc or 1 gram / 757905010209 / A6010 / 9902ZOD / $14.00 / per gram
Medifil Particles II 15 cc or 1.5 gram / 757905010309 / A6010 / 9902ZOD / $14.00 / per gram
Southwest Technologies – 2V
Stimulen collagen powder, 1 gm packets / 745713695012 / A6010 / 9902Z2V / $14.00 / per gram
COMPOSITE DRESSINGS (* Limited to no more than 12 pads per wound per 27 days, per recipient, without authorization.)
For composite dressings, pad size more than 48 sq. in., with any size adhesive border (HCPCS code A6205) refer to Medical Supply Products:
Wound Care – Advanced “By Report.”
Derma Sciences – 5S
Dudress Film Top Dressing, 4" x 4" / 80995808890 / A6203 / 9910N / $1.60 / each††
Dudress Film Top Dressing, 6" x 6" / 80995808920 / A6203 / 9910P / $2.40 / each††
Dudress Film Top Dressing, 6" x 8" / 80995808930 / A6204 / 9910Q / $2.64 / each††
Gentell – 2J
Comfortell Composite 4" x 4" (2.5" x 2.5"pad) / 6155412604 / A6203 / 9910N / $1.60 / each
Comfortell Composite 6" x 6" (4.5" x 4.5"pad) / 6155412606 / A6203 / 9910P / $2.40 / each

††Effective December 1, 2008

* Code I. See A(3) of the Medical Supplies: Introduction to List section in this manual for authorization and prescription documentation requirements.

2 – Medical Supply Products: Wound Care – Advanced ContractedSeptember 2008

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Description / UPN / HCPCS(reference only) / Billing
Code / MAC / Unit of
Measure
McKesson – MK
Medi-Pak Performance Barrier Island Dressing 4" x 4"/2" x 2" Sterile / 40612479140682 / A6203 / 9910N / $1.60 / each
Medi-Pak Performance Barrier Island Dressing 6" x 6"/4" x 4" Sterile / 40612479140712 / A6203 / 9910P / $2.40 / each
Medi-Pak Performance Barrier Island Dressing 6" x 8"/4" x 6" Sterile / 40612479140743 / A6204 / 9910Q / $2.64 / each
Medline – ZH
Suresite 123 + Pad Composite 2.4" x 2.8" (1.3" x 1.6" pad) / 10080196774197 / A6203 / 9910N / $1.60 / each
Suresite 123 + Pad Composite 4" x 4.8" (2.4" x 3.2" pad) / 10080196774203 / A6203 / 9910N / $1.60 / each
Stratasorb Composite 4" x 4" (2.5" x 2" pad) / 10080196669417 / A6203 / 9910N / $1.60 / each
Stratasorb Composite 6" x 6" (4" x 4" pad) / 10080196669462 / A6203 / 9910P / $2.40 / each
Stratasorb Composite 4" x 10" (2" x 8" pad) / 10080196743049 / A6203 / 9910P / $2.40 / each
Stratasorb Composite 4" x 14" (2" x 12" pad) / 10080196743032 / A6204 / 9910Q / $2.64 / each
Stratasorb Composite 6" x 7.5" (4" x 6" pad) / 10080196669493 / A6204 / 9910Q / $2.64 / each
Molnlycke – S7
Alldress Absorbent Composite 4" x 4" / 7310791081113 / A6203 / 9910N / $1.60 / each
Alldress Absorbent Composite 6" x 6" / 7332430345776 / A6203 / 9910P / $2.40 / each
Mepore Pro Showerproof Self Adhesive 2.5" x 3" / 7332430742650 / A6203 / 9910N / $1.60 / each
Mepore Pro Showerproof Self Adhesive 3.6" x 4" / 7332430742735 / A6203 / 9910N / $1.60 / each
Mepore Pro Showerproof Self Adhesive 3.6" x 6" / 7332430742788 / A6203 / 9910N / $1.60 / each
Mepore Pro Showerproof Self Adhesive 3.6" x 8" / 7332430742827 / A6203 / 9910N / $1.60 / each
Mepore Pro Showerproof Self Adhesive 3.6" x 10" / 7332430742865 / A6203 / 9910P / $2.40 / each
Mepore Pro Showerproof Self Adhesive 3.6" x 12" / 7332430742919 / A6203 / 9910P / $2.40 / each
Alldress Absorbent Composite 6" x 8" / 7332430366566 / A6204 / 9910Q / $2.64 / each

* Code I. See A(3) of the Medical Supplies: Introduction to List section in this manual for authorization and prescription documentation requirements.

2 – Medical Supply Products: Wound Care – Advanced ContractedOctober 2008

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Description / UPN / HCPCS(reference only) / Billing
Code / MAC / Unit of
Measure
MPM Medical – ZX
MPM Multi-Layered Bordered Composite 4" x 4" Overall,
2" x 2" Pad / 366977072441 / A6203 / 9910N / $1.60 / each
MPM Multi-Layered Bordered Composite 6" x 6" Overall,
4" x 4" Pad / 366977072663 / A6203 / 9910P / $2.40 / each
MPM Repel Bordered Composite 4" x 4" Overall, 2" x 2" Pad / 366977082440 / A6203 / 9910N / $1.60 / each
MPM Multi-Layered Bordered Composite 6" x 8" Overall,
4" x 6" Pad / 366977072687 / A6204 / 9910Q / $2.64 / each
MPM Repel Bordered Composite 6" x 6" Overall, 4" x 4" Pad / 366977082662 / A6204 / 9910P / $2.40 / each
MPM Repel Bordered Composite 6" x 8" Overall, 4" x 6" Pad / 366977082686 / A6204 / 9910Q / $2.64 / each

* Code I. See A(3) of the Medical Supplies: Introduction to List section in this manual for authorization and prescription documentation requirements.

2 – Medical Supply Products: Wound Care – Advanced ContractedOctober 2008

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Description / UPN / HCPCS(reference only) / Billing
Code / MAC / Unit of
Measure
CONTACT LAYERS (* Limited to no more than 4 pads per wound per 27 days, per recipient, without authorization.)
Hollister – HS
Restore Contact Layer with Triact Technology 4" x 5" / 20894689001014 / A6207 / 9910S / $7.52 / each
Restore Contact Layer with Triact Technology 6" x 8" / 20894689001021 / A6207 / 9910U / $13.85 / each
Molnlycke – S7
Mepitel Contact Layer 2" x 3" / 7332430319012 / A6206 / 9910S / $7.52 / each
Mepitel Contact Layer 3" x 4" / 7332430319050 / A6206 / 9910S / $7.52 / each
Mepitel Contact Layer 4" x 7.2" / 7332430319098 / A6207 / 9910T / $11.94 / each
Mepitel Contact Layer 8" x 12" / 7310791071473 / A6208 / 9910L / $33.61 / each

* Code I. See A(3) of the Medical Supplies: Introduction to List section in this manual for authorization and prescription documentation requirements.

2 – Medical Supply Products: Wound Care – Advanced ContractedJune 2008

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Description / UPN / HCPCS(reference only) / Billing
Code / MAC / Unit of
Measure
FOAM DRESSINGS (* Limited to no more than 12 pads per wound per 27 days, per recipient, without authorization.)
For foam dressings, pad size more than 48 sq. in., with any size adhesive border (HCPCS code A6214) and foam dressing, wound filler (HCPCS code A6215) refer to Medical Supply Products: Wound Care – Advanced “By Report.”
Coloplast – JN
Biatain Non-Adhesive Foam 2" Round (5 cm) / 0762123028414 / A6209 / 9908Q / $4.92 / each
Biatain Non-Adhesive Foam 3" Round (8 cm) / 0762123028445 / A6209 / 9908Q / $4.92 / each
Biatain Non-Adhesive Foam 4" x 4" (10 x 10 cm) / 0762123025444 / A6209 / 9908Q / $4.92 / each
Biatain Non-Adhesive Foam 6" x 6" (15 x 15 cm) / 0762123025468 / A6210 / 9910W / $11.87 / each
Biatain Non-Adhesive Foam 4" x 8" (10 x 20 cm) / 0762123049952 / A6210 / 9910W / $11.87 / each
Biatain Non-Adhesive 8" x 8" (20 x 20 cm) / 0762123029084 / A6211 / 9910X / $23.49 / each
Biatain Adhesive Foam 4" x 4" (10 x 10 cm) / 0762123031919 / A6212 / 9908Q / $4.92 / each
Biatain Adhesive Foam 5" x 5" (12 1/2 x 12 1/2 cm) / 0762123025482 / A6212 / 9910Y / $8.00 / each
Biatain Adhesive Foam 7" x 7" (18 x 18 cm) / 0762123025505 / A6213 / 9910Z / $14.05 / each
Derma Sciences – 5S
Sorbacel Foam Dressing 1" x 8" / 80995808820 / A6209 / 9910V / $3.19 / each††
Sorbacel Foam Dressing 4" x 4" / 80995808840 / A6209 / 9908Q / $4.92 / each††
Hydrocel Foam Dressing 4" x 4" / 80995808680 / A6209 / 9908Q / $4.92 / each††
Hydrocel Foam Dressing 6" x 6" / 80995808700 / A6210 / 9910W / $11.87 / each††
Hydrocel Adhesive Foam Dressing 4" x 4" / 80995808580 / A6212 / 9908Q / $4.92 / each††
Hydrocel Adhesive Foam Dressing 6" x 6" / 80995808600 / A6213 /
9910Z
/ $14.05 / each††

††Effective December 1, 2008

* Code I. See A(3) of the Medical Supplies: Introduction to List section in this manual for authorization and prescription documentation requirements.

2 – Medical Supply Products: Wound Care – Advanced ContractedJune 2008

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Description / UPN / HCPCS(reference only) / Billing
Code / MAC / Unit of
Measure
Ferris Mfg.Corp. – FH
Polymem Non-Adhesive 3" x 3" / 735471150335 / A6209 / 9908Q / $4.92 / each
Polymem Non-Adhesive 4" x 4" / 735471150441 / A6209 / 9908Q / $4.92 / each
Polymem Shaped Tube 3.5" x 3.5" Tube Site / 735471153350 / A6209 / 9908Q / $4.92 / each
Polymem Silver Non-Adhesive 4.25" x 4.25" / 735471110445 / A6210 / 9910W / $11.87 / each
Polymax Non-Adhesive 4.5" x 4.5" / 735471150458 / A6210 / 9910W / $11.87 / each
Polymem Non-Adhesive 5" x 5" / 735471150557 / A6210 / 9910W / $11.87 / each
Polymem Silver Non-Adhesive 6.5" x 7.5" / 735471110773 / A6211 / 9910X / $23.49 / each
Polymem Non-Adhesive 6.5" x 7.5" / 735471150779 / A6211 / 9910X / $23.49 / each
Polymem Max Non-Adhesive 8" x 8” / 735471250882 / A6211 / 9910X / $23.49 / each
Polymem Non-Adhesive 4" x 12.5" / 735471151240 / A6211 / 9910X / $23.49 / each
Polymem Non-Adhesive 4" x 24" Roll / 735471152445 / A6211 / 9910X / $23.49 / each
Polymem Adhesive 2" x 2" Film Dot / 735471102037 / A6212 / 9908Q / $4.92 / each
Polymem Adhesive 4" x 5" Film Island / 735471104055 / A6212 / 9908Q / $4.92 / each
Polymem Adhesive 6" x 6" Film Island / 735471106066 / A6212 / 9910Y / $8.00 / each

* Code I. See A(3) of the Medical Supplies: Introduction to List section in this manual for authorization and prescription documentation requirements.

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Description / UPN / HCPCS(reference only) / Billing
Code / MAC / Unit of
Measure
Ferris Mfg.Corp. – FH
Polymem Silver Adhesive 6" x 6" Cloth / 735471117666 / A6212 / 9910Y / $8.00 / each
Polymem Shapes Silver #1 Oval / 735471318155 / A6212 / 9910Y / $8.00 / each
Polymem Shapes Silver #3 Oval / 735471318230 / A6212 / 9910Y / $8.00 / each
Polymem Shapes Silver #5 Oval / 735471318537 / A6212 / 9910Y / $8.00 / each
Polymem Adhesive 1" x 3" Film Strip / 735471130313 / A6212 / 9908Q / $4.92 / each
Polymem Adhesive 2" x 4" Film Strip / 735471130429 / A6212 / 9908Q / $4.92 / each
Polymem Shapes 7.2" x 7.8" Sacral / 735471137091 / A6212 / 9910Y / $8.00 / each
Polymem Adhesive 1" x 3" Cloth Strip / 735471170319 / A6212 / 9908Q / $4.92 / each
Polymem Adhesive 2" x 4" Cloth Strip / 735471170425 / A6212 / 9908Q / $4.92 / each
Polymem Adhesive 2" x 2" Cloth Dot / 735471172030 / A6212 / 9908Q / $4.92 / each
Polymem Adhesive 4" x 5" Cloth Island / 735471174058 / A6212 / 9908Q / $4.92 / each
Polymem Adhesive 6" x 6" Cloth Island / 735471176069 / A6212 / 9910Y / $8.00 / each
Polymem Shapes #1 Oval / 735471180158 / A6212 / 9908Q / $4.92 / each
Polymem Shapes #3 Oval / 735471180233 / A6212 / 9908Q / $4.92 / each
Polymem Shapes #5 Oval / 735471180530 / A6212 / 9908Q / $4.92 / each
Polymem Adhesive 4" x 12.5" Film Island / 735471134120 / A6213 / 9910Z / $14.05 / each
Polymem Shapes #8 Oval / 735471180868 / A6213 / 9910Z / $14.05 / each

* Code I. See A(3) of the Medical Supplies: Introduction to List section in this manual for authorization and prescription documentation requirements.

2 – Medical Supply Products: Wound Care – Advanced ContractedJune 2008

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Description / UPN / HCPCS(reference only) / Billing
Code / MAC / Unit of
Measure
Gentell – 2J
LoProfile Foam Plus 4" x 4" (2" x 2" pad) / 6155414404 / A6212 / 9908Q / $4.92 / each
LoProfile Foam Plus 6" x 6" (4" x 4" pad) / 6155414606 / A6212 / 9910Y / $8.00 / each
Hartmann-Conco – 2Q
PermaFoam Non-adhesive Foam 4" x 4" / 0120612553012962 / A6209 / 9908Q / $4.92 / each
PermaFoam Non-adhesive Foam (Tracheostomy) 3.2" x 3.2" / 0120612553017776 / A6209 / 9908Q / $4.92 / each
PermaFoam Non-adhesive Foam 6" x 6" / 0120612553012979 / A6210 / 9910W / $11.87 / each
PermaFoam Comfort Adhesive Foam 4" x 4" / 0120612553012986 / A6212 / 9908Q / $4.92 / each
PermaFoam Comfort Adhesive Foam 6" x 6" / 0120612553012993 / A6212 / 9910Y / $8.00 / each
Hollister – HS
Restore Non-Adhesive Foam with Triact Technology 4" x 4" / 20894689001052 / A6209 / 9908Q / $4.92 / each
Restore Odor-Absorbent Foam 4" x 4" / 20894689001175 / A6209 / 9908Q / $4.92 / each
Restore Non-Adhesive Foam with Triact Technology 6" x 8" / 20894689001069 / A6210 / 9910W / $11.87 / each
Restore Odor-Absorbent Foam 6" x 10" / 20894689001199 / A6211 / 9910X / $23.49 / each
Restore Adhesive Foam with Triact Technology 4" x 4" / 20894689001090 / A6212 / 9908Q / $4.92 / each
Restore Adhesive Foam with Triact Technology 6" x 6" / 20894689001106 / A6212 / 9910Y / $8.00 / each
Restore Adhesive Foam with Triact Technology 6" x 8" / 20894689001113 / A6213 / 9910Z / $14.05 / each

* Code I. See A(3) of the Medical Supplies: Introduction to List section in this manual for authorization and prescription documentation requirements.

2 – Medical Supply Products: Wound Care – Advanced ContractedJune 2008

mc sup prod wou adv con

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Description / UPN / HCPCS(reference only) / Billing
Code / MAC / Unit of
Measure
Lohmann & Rauscher – 2U
Suprasorb P, PU Foam 5 x 5 cm / 4021447204055 / A6209 / 9910V / $3.19 / each
Suprasorb P, PU Foam 7.5 x 7.5 cm / 4021447204062 / A6209 / 9910V / $3.19 / each
Suprasorb P, PU Foam 10 x 10 cm / 4021447204079 / A6209 / 9908Q / $4.92 / each
Suprasorb P, PU Foam 15 x 15 cm / 4021447204086 / A6210 / 9910W / $11.87 / each
Suprasorb P, PU Foam 15 x 20 cm / 4021447204093 / A6210 / 9910W / $11.87 / each
Suprasorb P, PU Foam 7.5 x 7.5 cm / 4021447204161 / A6212 / 9908Q / $4.92 / each
Suprasorb P, PU Foam 10 x 10 cm / 4021447204178 / A6212 / 9908Q / $4.92 / each
Suprasorb P, PU Foam 15 x 15 cm / 4021447204185 / A6213 / 9910Z / $14.05 / each
Suprasorb P, PU Foam 15 x 20 cm / 4021447204192 / A6213 / 9910Z / $14.05 / each

* Code I. See A(3) of the Medical Supplies: Introduction to List section in this manual for authorization and prescription documentation requirements.

2 – Medical Supply Products: Wound Care – Advanced ContractedJune 2008

mc sup prod wou adv con

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Description / UPN / HCPCS(reference only) / Billing
Code / MAC / Unit of
Measure
McKesson – MK
Medi-Pak Performance Hydrophilic Foam 1" x 8" / 40612479145472 / A6209 / 9910V / $3.19 / each
Medi-Pak Performance Hydrophilic Foam 2" x 2" / 40612479145502 / A6209 / 9910V / $3.19 / each
Medi-Pak Performance Hydrophilic Foam 4" x 4" / 40612479145533 / A6209 / 9908Q / $4.92 / each
Medi-Pak Performance Thin Adhesive Foam 2" x 3" / 40612479145410 / A6209 / 9910V / $3.19 / each
Medi-Pak Performance Thin Adhesive Foam 4" x 4" / 40612479145441 / A6209 / 9908Q / $4.92 / each
Medi-Pak Performance Hydrocellular Foam with Film Backing 4" x 4" / 40612479145298 / A6209 / 9908Q / $4.92 / each
Medi-Pak Performance Hydrocellular Foam with Film Backing 6" x 6" / 40612479145328 / A6210 / 9910W / $11.87 / each
Medi-Pak Performance Adhesive Foam 4" x 4" / 40612479145359 / A6212 / 9908Q / $4.92 / each
Medi-Pak Performance Adhesive Foam 6" x 6" / 40612479145380 / A6213 / 9910Z / $14.05 / each

* Code I. See A(3) of the Medical Supplies: Introduction to List section in this manual for authorization and prescription documentation requirements.

2 – Medical Supply Products: Wound Care – Advanced ContractedJune 2008

mc sup prod wou adv con

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Description / UPN / HCPCS(reference only) / Billing
Code / MAC / Unit of
Measure
Medline – ZH
Gentleheal Extra Foam 4" x 4" / 10080196771356 / A6209 / 9908Q / $4.92 / each
Gentleheal Standard Foam 4" x 4" / 10080196764518 / A6209 / 9908Q / $4.92 / each
Optifoam Basic Foam 3" x 3" / 10080196773374 / A6209 / 9910V / $3.19 / each
Optifoam Basic, 3" x 3" with Fenestration / 10080196773381 / A6209 / 9910V / $3.19 / each
Optifoam Non-Adhesive Foam 4" x 4" / 10080196733149 / A6209 / 9908Q / $4.92 / each
Optifoam Ag Non-Adhesive Foam 4" x 4" / 10080196782864 / A6209 / 9908Q / $4.92 / each
Gentleheal Extra Foam 4" x 8" / 10080196771363 / A6210 / 9910W / $11.87 / each
Gentleheal Standard Foam 4" x 8" / 10080196764525 / A6210 / 9910W / $11.87 / each
Optifoam Basic Foam 4" x 5" / 10080196773398 / A6210 / 9910W / $11.87 / each
Optifoam Non-Adhesive Foam 6" x 6" / 10080196733156 / A6210 / 9910W / $11.87 / each
Gentleheal Secure Adhesive Foam 3" x 3" (1.6" x 1.6" pad) / 10080196914463 / A6212 / 9908Q / $4.92 / each
Gentleheal Secure Adhesive Foam 5" x 5" (3.3" x 3.3" pad) / 10080196914470 / A6212 / 9910Y / $8.00 / each
Optifoam Adhesive Foam 4" x 4" / 10080196730810 / A6212 / 9908Q / $4.92 / each
Optifoam Ag Adhesive Foam 4" x 4" / 10080196782871 / A6212 / 9910Y / $8.00 / each
Optifoam Sacral Adhesive Foam 6" x 5.6" / 10080196782833 / A6212 / 9910Y / $8.00 / each
Optifoam Adhesive Foam 6" x 6" / 10080196730827 / A6213 / 9910Z / $14.05 / each

* Code I. See A(3) of the Medical Supplies: Introduction to List section in this manual for authorization and prescription documentation requirements.

2 – Medical Supply Products: Wound Care – Advanced ContractedJune 2008

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Description / UPN / HCPCS(reference only) / Billing
Code / MAC / Unit of
Measure
Molnlycke – S7
Mepilex Lite Thin Foam 2.4" x 3.4" / 7332430662736 / A6209 / 9910V / $3.19 / each
Mepilex Lite Thin Foam 4" x 4" / 7332430662828 / A6209 / 9908Q / $4.92 / each
Mepilex Foam 4" x 4" / 7310791267715 / A6209 / 9908Q / $4.92 / each
Mepilex Foam 4" x 8" / 7310791267746 / A6210 / 9910W / $11.87 / each
Mepilex Foam 6" x 6" / 7310791267777 / A6210 / 9910W / $11.87 / each
Mepilex Heel Foam 5" x 8" / 7332430718761 / A6210 / 9910W / $11.87 / each
Mepilex Transfer Foam 6" x 8" / 7332430054661 / A6210 / 9910W / $11.87 / each
Mepilex Lite Thin Foam 6" x 6" / 7332430782083 / A6210 / 9910W / $11.87 / each
Mepilex Foam 8" x 8" / 7310791267807 / A6211 / 9910X / $23.49 / each
Mepilex Lite Thin Foam 8" x 20" / 7332430766298 / A6211 / 9910X / $23.49 / each

* Code I. See A(3) of the Medical Supplies: Introduction to List section in this manual for authorization and prescription documentation requirements.

2 – Medical Supply Products: Wound Care – Advanced ContractedJune 2008

mc sup prod wou adv con

1

Description / UPN / HCPCS(reference only) / Billing
Code / MAC / Unit of
Measure
Molnlycke – S7
Mepilex Transfer Foam 8" x 20" / 7332430787378 / A6211 / 9910X / $23.49 / each
Mepilex Border Foam 3" x 3" / 7332430494030 / A6212 / 9908Q / $4.92 / each
Mepilex Border Foam 4" x 4" / 7332430497598 / A6212 / 9908Q / $4.92 / each
Mepilex Border Lite Foam 2" x 5" / 7332430520425 / A6212 / 9908Q / $4.92 / each
Mepilex Border Lite Foam 3" x 3" / 7332430527745 / A6212 / 9908Q / $4.92 / each
Mepilex Border Lite Foam 4" x 4" / 7332430527776 / A6212 / 9908Q / $4.92 / each
Mepilex Border Lite Foam 6" x 6" / 7332430527806 / A6213 / 9910Z / $14.05 / each
Mepilex Border Foam 6" x 6" / 7332430732767 / A6213 / 9910Z / $14.05 / each
Mepilex Border Foam 6" x 8" / 7332430732705 / A6213 / 9910Z / $14.05 / each

* Code I. See A(3) of the Medical Supplies: Introduction to List section in this manual for authorization and prescription documentation requirements.

2 – Medical Supply Products: Wound Care – Advanced ContractedJune 2008

mc sup prod wou adv con

1

Description / UPN / HCPCS(reference only) / Billing
Code / MAC / Unit of
Measure
MPM Medical – ZX
MPM Foam Non-Bordered 2" x 2" / 366977500227 / A6209 / 9910V / $3.19 / each
MPM Foam Non-Bordered 4" x 4" / 366977500241 / A6209 / 9908Q / $4.92 / each
MPM Foam Non-Bordered 6" x 6" / 366977500265 / A6210 / 9910W / $11.87 / each
MPM Foam Bordered 4" x 4" Overall, 2" x 2" Pad / 366977500449 / A6212 / 9908Q / $4.92 / each
MPM Foam Circular Fenestrated Bordered 4" Diameter, 2" pad / 366977500258 / A6212 / 9908Q / $4.92 / each
MPM Foam Bordered 6" x 6" Overall, 4" x 4" Pad / 366977500661 / A6212 / 9910Y / $8.00 / each
MPM Foam Bordered 5" x 5" Overall, 3" x 3" Pad / 366977500333 / A6212 / 9910Y / $8.00 / each
MPM Foam Bordered 9" x 9" Overall, 6" x 6" Pad / 366977500999 / A6213 / 9910Z / $14.05 / each

* Code I. See A(3) of the Medical Supplies: Introduction to List section in this manual for authorization and prescription documentation requirements.

2 – Medical Supply Products: Wound Care – Advanced ContractedJune 2008

mc sup prod wou adv con

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Description / UPN / HCPCS(reference only) / Billing
Code / MAC / Unit of
Measure
HYDROCOLLOID DRESSINGS (* Limited to no more than 12 pads or 360 cc paste would filler or 90 gm powder wound filler per wound per 27 days,
per recipient, without authorization.)
For hydrocolloid dressing, pad size more than 48 sq. in., with any size adhesive border (HCPCS code A6239) refer to Medical Supply Products: Wound Care – Advanced “By Report.”
Coloplast – JN
Comfeel Plus Clear Hydrocolloid 2" x 2 3/4" (5 x 7 cm) / 0762123009987 / A6234 / 9910M / $2.18 / each
Comfeel Plus Clear Hydrocolloid 4" x 4" (10 x 10 cm) / 0762123010013 / A6234 / 9911G / $5.61 / each
Comfeel Plus Ulcer Hydrocolloid 1 1/2" x 2 1/2" (4 x 6 cm) / 0762123032572 / A6234 / 9910M / $2.18 / each
Comfeel Plus Ulcer Hydrocolloid 4" x 4" (10 x 10 cm) / 0762123005378 / A6234 / 9911G / $5.61 / each
Comfeel Ulcer Care Hydrocolloid 1 1/2" x 2 1/2" (4 x 6 cm) / 0762123002216 / A6234 / 9910M / $2.18 / each
Comfeel Ulcer Care Hydrocolloid 4" x 4" (10 x 10 cm) / 0762123002186 / A6234 / 9911G / $5.61 / each
Comfeel Plus Ulcer Hydrocolloid 6" x 6" (15 x 15 cm) / 0762123005385 / A6235 / 9911H / $12.50 / each
Comfeel Plus Clear Hydrocolloid 3 1/2" x 5 1/2" (9 x 14 cm) / 0762123010037 / A6235 / 9911H / $12.50 / each
Comfeel Plus Clear Hydrocolloid 6" x 6" (15 x 15 cm) / 0762123010068 / A6235 / 9911H / $12.50 / each
Comfeel Plus Clear Hydrocolloid 6" x 8" (15 x 20 cm) / 0762123010099 / A6235 / 9911H / $12.50 / each
Comfeel Plus Contour Hydrocolloid 24 sq. in. (6 x 8 cm) / 0762123010235 / A6235 / 9911H / $12.50 / each
Comfeel Plus Contour Hydrocolloid 42 sq. in. (9 x 11 cm) / 0762123010266 / A6235 / 9911H / $12.50 / each

* Code I. See A(3) of the Medical Supplies: Introduction to List section in this manual for authorization and prescription documentation requirements.