mc sup prod trach n

Medical Supply Products: Tracheostomy – N thru S Manufacturers1

This section lists the billing codes, manufacturer codes and units for tracheostomy supplies manufactured by companies with names that begin with the letters N-S. In this section “MAC” refers to 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.

Treatment Authorization Requests (TARs) are issued only for products that exceed billing limitations, or where otherwise indicated. Miscellaneous procedure codes, such as 9999A or 9999C, may not be substituted.

MAC Guarantee ThroughThe Department of Health Care Services (DHCS) negotiated a contract with a distributor, Independence Medical, to

Independence Medical Onlyestablish maximum acquisition cost (MAC) agreements for tracheostomy products. The maximum acquisition cost listed in the “MAC” column in this section reflects the guaranteed MAC only when providers buy tracheostomy products through Independence Medical. This price is not guaranteed if providers purchase directly from the manufacturer or another source. “Item” numbers listed in this section are Independence Medical item numbers.

Billing InstructionsClaims submitted for contracted tracheostomy products must include both the billing code and either the UPN or item number. All attachments submitted with paper claims (invoice, catalog page or price list) must include the UPN or item number for the product being billed. If the UPN or item number is not pre-printed on the attachment, it should be handwritten on the attachment next to the supply for which it is required. If the UPN or item number is not included or is illegible the claim will be denied.

Computer Media Claims require the UPN or item number to be included in the Remarks field. All tracheostomy products must be billed to Medicare before being billing to Medi-Cal.

Effective DatesTracheostomy products in this section are effective for dates of service on or after November 1, 2008, unless
otherwise noted.

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Billing LimitationsTracheostomy supplies are limited to the following quantities without authorization.

Billing Code / Limitation
9916L, 9916M, 9916S, 9916U, 9916W / No more than 90 in an 81-day period
9916N, 9916Y, 9916Z / No more than 6 in an 81-day period
9916P, 9916Q, 9917P, 9917Q, 9917V / No more than 3 in an 81-day period
9916R, 9916V, 9916X / No more than 1 unit per dispensing and 4 dispensings in a year
9916T / No more than 12 in a 365-day period
9917S / No more than 15 in an 81-day period
9917T / No more than 12 in an 81-day period
9917U / No more than 18 in an 81-day period

9981E, 9981J

/

No more than 90 in an 81-day period

9981F

/ No more than 360 in an 81-day period

Medical Supply Code 9916X:For instructions to bill medical supply codes 9916X (filter holder and integrated filter housing, and adhesive, for use as a

Billing Instructionsheat and moisture exchange system), see “Filter Holder and Integrated Filter Housing: Medical Supply Code 9916X” section of this manual.

2 – Medical Supply Products: Tracheostomy – N thru S ManufacturersOctober 2008

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TRACHEOSTOMY
Description /
Item
Number /
UPN / HCPCS(reference only) /
Billing
Code /
MAC /
Unit of
Measure
Rusch – RY
Tracheoflex trach set, cuffed, adj flange, size 8.0 mm / RU12058908 / 04026704011995 / A7521 / 9916Z / $191.36 / each
Tracheoflex trach set, cuffed, adj flange, size 7.0 mm / RU12058907 / 04026704011988 / A7521 / 9916Z / $191.36 / each
Tracheoflex trach set, Pediatric, no cuff, adj flange, size 6.0 mm / RU12058206 / 04026704011957 / A7520 / 9916Z / $125.62 / each
Ultra Tracheoflex trach set, cuffed, adj flange, size 10.0 mm / RU12038110 / 04026704011216 / A7521 / 9916Z / $81.37 / each
Ultra Tracheoflex trach set, cuffed, adj flange, size 9.0 mm / RU12038109 / 04026704011209 / A7521 / 9916Z / $81.37 / each
Suction cath kit, 14Fr / RU40460014 / 04026704323272 / A4624 / 9981F / $0.91 / each

Guaranteed maximum acquisition cost is through Independence Medical only. Independence Medical item numbers listed.

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Description /
Item
Number /
UPN / HCPCS(reference only) /
Billing
Code /
MAC /
Unit of
Measure
Shiley – 3T
Trach tube holder, cotton, pediatric & adults / SHTTH / 20840029008489 / A7526 / 9917U / $5.03 / each
Custom pediatric trach, size #4 / SHM4PT / 00000SHM4PT / A7520 / 9916Y / $163.35 / each
Custom pediatric trach fenestrated, 4.5 ID, 6.5 OD / SHM45PED / 000SHM45PED / A7520 / 9916Y / $175.45 / each
Single cannula trach tube, size 9 / SH9SCT / 20840029009059 / A7521 / 9916Z / $44.00 / each
Spare inner cannula, size 8 / SH8SIC / 20840029008595 / A4623 / 9981J / $13.66 / each
Single cannula cuffed trach tube, 8.0 / SH8SCT / 20840029009042 / A7521 / 9916Z / $44.00 / each
Reusable inner cannula low pressure, size 8 / SH8LPC / 20840029007543 / A7521 / 9916Z / $98.28 / each
Laryngectomy tube, size 8 / SH8LGT / 20840029007802 / A7520 / 9916Y / $83.74 / each
Reusable inner cannula low pressure cuffed fenestrated, size 8 / SH8FEN / 20840029007598 / A7521 / 9916Z / $97.85 / each
Disp inner cannula fenestracted, size 8 use w/DCFN & DFEN trach tubes / SH8DICFEN / 20840029008984 / A4623 / 9981J / $5.17 / each
Disp inner cannula, size 8 / SH8DIC / 20840029008540 / A4623 / 9981J / $5.18 / each
Custom Peds trach sterile, size 4 / SH8DFEN / 20840029008168 / A7521 / 9916Z / $63.72 / each
Custom Peds trach 6.5 OD, 4.5 ID, w/fen / SH8DCT / 20840029008113 / A7521 / 9916Z / $60.91 / each
Disp cannula cuffless, size 9 / SH8DCFS / 20840029008243 / A7520 / 9916Y / $54.80 / each
Disp cannula cuffless, fenes, size 8 / SH8DCFN / 20840029008298 / A7520 / 9916Y / $57.69 / each

Guaranteed maximum acquisition cost is through Independence Medical only. Independence Medical item numbers listed.

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Description /
Item
Number /
UPN / HCPCS(reference only) /
Billing
Code /
MAC /
Unit of
Measure
Trach tubes, single cannula, cuffed / SH8CFS / 20840029007710 / A7520 / 9916Y / $66.34 / each
Low pressure cuffed / SH8CFN / 20840029007765 / A7520 / 9916Y / $71.32 / each
Trach tube, cuffed fennestrated / SH80XLTUD / 20840029008915 / A7520 / 9916Y / $7.50 / each
Tracheosoft XLT disp inner cannula, 8.0 ID, 13.3 OD, 105 length / SH80XLTIN / 20840029008946 / A4623 / 9981J / $6.05 / each
Shiley XLT 8.0 mm ID, 13.3 mm OD, 105 mm length / SH809XLTCP / 20840029008922 / A7521 / 9916Z / $75.02 / each
Single cannula trach tube, Size 7, 9.6 mm OD, 7.0 mm ID, 80 mm length / SH7SCT / 20840029009035 / A7521 / 9916Z / $44.00 / each
Tracheosoft XLT disposable inner cannula, 7.0 mm ID / SH70XLTIN / 20840029008885 / A4623 / 9981J / $6.05 / each
Shiley XLT 7.0 mm ID, cuffed, proximal extension / SH70XLTCP / 20840029008861 / A7521 / 9916Z / $75.02 / each
Spare inner cannula, size 6 / SH6SIC / 20840029008588 / A4623 / 9981J / $13.66 / each
Single cannula trach tube, size 6, 6.0 mm OD, 8.3 mm ID, 67 mm length / SH6SCT / 20840029009028 / A7521 / 9916Z / $44.00 / each
Inner Cannula low pressure, cuffed, reusable, size 6 / SH6LPC / 20840029007536 / A7521 / 9916Z / $98.28 / each
Laryngectomy tube, cuffless, size 6 / SH6LGT / 20840029007796 / A7520 / 9916Y / $83.74 / each
XLT 8.0 ID, 13.3 OD, 105 mm length / SH6FEN / 20840029007581 / A7521 / 9916Z / $97.85 / each
Disposable inner cannula, fenes, size 7 / SH6DICFEN / 20840029008977 / A4623 / 9981J / $5.18 / each
Disposable inner cannula, size 7 / SH6DIC / 20840029008533 / A4623 / 9981J / $5.18 / each

Guaranteed maximum acquisition cost is through Independence Medical only. Independence Medical item numbers listed.

2 – Medical Supply Products: Tracheostomy – N thru S ManufacturersOctober 2008

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Description /
Item
Number /
UPN / HCPCS(reference only) /
Billing
Code /
MAC /
Unit of
Measure
Trach tube, low pressure, cuff, size 6 / SH6DFEN / 20840029008151 / A7521 / 9916Z / $63.72 / each
Single cannula, 6 mm ID, 8.3 OD, 67 mm length / SH6DCT / 20840029008106 / A7520 / 9916Y / $60.91 / each
XLT 7.0 ID, cuffed / SH6DCFS / 20840029008236 / A7520 / 9916Y / $54.80 / each
Low pressure reusable cannula cuffed, size 6 / SH6DCFN / 20840029008281 / A7520 / 9916Y / $57.69 / each
Trach tube, cuffless, w/reuse inner cannula, size 6 / SH6CFS / 20840029007703 / A7520 / 9916Y / $66.34 / each
Trach tube, fenestrated, cuffless, size 6 / SH6CFN / 20840029007758 / A7520 / 9916Y / $71.32 / each
Pediatric trach tube, cuffed, 9.0 OD, 6.5 ID, 56 mm long / SH65PLC / 20840029008076 / A7521 / 9916Z / $64.89 / each
Long Pediatric Trach tube, size 6.5, length
56 mm / SH65PDL / 20840029007987 / A7520 / 9916Y / $49.78 / each
Tracheosoft XLT Extended-Length Trach tube, uncuffed, 6.0 mm ID, 11.0 mm O.D., 95 mm length Proximal extension / SH60XLTUP / 20840029008816 / A7520 / 9916Y / $75.02 / each
Tracheosoft XLT Extended-Length Trach Tube, 6.0 mm ID, 11.0 mm OD, 95 mm length / SH60XLTUD / 20840029008793 / A7520 / 9916Y / $75.02 / each
Tracheosoft XLT disposable inner cannula, 6.0 mm / SH60XLTIN / 20840029008823 / A4623 / 9981J / $6.05 / each
Shiley XLT 6.0 mm ID, 11.0 mm OD, 95 mm length, proximal extension / SH60XLTCP / 20840029008809 / A7521 / 9916Z / $75.02 / each
Tracheosoft XLT Extended-Length Trach Tube, 6.0 mm ID, 11.0 mm OD 95 mm length. Distal extension / SH60XLTCD / 20840029008786 / A7521 / 9916Z / $75.02 / each
Pediatric trach tube, cuffed, 6.0, 54 mm / SH60PLC / 20840029008069 / A7521 / 9916Z / $64.89 / each
Long pediatric trach tube, 6.0 / SH60PDL / 20840029007970 / A7520 / 9916Y / $49.78 / each

Guaranteed maximum acquisition cost is through Independence Medical only. Independence Medical item numbers listed.

2 – Medical Supply Products: Tracheostomy – N thru S ManufacturersSeptember 2008

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Description /
Item
Number /
UPN / HCPCS(reference only) /
Billing
Code /
MAC /
Unit of
Measure
Single cannula trach tube, size 5 / SH5SCT / 20840029009011 / A7521 / 9916Z / $44.00 / each
Long pediatric trach tube, cuffed, 5.5 mm ID, 7.7 mm OD, 52 mm long / SH55PLC / 20840029008052 / A7521 / 9916Z / $64.89 / each
Pediatric trach tube, cuffless, size 5.5 / SH55PED / 20840029007932 / A7520 / 9916Y / $49.78 / each
Pediatric trach tube, 5.5 mm ID, 52 mm long / SH55PDL / 20840029007963 / A7520 / 9916Y / $49.78 / each
Pediatric trach tub, cuffed, 5.5 mm ID, 46 mm long / SH55PDC / 20840029008038 / A7521 / 9916Z / $64.89 / each
Tracheosoft xlt extended-length trach tube, 5.0 mm / SH50XLTUD / 20840029008731 / A7520 / 9916Y / $75.02 / each
Tracheosoft xlt disposable inner cannula,
size 5 / SH50XLTIN / 20840029008762 / A4623 / 9981J / $6.05 / each
Pediatric trach tube, cuffless, size 5 / SH50PED / 20840029007925 / A7520 / 9916Y / $49.78 / each
Pediatric trach tube, size 5.0 long / SH50PDL / 20840029007956 / A7520 / 9916Y / $49.78 / each
Pediatric trach tube 5.0, cuffed, 44 mm long / SH50PDC / 20840029008021 / A7521 / 9916Z / $64.89 / each
Spare inner cannula, size 4 / SH4SIC / 20840029008571 / A4623 / 9981J / $13.66 / each
Reusable inner cannula, low pressure, cuffed, size 4 / SH4LPC / 20840029007529 / A7521 / 9916Z / $98.28 / each
Reusable cannula, fenestrated, low pressure, cuffed, size 4 / SH4FEN / 20840029007574 / A7521 / 9916Z / $97.85 / each
Disposable inner cannula, fenestrated, size 4 / SH4DICFEN / 20840029008960 / A4623 / 9981J / $5.18 / each
Disposable inner cannula, size 4 / SH4DIC / 20840029008526 / A4623 / 9981J / $5.18 / each
Disposable cannula, fenes, low pressure, cuff, size 4 / SH4DFEN / 20840029008144 / A7521 / 9916Z / $63.72 / each
Disposable cannula, low pressure, cuffed, size 4 / SH4DCT / 20840029008090 / A7521 / 9916Z / $60.91 / each
Disposable cannula, cuffless, size 4 / SH4DCFS / 20840029008229 / A7520 / 9916Y / $54.80 / each
Disposable cannula, fenes, cuffless, size 4 / SH4DCFN / 20840029008274 / A7520 / 9916Y / $57.69 / each

Guaranteed maximum acquisition cost is through Independence Medical only. Independence Medical item numbers listed.

2 – Medical Supply Products: Tracheostomy – N thru S ManufacturersOctober 2008

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Description /
Item
Number /
UPN / HCPCS(reference only) /
Billing
Code /
MAC /
Unit of
Measure
Trach tube, cuffless, non-fenes, size 4, 9.4 mm OD, 5.0 mm ID, 65 mm length / SH4CFS / 20840029007697 / A7520 / 9916Y / $66.34 / each
Trach tube, fenes, cuffless, size 4Fr / SH4CFN / 20840029007741 / A7520 / 9916Y / $71.32 / each
Pediatric trach tube, size 4.5, 6.5 mm OD, 4.5 mm ID, 42 mm length / SH45PED / 20840029007918 / A7520 / 9916Y / $49.78 / each
Pediatric trach tube, cuffed, size 4.5 / SH45PDC / 20840029008014 / A7521 / 9916Z / $64.89 / each
Neonatal trach tube, #4.5, 36 mm / SH45NEO / 20840029007864 / A7520 / 9916Y / $49.78 / each
Pediatric trach tube, size 4, cuffless, 4.00 mm ID, 5.9 mm OD, 41 mm length / SH40PED / 20840029007901 / A7520 / 9916Y / $49.78 / each
Pediatric trach, cuffed, 4.0 / SH40PDC / 20840029008007 / A7521 / 9916Z / $64.89 / each
Neonatal tracheostomy tube 4.0 / SH40NEO / 20840029007857 / A7520 / 9916Y / $49.78 / each
Pediatric 3.5 trach tube, 16Fr 40 mm long / SH35PED / 20840029007895 / A7520 / 9916Y / $49.78 / each
Neonatal 3.5 tracheostomy tube / SH35NEO / 20840029007840 / A7520 / 9916Y / $49.78 / each
Tracheolife HME, built in oxygen port / SH353U1900 / SH353U1900 / A7507 / 9916V / $1.60 / each
Pediatric trach tube #3, w/obturator, 39 mm / SH30PED / 20840029007888 / A7520 / 9916Y / $49.78 / each

Guaranteed maximum acquisition cost is through Independence Medical only. Independence Medical item numbers listed.

2 – Medical Supply Products: Tracheostomy – N thru S ManufacturersSeptember 2008

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Description /
Item
Number /
UPN / HCPCS(reference only) /
Billing
Code /
MAC /
Unit of
Measure
Neonatal trach tube #3 w/obt, 30 mm /

SH30NEO

/ 20840029007833 / A7520 / 9916Y / $49.78 / each
Single cannula trach tube, cuffed, size 10 / SH10SCT / 20840029009066 / A7521 / 9916Z / $44.00 / each
Reusable inner cannula, low pressure, cuffed, size 10 / SH10LPC / 20840029007550 / A7521 / 9916Z / $98.28 / each
Laryngectomy tube, cuffless, size 10,
13.7 mm OD, 8.9 mm ID, 50 mm length / SH10LGT / 20840029007819 / A7520 / 9916Y / $83.74 / each
Reusable cannula, fenes, low pressure, cuffed, size 10 / SH10FEN / 20840029007604 / A7521 / 9916Z / $97.85 / each
Disposable inner cannula, size 10 / SH10DIC / 20840029008557 / A4623 / 9981J / $4.28 / each
Disposable cannula, fenes, low pressure, cuff, size 10 / SH10DFEN / 20840029008175 / A7521 / 9916Z / $52.66 / each
Disposable cannula, low pressure, cuffed, size 10 / SH10DCT / 20840029008120 / A7521 / 9916Z / $50.34 / each
Disposable cannula, cuffless, size 10 / SH10DCFS / 20840029008250 / A7520 / 9916Y / $45.29 / each
Disposable cannula, fenes, cuffless, size 10 / SH10DCFN / 20840029008304 / A7520 / 9916Y / $47.68 / each
Trach tube cuffless, w/reusable inner cannula, size 10 / SH10CFS / 20840029007727 / A7520 / 9916Y / $54.83 / each
Reusable inner cannula, low pressure, size 10 / SH10CFN / 20840029007772 / A7520 / 9916Y / $58.94 / each
Decannulation plug, size 4 for use w/#4FEN & 4CFN trach tube / SH4DCP / 20840029008625 / A7527 / 9917V / $6.36 / each
Decannulation plug, size 6, for use w/FEN & CFN trach tube / SH6DCP / 20840029008632 / A7527 / 9917V / $6.36 / each
Decannulation plug, size 8 for use w/#8FEN & #8CFN trach tube / SH8DCP / 20840029008649 / A7527 / 9917V / $6.36 / each
Disposable decannulation plug/universal,
size 8 / SH8DDCP / 20840029008670 / A7527 / 9917V / $4.89 / each

Guaranteed maximum acquisition cost is through Independence Medical only. Independence Medical item numbers listed.

2 – Medical Supply Products: Tracheostomy – N thru S ManufacturersNovember 2008

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Description /
Item
Number /
UPN / HCPCS(reference only) /
Billing
Code /
MAC /
Unit of
Measure
Sims Portex – 2X
Concord steri-cath closed ventilation system / SF610114 / 30351688011774 / A4605 / 9916M / $7.58 / each
Steri-Cath closed ventilation suction system, single lumen, 12Fr / SF610112 / 30351688031697 / A4605 / 9916M / $7.96 / each
Inner cannula, 8.0 mm ID, w/15 mm termination for 9.0 mm, Lo-Profile trach tubes / SF597090 / 10351688038708 / A4623 / 9981J / $5.80 / each
Inner cannula for 9.0 mm Lo-Profile trach tube no ventilator termination / SF596090 / 10351688038753 / A4623 / 9981J / $5.80 / each
Inner cannula without connector for 7.0 mm Lo-Profile trach tube / SF596070 / 10351688038777 / A4623 / 9981J / $5.80 / each
Economy Trach Care Tray / SF6952 / 30351688032342 / A4629 / 9981E / $2.00 / each
Trach Care Tray, Full Component Tray / SF6950 / 30351688002185 / A4629 / 9981E / $2.78 / each
Lo-Profile trach tube, 6.0 mm ID, 8.5 mm OD, 67 mm length, cuffed / SF583060 / 10351688038982 / A7521 / 9916Z / $58.08 / each
Laryngectomy Tube, 10.0 mm ID, 14.0 mm OD, 50 mm length, yellow / SF562100 / 10351688003300 / A7520 / 9916Y / $47.19 / each
Pediatric trach tube, with 15 mm iso connector, 5.5 mm 52 mm length / SF555055 / 10351688005649 / A7520 / 9916Y / $19.06 / each

Guaranteed maximum acquisition cost is through Independence Medical only. Independence Medical item numbers listed.

2 – Medical Supply Products: Tracheostomy – N thru S ManufacturersSeptember 2008

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Description /
Item
Number /
UPN / HCPCS(reference only) /
Billing
Code /
MAC /
Unit of
Measure
Pediatric trach tube with iso connector,
5.0 mm / SF555050 / 10351688009289 / A7520 / 9916Y / $20.01 / each
Pediatric trach tube with 15 mm iso connector, 4.5 ID, 7.1 OD, 48 length / SF555045 / 10351688037428 / A7520 / 9916Y / $19.06 / each
Pediatric trach tube size 4.0 44 mm long / SF555040 / 10351688005342 / A7520 / 9916Y / $19.06 / each
Pediatric trach tube with 15 mm iso connector, 3.4 mm ID, 5.8 mm OD,
40 mm length / SF555035 / 10351688002556 / A7520 / 9916Y / $20.01 / each
Pediatric trach tube with 15 mm connector, 3.0 mm ID, 5.2 mm OD, 36 mm length' / SF555030 / 10351688028860 / A7520 / 9916Y / $19.06 / each
Inner cannula for 9 mm per-fit trach tube / SF537090 / 10351688051981 / A4623 / 9981J / $3.63 / each
Inner cannula, 10.0 mm, yellow / SF526100 / 30351688041160 / A4623 / 9981J / $2.21 / each
Inner cannula, 9.00 mm, blue / SF526090 / 30351688041153 / A4623 / 9981J / $2.14 / each
Inner cannula, 8.0 mm / SF526080 / 30351688041146 / A4623 / 9981J / $2.14 / each
Inner cannula, 7.0 mm / SF526070 / 30351688041139 / A4623 / 9981J / $2.14 / each
Inner cannula, 6.0 mm, for use w/portex DICE & Flex DIC Trach tubes / SF526060 / 30351688041122 / A4623 / 9981J / $2.14 / each
Trach tube holder, infant, foam w/fabric cover velcro fastener / SF520002 / 30351688034971 / A7526 / 9917U / $1.08 / each
Trach tube holder, pediatric, foam w/velco fastener / SF520001 / 30351688020820 / A7526 / 9917U / $1.26 / each
Trach tube holder, adult, foam, w/velco fastener / SF520000 / 30351688004608 / A7526 / 9917U / $1.21 / each

Guaranteed maximum acquisition cost is through Independence Medical only. Independence Medical item numbers listed.

2 – Medical Supply Products: Tracheostomy – N thru S ManufacturersOctober 2008

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Description /
Item
Number /
UPN / HCPCS(reference only) /
Billing
Code /
MAC /
Unit of
Measure
Cuffed Fenestrated D.I.C. trach tube,
10.0 mm ID, 14 mm OD, 80 mm long, yellow / SF513100 / 10351688033161 / A7521 / 9916Z / $37.86 / each
Cuffed Fenestrated D.I.C. trach tube, 9.0 mm ID, 12.6 mm OD, 80 mm long, blue / SF513090 / 10351688010339 / A7521 / 9916Z / $37.86 / each
Cuffed Fenestrated D.I.C. trach tube, 8.0 mm ID, 11.3 mm OD, 74 mm length, white / SF513080 / 10351688036933 / A7521 / 9916Z / $37.86 / each
Cuffed Fenestrated D.I.C. trach tube,
7.00 mm ID, 9.9 OD, 70 mm length, green / SF513070 / 10351688023544 / A7521 / 9916Z / $37.86 / each
Cuffed Fenestrated D.I.C. trach tube, 6.0 mm ID, 8.5 mm OD, 64 mm length, orange / SF513060 / 10351688001481 / A7521 / 9916Z / $37.86 / each
Uncuffed Fenestrated D.I.C. trach tube,
10 mm ID, 14 mm OD, 80 mm length, yellow / SF512100 / 10351688018809 / A7520 / 9916Y / $29.98 / each
Uncuffed Fenestrated D.I.C. trach tube,
9.0 mm ID, 12.6 mm OD, 80 mm length, blue / SF512090 / 10351688017949 / A7520 / 9916Y / $29.98 / each
Uncuffed Fenestrated D.I.C. trach tube,
8.0 mm ID, 11.3 mm OD, 74.0 mm length, white / SF512080 / 10351688036674 / A7520 / 9916Y / $29.98 / each
Uncuffed Fenestrated D.I.C. trach tube,
7.0 mm ID, 9.9 mm OD, 70 mm length, green / SF512070 / 10351688003782 / A7520 / 9916Y / $29.98 / each
Uncuffed Fenestrated D.I.C trach tube,
6.0 mm ID, 8.5 mm OD, 64 mm length, orange / SF512060 / 10351688018670 / A7520 / 9916Y / $29.98 / each

Guaranteed maximum acquisition cost is through Independence Medical only. Independence Medical item numbers listed.

2 – Medical Supply Products: Tracheostomy – N thru S ManufacturersSeptember 2008

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Description /
Item
Number /
UPN / HCPCS(reference only) /
Billing
Code /
MAC /
Unit of
Measure
Cuffed Flex D.I.C. trach tube, 10 mm ID,
13.7 mm OD, 80 mm length, yellow / SF505100 / 10351688027900 / A7521 / 9916Z / $33.88 / each
Cuffed Flex D.I.C. trach tube, 9 mm ID,
12.3 mm OD, 80 mm length, blue / SF505090 / 10351688024923 / A7521 / 9916Z / $33.88 / each
Cuffed Flex D.I.C. trach tube, 8 mm ID,
10.9 mm OD, 74 mm length, white / SF505080 / 10351688021007 / A7521 / 9916Z / $31.46 / each
Cuffed Flex D.I.C. trach tube, 7 mm ID,
9.6 mm OD, 70 mm length, green / SF505070 / 10351688000231 / A7521 / 9916Z / $33.88 / each
Cuffed Flex D.I.C. trach tube, 6 mm ID,
8.2 mm OD, 64 mm length, orange / SF505060 / 10351688000644 / A7521 / 9916Z / $33.88 / each
Uncuffed Flex D.I.C. trach tube, 9.0 mm ID, 12.3 mm OD, 80 mm length, blue / SF504090 / 10351688007049 / A7520 / 9916Y / $31.46 / each
Uncuffed Flex D.I.C. trach tube, 8.0 mm ID, 10.9 mm OD, 74 mm length, white / SF504080 / 10351688031358 / A7520 / 9916Y / $31.46 / each
Uncuffed Flex D.I.C. trach tube, 7.0 mm ID, 9.6 mm OD, 70 mm length, green / SF504070 / 10351688019066 / A7520 / 9916Y / $31.46 / each
Uncuffed Flex D.I.C. trach tube, 6.0 mm ID, 8.4 mm OD, 64 mm length, orange / SF504060 / 10351688037459 / A7520 / 9916Y / $31.46 / each

Guaranteed maximum acquisition cost is through Independence Medical only. Independence Medical item numbers listed.

2 – Medical Supply Products: Tracheostomy – N thru S ManufacturersOctober 2008

mc sup prod trach n

1


Description /
Item
Number /
UPN / HCPCS(reference only) /
Billing
Code /
MAC /
Unit of
Measure
Cuffed D.I.C. Regular trach tube, 10.0 mm ID, 14.0 mm OD, 80 mm long, yellow / SF503100 / 10351688022066 / A7521 / 9916Z / $34.30 / each
Cuffed D.I.C trach tube, 9.0 mm ID, 12.6 mm OD, 88 mm length / SF503090 / 10351688036117 / A7521 / 9916Z / $33.88 / each
Cuffed D.I.C. trach tube, #8 / SF503080 / 10351688006677 / A7521 / 9916Z / $33.88 / each
Cuffed Nonfenestrated D.I.C. trach tube, #7 / SF503070 / 10351688009265 / A7521 / 9916Z / $33.88 / each
Cuffed D.I.C. Regular trach tube, 6.0 mm ID, 8.5 mm OD, 64 mm length, orange / SF503060 / 10351688017772 / A7521 / 9916Z / $34.30 / each
Uncuffed D.I.C. trach tube, 9.0 mm ID / SF502090 / 10351688033239 / A7520 / 9916Y / $26.68 / each
Uncuffed D.I.C. Regular trach tube, 8.0 mm ID, 11.3 mm OD, 74 mm length / SF502080 / 10351688034045 / A7520 / 9916Y / $26.68 / each
Uncuffed D.I.C. trach tube, 7.00 mm ID / SF502070 / 10351688012883 / A7520 / 9916Y / $26.68 / each
Uncuffed D.I.C. Regular trach tube, 6.0 mm ID, 8.5 mm OD / SF502060 / 10351688037176 / A7520 / 9916Y / $26.68 / each

Guaranteed maximum acquisition cost is through Independence Medical only. Independence Medical item numbers listed.

2 – Medical Supply Products: Tracheostomy – N thru S ManufacturersSeptember 2008

mc sup prod trach n

1


Description /
Item
Number /
UPN / HCPCS(reference only) /
Billing
Code /
MAC /
Unit of
Measure
Trach tube kit, Blue Line Ultra "Suctionaid" / SF100875070 / 35019315047354 / A7521 / 9916Z / $78.65 / each
Blue Line inner cannula for trach tube, disposable, 8.0 mm ID / SF100790080 / 35019315056738 / A4623 / 9981J / $6.21 / each
Blue Line inner cannula for trach tube,
7.0 mm ID / SF100790070 / 35019315056721 / A4623 / 9981J / $6.21 / each
Trach-Talk Blue Line trach cuffed, 8.0 ID, 11.0 od, 75.0 mm length / SF100785080 / 35019315047934 / A7521 / 9916Z / $62.92 / each
Trach-Talk Blue Line trach tube, 7.0 ID,
9.7 OD, 65.0 mm length / SF100785070 / 35019315047910 / A7521 / 9916Z / $62.92 / each
Blue Line Extra Vertical Length trach tube double cuff, 10.0 ID, 13.8 OD, 52.0 vertical length, 113.0 mm total tube length / SF100784100 / 35019315047897 / A7521 / 9916Z / $62.92 / each
Blue Line double cuff specialty trach tube, 9.0 ID, 12.4 OD, 87 length / SF100784090 / 35019315047873 / A7521 / 9916Z / $62.92 / each
Blue Line trach tube cuffed, 8.0 ID, 11.0 OD, 76 length / SF100782080 / 35019315047613 / A7521 / 9916Z / $23.51 / each
Blue Line trach tube cuffed, 7.0 ID, 9.7 OD, 65 length / SF100782070 / 35019315047590 / A7521 / 9916Z / $23.51 / each
Blue Line trach tube uncuffed, 9.0 mm ID / SF100781090 / 35019315047736 / A7520 / 9916Y / $18.68 / each
Blue Line trach tube uncuffed, 8.0 mm ID / SF100781080 / 35019315047729 / A7520 / 9916Y / $18.68 / each
Blue Line trach tube uncuffed, 7.0 mm ID / SF100781070 / 35019315047699 / A7520 / 9916Y / $18.68 / each
Blue Line trach tube uncuffed, 6.0 mm ID / SF100781060 / 35019315047675 / A7520 / 9916Y / $18.68 / each

Guaranteed maximum acquisition cost is through Independence Medical only. Independence Medical item numbers listed.

2 – Medical Supply Products: Tracheostomy – N thru S ManufacturersOctober 2008

mc sup prod trach n

1


Description /
Item
Number /
UPN / HCPCS(reference only) /
Billing
Code /
MAC /
Unit of
Measure
Maxi-Flo coiled suction cath kit, 14Fr / SF600514 / 30351688008552 / A4624 / 9981F / $1.73 / each
Maxi-Flo looped suction cath, 8Fr / SF6200081 / 30351688033400 / A4624 / 9981F / $0.88 / each
Maxi-Flo suction cath kit, 14Fr, looped / SF6252141 / 30351688012177 / A4624 / 9981F / $1.39 / each
Maxi-Flo suction cath kit, 10Fr, looped / SF6275101 / 30351688000808 / A4624 / 9981F / $1.05 / each
Cathmark neonate suction cath kit, 10Fr, calibrated / SF6377101 / 30351688009511 / A4624 / 9981F / $1.48 / each
Cathmark neonatal suction cath kit, 8Fr, calibrated looped / SF6378081 / 30351688016540 / A4624 / 9981F / $1.50 / each
HEPA Filter (up to 150cm H20) / SF002890 / 30351688415466 / A4481 / 9916L / $3.33 / each
Universal 15 mm red cap plug for trach tubes / SFREDCAP / 0SFREDCAP / A7527 / 9917V / $0.74 / each
Spectrum Medical – 3S
Trach tube w/adapter, stainless steel, size 6, 69 mm long / SZ34916 / 000SZ34916 / A7522 / 9917P / $65.68 / each
Decannulation plug for Air-Lon, size 5, trach tube / SZ37835 / 000SZ37835 / A7527 / 9917V / $11.57 / each

Guaranteed maximum acquisition cost is through Independence Medical only. Independence Medical item numbers listed.

2 – Medical Supply Products: Tracheostomy – N thru S ManufacturersSeptember 2008