incont prod protect

Incontinence Products: Protective Underwear1

This section lists the billing codes, manufacturer codes and units for disposable incontinence protective underwear. In this section, “MAC” refers to the maximum acquisition cost and “UPN” refers to the Universal Product Number. For additional help, refer to the Incontinence Supplies section in this manual. HCPCS codes are for reference only.

Effective DateUnless otherwise stated, the disposable protective underwear listed in this section are effective September 1, 2008.

DISPOSABLE PROTECTIVE UNDERWEAR
Description /
Product Number
/ UPN / HCPCS (reference only) / Billing
Code / MAC / Unit of
Measure
SMALL DISPOSABLE PROTECTIVE UNDERWEAR (Restricted to no more than 120 in a 27-day period, per recipient, without authorization.)
Attends – PQ
Attends Underwear with Leakage Barrier, Super Plus Absorbency / APP0710 / 186679250295 / T4525 / 9917ZPQ / $0.3500 / each
First Quality Products – YU
Prevail Adult Protective Underwear / PV511 / 90891500000 / T4525 / 9917ZYU / $0.3500 / each
G. Hirsch – TI
Secure LC Protective Underwear / SR99112 / 000891991128 / T4525 / 9917ZTI / $0.3500 / each

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incont prod protect

Incontinence Products: Protective Underwear1

Hospital Specialty Company – YV
At Ease Small Pull-on Undergarment, Maximum Absorbency / 42122 / 075289075780 / T4525 / 9917ZYV / $0.3500 / each
Humanicare – VS
Dignity Premium Protective Underwear / 46076 / 044156469769 / T4525 / 9917ZVS / $0.3500 / each
Medline – ZH
Protection Plus Classic / MSC23000 / 40080196753483 / T4525 / 9917ZZH / $0.3500 / each
MegaCareLine – 2M
Premium Adult Protective Underwear / MCL2724 / 7290010633616 / T4525 / 9917Z2M / $0.3500 / each
Principle Business Enterprises – TJ
Select Disposable Absorbent Underwear / 2604 / 070319026046 / T4525 / 9917ZTJ / $0.3500 / each
*SCA Personal Care – 2H
TENA Protective Underwear Extra / 72131 / 768702721318 / T4525 / 9917Z2H / $0.3500 / each
TENA Protective Underwear Extra Discreet / 72146 / 768702721462 / T4525 / 9917Z2H / $0.3500 / each
Whitestone – WH
Compose DPU 4/22SM / 55190 / 078459551909 / T4525 / 9917ZWH / $0.3500 / each

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Description /
Product Number
/ UPN / HCPCS (reference only) / Billing
Code / MAC / Unit of
Measure
MEDIUM DISPOSABLE PROTECTIVE UNDERWEAR (Restricted to no more than 120 in a 27-day period, per recipient, without authorization.)
Attends – PQ
Attends Underwear Extra / AP0720 / 186679281480 / T4526 / 9932NPQ / $0.3600 / each
Attends Underwear with Leakage Barrier, Super Plus / APP0720 / 186679250318 / T4526 / 9932NPQ / $0.3600 / each
First Quality Products – YU
Prevail Adult Protective Underwear / PV512 / 90891500017 / T4526 / 9932NYU / $0.3600 / each
Prevail Refastenable Adult Protective Underwear / PVR512 / 90891501144 / T4526 / 9932NYU / $0.3600 / each
Prevail Adult Super Absorbent Protective Underwear / PVS512 / 90891501120 / T4526 / 9932NYU / $0.3600 / each
Prevail Ultra Thin Adult Protective Underwear / PVU512 / 90891500161 / T4526 / 9932NYU / $0.3600 / each
G. Hirsch – TI
Secure LC Protective Underwear / SR99113 / 000891991135 / T4526 / 9932NTI / $0.3600 / each
Secure Plus Protective Underwear / SR99103 / 000891991036 / T4526 / 9932NTI / $0.3600 / each

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Description /
Product Number
/ UPN / HCPCS (reference only) / Billing
Code / MAC / Unit of
Measure
Hospital Specialty Company – YV
At Ease Pull-on Undergarment, Maximum Absorbency / 42192 / 075289421921 / T4526 / 9932NYV / $0.3600 / each
At Ease Pull-on Undergarment, Extra Absorbency / 62192 / 075289621925 / T4526 / 9932NYV / $0.3600 / each
Humanicare – VS
Dignity Premium Protective Underwear / 46077 / 044156460776 / T4526 / 9932NVS / $0.3600 / each
Dignity Maximum Protective Underwear / 46087 / 044156460875 / T4526 / 9932NVS / $0.3600 / each
Medline – ZH
Protection Plus Classic / MSC23005 / 40080196753513 / T4526 / 9932NZH / $0.3600 / each
Protection Plus / MSC33005 / 40080196732556 / T4526 / 9932NZH / $0.3600 / each
MegaCareLine – 2M
Super Adult Protective Underwear / MSL2625 / 7290010633586 / T4526 / 9932N2M / $0.3600 / each
Premium Adult Protective Underwear / MSL2725 / 7290010633623 / T4526 / 9932N2M / $0.3600 / each

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Description /
Product Number
/ UPN / HCPCS (reference only) / Billing
Code / MAC / Unit of
Measure

Midwest Medical Supply – 2K

MMS Protective Underwear Regular Absorbency / 1605MMS / (01)10694393116966 / T4526 / 9932N2K / $0.3600 / each
MMS Protective Underwear Super Absorbency / 1205MMS / (01)10694393117055 / T4526 / 9932N2K / $0.3600 / each
Presto – 2P
Protective Underwear / NP61200 / 185211000015 / T4526 / 9932N2P / $0.3600 / each
Principle Business Enterprises – TJ
Basicare Disposable Absorbent Underwear / 2805 / 070319028057 / T4526 / 9932NTJ / $0.3600 / each
* SCA Personal Care – 2H
TENA Protective Underwear Plus / 72239 / 768702722391 / T4526 / 9932N2H / $0.3600 / each
TENA Protective Underwear Extra / 72231 / 768702722315 / T4526 / 9932N2H / $0.3600 / each
TENA Protective Underwear Extra Discreet / 72246 / 768702722469 / T4526 / 9932N2H / $0.3600 / each
Whitestone – WH
Compose DPU 4/20MD / 55390 / 078459553903 / T4526 / 9932NWH / $0.3600 / each

*Effective January 1, 2009

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Description /
Product Number
/ UPN / HCPCS (reference only) / Billing
Code / MAC / Unit of
Measure
LARGE DISPOSABLE PROTECTIVE UNDERWEAR (Restricted to no more than 120 in a 27-day period, per recipient, without authorization.)
Attends – PQ
Attends Underwear Extra Absorbent / AP0730 / 186679281497 / T4527 / 9933NPQ / $0.4800 / each
Attends Underwear with Leakage Barrier, Super Plus Absorbency / APP0730 / 186679250325 / T4527 / 9933NPQ / $0.4800 / each
First Quality Products – YU
Prevail Adult Protective Underwear / PV513 / 90891500024 / T4527 / 9933NYU / $0.4800 / each
Prevail Refastenable Adult Protective Underwear / PVR513 / 90891501151 / T4527 / 9933NYU / $0.4800 / each
Prevail Adult Super Absorbent Protective Underwear / PVS513 / 90891501137 / T4527 / 9933NYU / $0.4800 / each
Prevail Ultra Thin Adult Protective Underwear / PVU513 / 90891500178 / T4527 / 9933NYU / $0.4800 / each
G. Hirsch & Company – TI
Secure LC Protective Underwear / SR99114 / 000891991142 / T4527 / 9933NTI / $0.4800 / each
Secure Plus Protective Underwear / SR99104 / 000891991043 / T4527 / 9933NTI / $0.4800 / each

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Description /
Product Number
/ UPN / HCPCS (reference only) / Billing
Code / MAC / Unit of
Measure
Hospital Specialty Company – YV
At Ease Large Pull-on Undergarment, Maximum Absorbency / 42171 / 075289421716 / T4527 / 9933NYV / $0.4800 / each
At Ease Large Pull-on Undergarment, Extra Absorbency / 62171 / 075289621710 / T4527 / 9933NYV / $0.4800 / each
Humanicare – VS
Dignity Premium Protective Underwear / 46078 / 044156460783 / T4527 / 9933NVS / $0.4800 / each
Dignity Maximum Protective Underwear / 46088 / 044156460882 / T4527 / 9933NVS / $0.4800 / each
McKesson – MK
Brief Staydry Pull-on / 05014719 / 20612479147182 / T4527 / 9933NMK / $0.4800 / each
Medline – ZH
Protection Plus Classic / MSC23505 / 40080196753520 / T4527 / 9933NZH / $0.4800 / each
Protection Plus / MSC33505 / 40080196732563 / T4527 / 9933NZH / $0.4800 / each
MegaCareLine – 2M
Super Adult Protective Underwear / MCL2626 / 7290010633593 / T4527 / 9933N2M / $0.4800 / each
Premium Adult Protective Underwear / MCL2726 / 7290010633630 / T4527 / 9933N2M / $0.4800 / each

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Description /
Product Number
/ UPN / HCPCS (reference only) / Billing
Code / MAC / Unit of
Measure
Midwest Medical Supply – 2K
MMS Protective Underwear Super Absorbency / 1215MMS / (01)10694393117062 / T4527 / 9933N2K / $0.4800 / each
MMS Protective Underwear Regular Absorbency / 1615MMS / (01)10694393116973 / T4527 / 9933N2K / $0.4800 / each
Presto Absorbent Products, Inc. – 2P
Protective Underwear / NP61300 / 185211000022 / T4527 / 9933N2P / $0.4800 / each
Principle Business Enterprises – TJ
Basicare Disposable Absorbent Underwear / 2806 / 070319028064 / T4527 / 9933NTJ / $0.4800 / each
Select Disposable Absorbent Underwear / 2606 / 070319026060 / T4527 / 9933NTJ / $0.4800 / each
* SCA Personal Care – 2H
TENA Protective Underwear Plus / 72339 / 768702723398 / T4527 / 9933N2H / $0.4800 / each
TENA Protective Underwear Extra / 72331 / 768702723312 / T4527 / 9933N2H / $0.4800 / each
TENA Protective Underwear Extra Discreet / 72346 / 768702723466 / T4527 / 9933N2H / $0.4800 / each

Whitestone – WH

Compose DPU 4/18LRG / 55590 / 078459555907 / T4527 / 9933NWH / $0.4800 / each

*Effective January 1, 2009

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Description /
Product Number
/ UPN / HCPCS (reference only) / Billing
Code / MAC / Unit of
Measure
EXTRA LARGE DISPOSABLE PROTECTIVE UNDERWEAR (Restricted to no more than 120 in a 27-day period, per recipient, without authorization.)
Attends – PQ
Attends Underwear Extra Absorbency / AP0740 / 186679281503 / T4528 / 9934NPQ / $0.4800 / each
Attends Underwear with Leakage Barrier, Super Plus Absorbency / APP0740 / 186679250332 / T4528 / 9934NPQ / $0.4800 / each
First Quality Products – YU
Prevail Adult Protective Underwear / PV514 / 90891500031 / T4528 / 9934NYU / $0.4800 / each
Prevail XXL Adult Protective Underwear / PV517 / 90891501168 / T4528 / 9934NYU / $0.4800 / each
G. Hirsch – TI
Secure LC Protective Underwear / SR99115 / 000891991159 / T4528 / 9934NTI / $0.4800 / each
Secure Plus Protective Underwear / SR99105 / 000891991050 / T4528 / 9934NTI / $0.4800 / each
Hospital Specialty Company – YV
At Ease Extra Large Pull-on Undergarment, Maximum Absorbency / 42356 / 075289423567 / T4528 / 9934NYV / $0.4800 / each
At Ease Extra Large Pull-on Undergarment, Extra Absorbency / 62356 / 075289623561 / T4528 / 9934NYV / $0.4800 / each

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Description /
Product Number
/ UPN / HCPCS (reference only) / Billing
Code / MAC / Unit of
Measure
Humanicare – VS
Dignity Premium Protective Underwear / 46079 / 044156460790 / T4528 / 9934NVS / $0.4800 / each
Dignity Maximum Protective Underwear / 46089 / 044156460899 / T4528 / 9934NVS / $0.4800 / each
Medline – ZH
Protection Plus Classic / MSC23600 / 40080196753537 / T4528 / 9934NZH / $0.4800 / each
MegaCareLine – 2M
Super Adult Protective Underwear / MCL2627 / 7290010633654 / T4528 / 9934N2M / $0.4800 / each
Premium Adult Protective Underwear / MCL2727 / 7290010633661 / T4528 / 9934N2M / $0.4800 / each
Midwest Medical Supply – 2K
MMS Protective Underwear Regular Absorbency / 1625MMS / (01)10694393116980 / T4528 / 9934N2K / $0.4800 / each
MMS Protective Underwear Super Absorbency / 1225MMS / (01)10694393116997 / T4528 / 9934N2K / $0.4800 / each

2 – Incontinence Products: Protective UnderwearAugust 2008

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Description /
Product Number
/ UPN / HCPCS (reference only) / Billing
Code / MAC / Unit of
Measure
Presto – 2P
Protective Underwear / NP61400 / 185211000039 / T4528 / 9934N2P / $0.4800 / each
Principle Business Enterprises – TJ
Basicare Disposable Absorbent Underwear / 2807 / 070319028071 / T4528 / 9934NTJ / $0.4800 / each
* SCA Personal Care – 2H
TENA Protective Underwear Plus / 72439 / 768702724395 / T4528 / 9934N2H / $0.4800 / each
TENA Protective Underwear Extra / 72412 / 768702724128 / T4528 / 9934N2H / $0.4800 / each
Whitestone – WH
Compose DPU 4/14XLRG / 55690 / 078459556904 / T4528 / 9934NWH / $0.4800 / each

*Effective January 1, 2009

2 – Incontinence Products: Protective UnderwearNovember 2008