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Medical Supply Products: Wound Care – Advanced Non-contracted 1

This section lists the billing codes and units of measure for non-contracted advanced dressing types. In this section, “MAPC” refers to the maximum allowable product cost. For additional help, refer to the Medical Supplies section in this manual. HCPCS codes are for reference only.

Effective Date The effective date for the products in this section is July 1, 2008, unless otherwise indicated.

ADVANCED NON-CONTRACTED WOUND CARE
Description / HCPCS (reference only) / Billing
Code / MAPC / Unit of
Measure
Gauze, impregnated, hydrogel, for direct wound contact, pad size greater than 16 sq. in.,
but less than or equal to 48 sq. in. / A6232 / 9908U / $5.50 / each
* Limited to no more than 30 pads per wound per 27 days.
Gauze, impregnated, hydrogel, for direct wound contact, pad size more than 48 sq. in. / A6233 / 9911L / $15.35 / each
* Limited to no more than 30 pads per wound per 27 days.
Hydrogel dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive border / A6245 / 9911R / $5.82 / each
* Limited to no more than 12 pads per wound per 27 days.
Hydrogel dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border / A6246 / 9911S / $7.94 / each
* Limited to no more than 12 pads per wound per 27 days.

* 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 Non-contracted June 2008

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Description / HCPCS (reference only) / Billing
Code / MAPC / Unit of
Measure
Hydrogel dressing, wound cover, pad size more than 48 sq. in. with any size adhesive border / A6247 / 9911T / $19.02 / each
* Limited to no more than 12 pads per wound per 27 days.
Specialty absorptive dressing, wound cover, pad size 16 sq. in. or less, without adhesive border / A6251 / 9911V / $1.59 / each
* Limited to no more than 30 pads per wound per 27 days.
Specialty absorptive dressing, wound cover, pad size more than 16 sq. in. but less than 48 sq.in., without adhesive border / A6252 / 9911W / $2.60 / each
* Limited to no more than 30 pads per wound per 27 days.
Specialty absorptive dressing, wound cover, pad size more than 48 sq. in., without adhesive border / A6253 / 9911X / $5.07 / each
* Limited to no more than 30 pads per wound per 27 days.
Specialty absorptive dressing, wound cover, pad size 16 sq. in., or less with any size adhesive border / A6254 / 9911Y / $1.21 / each
* Limited to no more than 30 pads per wound per 27 days.
Specialty absorptive dressing, wound cover, pad size more than 16 sq. in. but less than or
equal to 48 sq.in. with any size adhesive border / A6255 / 9911Z / $2.42 / each
* Limited to no more than 30 pads per wound per 27 days.
Specialty absorptive dressing, wound cover, pad size more than 48 sq. in., with any size adhesive border / A6256 / 9911X / $5.07 / each
* Limited to no more than 30 pads per wound per 27 days.

* 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 Non-contracted ___ 2008