mc sup prod wou

Medical Supply Products: Wound Care1

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.

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 prior 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

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
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

* All advanced wound care products are effective May 1, 2007.

2 – Medical Supply Products: Wound CareMarch 2007

mc sup prod wou

Medical Supply Products: Wound Care1

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

All advanced wound care products are effective May 1, 2007.

2 – Medical Supply Products: Wound CareMarch 2007

mc sup prod wou

3

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 prior authorization.)
Coloplast – JN
SeaSorb Soft Alginate 1" x 17 1/2" Rope / 0762123035863 / A6199 / 9908XJN / $ 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

All advanced wound care products are effective May 1, 2007.

2 – Medical Supply Products: Wound CareMarch 2007

mc sup prod wou

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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 prior 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
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
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 prior 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
Medline – ZH
Maxorb Extra AG CMC Alginate with Silver 12" Rope / 10080196759262 / A6199 / 9908ZZH / 0.40 / per inch

All advanced wound care products are effective May 1, 2007.

2 – Medical Supply Products: Wound CareMarch 2007

mc sup prod wou

1

Description / UPN / Billing
Code / MAC / Unit of
Measure
COLLAGEN DRESSING (Code 1 – 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 prior 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 ml) 2" x 2" / 10080196285808 / A6021 / 9900XZH / 3.50 / each
Puracol Collagen (1 ml) 4" x 4.25" / 10080196285815 / A6022 / 9900ZZH / 7.50 / each
Puracol PLUS Collagen (2 ml) 2" x 2.25" / 10080196285822 / A6021 / 9900XZH / 3.50 / each
COLLAGEN BASED WOUND FILLER, DRY FORM (Code 1 – 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 prior authorization.)

BioCore Medical Technologies – OD

Medifil Particles II 5 ml or 0.5 gram / 757905010109 / A6010 / 9902ZOD / 14.00 / per gram
Medifil Particles II 10 ml or 1 gram / 757905010209 / A6010 / 9902ZOD / 14.00 / per gram
Medifil Particles II 15 ml 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

All advanced wound care products are effective May 1, 2007.

2 – Medical Supply Products: Wound CareMarch 2007