mc sup prod wou tr

Medical Supply Products: Wound Care – Traditional1

This section lists the billing codes and unit of measure for traditional wound care supplies such as gauze dressings, packing strips, eye pads and bandages. These are non-contracted items. 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.

Unless otherwise indicated, up to a 90-day supply may be dispensed for traditional wound care products. Product descriptions in this section were updated and became effective May 1, 2008.

TRADITIONAL WOUND CARE
Description / HCPCS(reference only) / Billing
Code / MAPC / Unit of
Measure
Gauze, non-impregnated, non-sterile, pad size 16 sq. in. or less, without adhesive border / A6216 / 9941D / $0.04 / each
* Limited to no more than 200 pads per wound per 27 days.
Gauze, non-impregnated, non-sterile, pad size more than 16 sq. in. but less than or equal to
48 sq. in., without adhesive border / A6217 / 9948B / $0.08 / each
* Limited to no more than 200 pads per wound per 27 days.
Gauze, non-impregnated, non-sterile, pad size more than 48 sq. in., without adhesive border / A6218 / 9948D / $0.25 / each
* Limited to no more than 200 pads per wound per 27 days.
Gauze, non-impregnated, pad size 16 sq. in. or less, with any size adhesive border / A6219 / 9918U / $0.76 / each
* Limited to no more than 50 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 – TraditionalMarch 2008

mc sup prod wou tr

Medical Supply Products: Wound Care – Traditional1

Gauze, non-impregnated, pad size more than 16 sq. in. but less than
or equal to 48 sq. in., with any size adhesive border / A6220 / 9918W / $2.06 / each
* Limited to no more than 50 pads per wound per 27 days.
Gauze, non-impregnated, pad size more than 48 sq. in., with any size adhesive border / A6221 / 9918X / $2.06 / each
* Limited to no more than 50 pads per wound per 27 days.
Gauze, impregnated with other than water, normal saline or hydrogel, pad size 16 sq. in. or less without adhesive border / A6222 / 9908Y / $1.70 / each
* Limited to no more than 50 pads per wound per 27 days.
Gauze, impregnated with other than water, normal saline or hydrogel, pad size
more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border / A6223 / 9900Y / $1.94 / each
* Limited to no more than 50 pads per wound per 27 days.
Gauze, impregnated with other than water, normal saline or hydrogel, pad size
more than 48 sq. in., without adhesive border / A6224 / 9901Q / $2.89 / each
* Limited to no more than 50 pads per wound per 27 days.
Gauze, impregnated, water or normal saline, pad size 16 sq. in. or less,
without adhesive border / A6228 / 9918Y / $0.04 / each
* Limited to no more than 200 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 – TraditionalMarch 2008

mc sup prod wou tr

3

Description / HCPCS(reference only) / Billing
Code / MAPC / Unit of
Measure
Gauze, impregnated, water or normal saline, pad size more than 16 sq. in. but
less than or equal to 48 sq. in., without adhesive border / A6229 / 9918Z / $0.08 / each
* Limited to no more than 200 pads per wound per 27 days.
Gauze, impregnated, water or normal saline, pad size more than 48 sq. in.,
without adhesive border / A6230 / 9919G / $0.25 / each
* Limited to no more than 200 pads per wound per 27 days.
Gauze, impregnated, other than water, normal saline, or zinc paste, any width / A6266 / 9986R / $1.54 / yard
* Limited to no more than 25 yards per wound per 27 days.
Gauze, non-impregnated, sterile, pad size more than 16 sq. in. or less, without adhesive border / A6402 / 9946A / $0.10 / each
* Limited to no more than 200 pads per wound per 27 days.
Gauze, non-impregnated, sterile, pad size more than 16 sq. in. but less than
or equal to 48 sq. in., without adhesive border / A6403 / 9948F / $0.34 / each
* Limited to no more than 200 pads per wound per 27 days.
Gauze, non-impregnated, sterile, pad size more than 48 sq. in., without adhesive border / A6404 / 9948H / $0.34 / each
* Limited to no more than 200 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 – TraditionalMarch 2008

mc sup prod wou tr

3

Description / HCPCS(reference only) / Billing
Code / MAPC / Unit of
Measure
Packing strips, non-impregnated, up to 2 in. wide / A6407 / 9935L / $0.90 / yard
* Limited to no more than 30 yards per wound per 27 days.
Eye pad, sterile / A6410 / 9950A / $0.31 / each
* Limited to no more than 100 pads per wound per 27 days.
Eye pad, non-sterile / A6411 / 9946Y / $0.15 / each
* Limited to no more than 100 pads per wound per 27 days.
Conforming bandage, non-elastic, knitted/woven, non-sterile, width less than 3 in. / A6442 / 9935N / $0.14 / yard
* Limited to no more than 90 yards per wound per 27 days.
Conforming bandage, non-elastic, knitted/woven, non-sterile, width greater than
or equal to 3 in. and less than 5 in. / A6443 / 9938Y / $0.23 / yard
* Limited to no more than 90 yards per wound per 27 days.
Conforming bandage, non-elastic, knitted/woven, non-sterile, width
greater than or equal to 5 in. / A6444 / 9935T / $0.45 / yard
* Limited to no more than 90 yards per wound per 27 days.
Conforming bandage, non-elastic, knitted/woven, sterile, width less than 3 in. / A6445 / 9935D / $0.26 / yard
* Limited to no more than 90 yards 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 – TraditionalMarch 2008

mc sup prod wou tr

1

Description / HCPCS(reference only) / Billing
Code / MAPC / Unit of
Measure
Conforming bandage, non-elastic, knitted/woven, sterile, width greater than or
equal to 3 in. and less than 5 in. / A6446 / 9946N / $0.33 / yard
* Limited to no more than 90 yards per wound per 27 days.
Conforming bandage, non-elastic, knitted/woven, sterile, width greater than or equal to 5 in. / A6447 / 9946S / $0.54 / yard
* Limited to no more than 90 yards per wound per 27 days.
Self-adhesive bandage, elastic, non-knitted/nonwoven, width less than 3 in. / A6453 / 9919Q / $0.49 / yard
* Limited to no more than 30 yards per wound per 27 days.
Self-adhesive bandage, elastic, non-knitted/nonwoven, width greater than or
equal to 3 in. and less than 5 in. / A6454 / 9919U / $0.62 / yard
* Limited to no more than 30 yards per wound per 27 days.
Self-adhesive bandage, elastic, non-knitted/nonwoven, width greater than or equal to 5 in. / A6455 / 9919V / $1.11 / yard
* Limited to no more than 30 yards 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 – TraditionalMarch 2008