Reimbursement Overview

Dressing		Exudate - Low	Exudate - Medium	Exudate - High	Dressing Change	Per Month

Alginate or Other Gelling Fiber					Once Daily	30
16 sqin or less	A6196	not indicated	indicated	indicated	Once Daily	30
> 16sqin < 48sqin	A6197	not indicated	indicated	indicated	Once Daily	30
>48sqin	A6198	not indicated	indicated	indicated	Once Daily	30
rope/ribbon (per 6" length)	A6199	not indicated	indicated	indicated	Once Daily	30

Collagen
16 sqin or less	A6021	indicated	indicated	not indicated	Once Daily	30
> 16sqin < 48sqin	A6022	indicated	indicated	not indicated	Once Daily	30
>48sqin	A6023	indicated	indicated	not indicated	Once Daily	30
Powder (per gm)	A6010	indicated	indicated	not indicated	Once Daily	30

Foam Dressing Non-Bordered
16 sqin or less	A6209	not indicated	indicated	indicated	3 per week	12
> 16sqin < 48sqin	A6210	not indicated	indicated	indicated	3 per week	12
>48sqin	A6211	not indicated	indicated	indicated	3 per week	12

Foam Dressing Bordered
16 sqin or less	A6212	not indicated	indicated	indicated	3 per week	12
> 16sqin < 48sqin	A6213	not indicated	indicated	indicated	not reimbursed	0
>48sqin	A6214	not indicated	indicated	indicated	3 per week	12

Hydrocolloid Non-Bordered
16 sqin or less	A6234	indicated	indicated	not indicated	3 per week	12
> 16sqin < 48sqin	A6235	indicated	indicated	not indicated	3 per week	12
>48sqin	A6236	indicated	indicated	not indicated	3 per week	12

Hydrocolloid Bordered (Pad Size)
16 sqin or less	A6237	indicated	indicated	not indicated	3 per week	12
> 16sqin < 48sqin	A6238	indicated	indicated	not indicated	3 per week	12
>48sqin	A6239	indicated	indicated	not indicated	3 per week	12

Specialty Absorptive Dressing Non-Bordered
16 sqin or less	A6251	not indicated	indicated	indicated	Once Daily	30
> 16sqin < 48sqin	A6252	not indicated	indicated	indicated	Once Daily	30
>48sqin	A6253	not indicated	indicated	indicated	Once Daily	30

Specialty Absorptive Dressing Bordered (Pad Size)
16 sqin or less	A6254	not indicated	indicated	indicated	1 every 2 days	15
> 16sqin < 48sqin	A6255	not indicated	indicated	indicated	1 every 2 days	15
>48sqin	A6253	not indicated	indicated	indicated	1 every 2 days	15

Medical Tape
Waterproof ( 1 unit =18sqin)	A4452				At Dressing Change
16 sqin or less	2 Units	2 Units				n.a.
> 16sqin < 48sqin	3 Units	3 Units				n.a.
>48sqin	4 Units	4 Units				n.a.


Mattress Class II Alternating Low Air loss	E0277	indicated	indicated	indicated	1 per 5 yrs.	n.a.

MedVance Silicone Foam Dressing with Border

Product Code	DressingSize	Pad size	HCPCS	Dressings per Box	Boxes/ Case
V3010202	2" x 2"	1" x 1"	A6212	5	80
V3010205	2" x 5"	1 "x 3"	A6212	5	80
V3010303	3" x 3"	1.8" x 1.8"	A6212	5	80
V3010404	4" x 4"	2.7" x 2.7"	A6212	5	80
V3010408	4" x 8"	2" x 6"	A6213	5	80
V3010408W	4" x 8"	2" x 6"	A6212	5	40
V3010412	4" x 12"	2.4" x 10.4"	A6213	5	80
V3010412W	4" x 12"	2.4" x 10.4"	A6213	5	40
V3010606	6" x 6"	4.1" x 4.1"	A6212	5	40
V3010608	6" x 8"	4.4" x 6.4"	A6213	5	40
V3010707	7" x 7"	5" x 5"	A6213	5	80
V3210508 Heel/Elbow	5" x 8"	3.25" x 3.5"	A6212	5	80
V3110707 Sacral small.	7" x 7"	5.1" x 5.4"	A6213	5	80
V3110909 Sacral large.	9" x 9"	6.1" x 6.6"	A6213	5	40


MedVance Silicone Foam Dressing
Product Code	DressingSize		HCPCS	Dressings per Box	Boxes/ Case
V3000202	2" x 2"		A6209	5	80
V3000303	3" x 3"		A6209	5	80
V3000404	4" x 4"		A6209	5	80
V3000405	4" x 5"		A6210	5	80
V3000408	4" x 8"		A6210	5	80
V3000606	6" x 6"		A6210	5	40
V3000608	6" x 8"		A6210	5	40
V3000808	8" x 8"		A6211	5	40



Medvance Silicone Foam Transfer Dressing
Product Code	DressingSize		HCPCS	Dressings per Box	Boxes/ Case
V3020820	8" x 20"		A6211	5	20

MedVance Non-Adherent Foam Dressing
Product Code	Dressing Size		HCPCS	Dressings per Box	Boxes/ Case
V1000202	2" x 2"		A6209	5	80
V1000404	4” x 4”		A6209	5	80
V1000606	6” x 6”		A6210	5	80



MedVance Non-Adherent Foam Dressing with Border
Product Code	Dressing Size	Pad Size	HCPCS	Dressings per Box	Boxes/ Case
V1010404	4” x 4”	2" x 2"	A6212	5	80
V1010606	6" x 6"	4.2" x 4.1"	A6212	5	80

MedVance Alginate Dressing
Product Code	Size	Box	Boxes/ Case	HCPCS
V4000202	2" x 2"	5	80	A6196
V4000408	4” x 8”	5	80	A6197
V4004242	4.25” x 4.25”	5	80	A6197
V4000012	12” Rope	5	80	A6199

MedVance Hydrocolloid Dressing – Extra-Thin
Product Code	Size		HCPCS	Dressings per Box	Boxes/ Case
V2400404	4” x 4”		A6234	5	80
V2400606	6” x 6”		A6235	5	80


MedVance Hydrocolloid Dressing with Border
Product Code	Dressing Size	Pad Size	HCPCS	Dressings per Box	Boxes/ Case
V2010202	2" x 2"	1" x 1"	A6237	5	80
V2010404	4” x 4”	2" x 2"	A6237	5	80
V2010606	6” x 6”	4" x 4"	A6238	5	80
V2110607 Sacral	6” x 7”	4" x 5"	A6238	5	80
V2213505 Heel	3.5” x 5”	1.5" x 3"	A6237	5	80


MedVance Hydrocolloid Dressing with Foam Top
Product Code	Dressing Size		HCPCS	Dressings per Box	Boxes/ Case
V2500404	4” x 4”		A6212	5	80

CuraVance Bordered Silicone Foam Ag Dressing
Product Code	Dressing Size	Pad Size	HCPCS	Dressings per Box	Boxes/ Case
H3010404	4” x 4”	2" x 2"	A6212	5	80
H3110707 Sacral Small	7” x 7”	5" x 5 "	A6213	5	80
H3110909 Sacral Large	9” x 9”	7" x 7"	A6214	5	80

CuraVance Bordered Foam Ag Dressing
Product Code	Dressing Size	Pad Size	HCPCS	Dressings per Box	Boxes/ Case
H1010404	4” x 4”	2" x 2"	A6212	5	80

CuraVance Non-Bordered Foam Ag Dressing
Product Code	Dressing Size		HCPCS	Box	Boxes/ Case
H1000404	4” x 4”		A6209	5	80

CuraVance Silver Alginate Dressing
Product Code	Size	Box	Boxes/ Case
H4000012	0.8” x 12”	5	80
H4000202	2” x 2”	5	80
H4004242	4.25” x 4.25”	5	80

MedAir Elite Alternating Pressure Low Air Loss Mattress

Product code	Unit	HCPCS
MA-M4P8-US	1	E0277

Reimbursement Overview

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