| | | | | | |
| 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. |
| | | | | | |
| | | | | | |
