Reimbursement Overview
- Reimbursement Overview
- MedVance Silicone Foam
- MedVance Foam
- MedVance Alginate
- MedVance Hydrocolloid
- CuraVance Silicone
- CuraVance Foam
- CuraVance Alginate Ag
- MedAir Elite Mattress
- Vaikto NPWT
| 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. |
| NPWT Kit | A6550 | indicated | indicated | indicated | 1 every 2 days | 15 |
| 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 |
| Universal NPWT Foam Kits | ||||||||
|---|---|---|---|---|---|---|---|---|
| Product Description | Size | DESCRIPTION | KIT ITEM (Pack/Piece) | SIZE | HCPCS | |||
| MV-KITF-S | Small Kit | Small Foam Dressing | 1 pc | 10ˣ7.5ˣ2.5 cm (4ˣ3ˣ1 in) | ||||
| Transparet Drape | 1 pc | 30ˣ30 cm (12ˣ12 in) | ||||||
| Suction Bell | 1 pc | 1.5 m (5 feet) | ||||||
| MV-KITF-M | Medium Kit | Medium Foam Dressing | 1 pc | 18ˣ12.5ˣ2.5 cm (7.2ˣ5ˣ1 in ) | ||||
| Transparet Drape | 1 pc | 30ˣ30 cm (12ˣ12 in) | ||||||
| Suction Bell | 1 pc | 1.5 m (5 feet) | A6550 | |||||
| MV-KITF-L | Large Kit | Large Foam Dressing | 1 pc | 26ˣ15ˣ2.5 cm (10ˣ6ˣ1 in) | ||||
| Transparet Drape | 2 pcs | 30ˣ30 cm (12ˣ12 In) | ||||||
| Suction Bell | 1 pc | 1.5 m (5 feet) | ||||||
| MV-KITF-XL | X Large KiT | Extra-Large Foam Dressing | 1 pc | 45ˣ30ˣ2.5 cm (18ˣ12ˣ1 in) | ||||
| Transparet Drape | 4 pcs | 30ˣ30 cm (12ˣ12 in) | ||||||
| Suction Bell | 2 pcs | 1.5 m (5 feet) | ||||||