Reimbursement Overview

Dressing Exudate - LowExudate - MediumExudate - HighDressing ChangePer Month
Alginate or Other Gelling FiberOnce Daily30
16 sqin or lessA6196not indicatedindicatedindicatedOnce Daily30
> 16sqin < 48sqinA6197not indicatedindicatedindicatedOnce Daily30
>48sqinA6198not indicatedindicatedindicatedOnce Daily30
rope/ribbon (per 6" length)A6199not indicatedindicatedindicatedOnce Daily30
Collagen
16 sqin or lessA6021indicatedindicatednot indicatedOnce Daily30
> 16sqin < 48sqinA6022indicatedindicatednot indicatedOnce Daily30
>48sqinA6023indicatedindicatednot indicatedOnce Daily30
Powder (per gm)A6010indicatedindicatednot indicatedOnce Daily30
Foam Dressing Non-Bordered
16 sqin or lessA6209not indicatedindicatedindicated3 per week12
> 16sqin < 48sqinA6210not indicatedindicatedindicated3 per week12
>48sqinA6211not indicatedindicatedindicated3 per week12
Foam Dressing Bordered
16 sqin or lessA6212not indicatedindicatedindicated3 per week12
> 16sqin < 48sqinA6213not indicatedindicatedindicatednot reimbursed0
>48sqinA6214not indicatedindicatedindicated3 per week12
Hydrocolloid Non-Bordered
16 sqin or lessA6234indicatedindicatednot indicated3 per week12
> 16sqin < 48sqinA6235indicatedindicatednot indicated3 per week12
>48sqinA6236indicatedindicatednot indicated3 per week12
Hydrocolloid Bordered (Pad Size)
16 sqin or lessA6237indicatedindicatednot indicated3 per week12
> 16sqin < 48sqinA6238indicatedindicatednot indicated3 per week12
>48sqinA6239indicatedindicatednot indicated3 per week12
Specialty Absorptive Dressing Non-Bordered
16 sqin or lessA6251not indicatedindicatedindicatedOnce Daily30
> 16sqin < 48sqinA6252not indicatedindicatedindicatedOnce Daily30
>48sqinA6253not indicatedindicatedindicatedOnce Daily30
Specialty Absorptive Dressing Bordered (Pad Size)
16 sqin or lessA6254not indicatedindicatedindicated1 every 2 days15
> 16sqin < 48sqinA6255not indicatedindicatedindicated1 every 2 days15
>48sqinA6253not indicatedindicatedindicated1 every 2 days15
Medical Tape
Waterproof ( 1 unit =18sqin)A4452At Dressing Change
16 sqin or less2 Units2 Unitsn.a.
> 16sqin < 48sqin3 Units3 Unitsn.a.
>48sqin4 Units4 Unitsn.a.
Mattress Class II Alternating Low Air lossE0277indicatedindicatedindicated1 per 5 yrs.n.a.
NPWT KitA6550indicatedindicatedindicated1 every 2 days15

MedVance Silicone Foam Dressing with Border       
Product CodeDressingSizePad sizeHCPCSDressings per BoxBoxes/ Case
V30102022" x 2"1" x 1"A6212580
V30102052" x 5"1 "x 3"A6212580
V30103033" x 3"1.8" x 1.8"A6212580
V30104044" x 4"2.7" x 2.7"A6212580
V30104084" x 8"2" x 6"A6213580
V3010408W4" x 8"2" x 6"A6212540
V30104124" x 12"2.4" x 10.4"A6213580
V3010412W4" x 12"2.4" x 10.4"A6213540
V30106066" x 6"4.1" x 4.1"A6212540
V30106086" x 8"4.4" x 6.4"A6213540
V30107077" x 7"5" x 5"A6213580
V3210508 Heel/Elbow5" x 8"3.25" x 3.5"A6212580
V3110707 Sacral small.7" x 7"5.1" x 5.4"A6213580
V3110909 Sacral large.9" x 9"6.1" x 6.6"A6213540
MedVance Silicone Foam Dressing
Product CodeDressingSizeHCPCSDressings per BoxBoxes/ Case
V30002022" x 2"A6209580
V30003033" x 3"A6209580
V30004044" x 4"A6209580
V30004054" x 5"A6210580
V30004084" x 8"A6210580
V30006066" x 6"A6210540
V30006086" x 8"A6210540
V30008088" x 8"A6211540
Medvance Silicone Foam Transfer Dressing 
Product CodeDressingSizeHCPCSDressings per BoxBoxes/ Case
V30208208" x 20"A6211520
MedVance Non-Adherent Foam Dressing       
Product CodeDressing SizeHCPCSDressings per BoxBoxes/ Case
V10002022" x 2"A6209580
V10004044” x 4”A6209580
V10006066” x 6”A6210580
MedVance Non-Adherent Foam Dressing with Border
Product CodeDressing SizePad SizeHCPCSDressings per BoxBoxes/ Case
V10104044” x 4”2" x 2"A6212580
V10106066" x 6"4.2" x 4.1"A6212580

MedVance Alginate Dressing      
Product CodeSizeBoxBoxes/ CaseHCPCS
V40002022" x 2"580A6196
V40004084” x 8”580A6197
V40042424.25” x 4.25”580A6197
V400001212” Rope580A6199

MedVance Hydrocolloid Dressing – Extra-Thin      
Product CodeSizeHCPCSDressings per BoxBoxes/ Case
V24004044” x 4”A6234580
V24006066” x 6”A6235580
MedVance Hydrocolloid Dressing with Border
Product CodeDressing SizePad SizeHCPCSDressings per BoxBoxes/ Case
V20102022" x 2"1" x 1"A6237580
V20104044” x 4”2" x 2"A6237580
V20106066” x 6”4" x 4"A6238580
V2110607 Sacral6” x 7”4" x 5"A6238580
V2213505 Heel3.5” x 5”1.5" x 3"A6237580
MedVance Hydrocolloid Dressing with Foam Top
Product CodeDressing SizeHCPCSDressings per BoxBoxes/ Case
V25004044” x 4”A6212580

CuraVance Bordered Silicone Foam Ag Dressing      
Product CodeDressing SizePad SizeHCPCSDressings per BoxBoxes/ Case
H30104044” x 4”2" x 2"A6212580
H3110707 Sacral Small7” x 7”5" x 5 "A6213580
H3110909 Sacral Large9” x 9”7" x 7"A6214580
CuraVance Bordered Foam Ag Dressing      
Product CodeDressing SizePad SizeHCPCSDressings per BoxBoxes/ Case
H10104044” x 4”2" x 2"A6212580
CuraVance Non-Bordered Foam Ag Dressing
Product CodeDressing SizeHCPCSBoxBoxes/ Case
H10004044” x 4”A6209580

CuraVance Silver Alginate Dressing   
Product CodeSizeBoxBoxes/ Case
H40000120.8” x 12”580
H40002022” x 2”580
H40042424.25” x 4.25”580

MedAir Elite Alternating Pressure Low Air Loss Mattress     
Product codeUnitHCPCS
MA-M4P8-US1E0277

Universal NPWT Foam Kits        
Product DescriptionSizeDESCRIPTIONKIT ITEM (Pack/Piece)SIZEHCPCS
MV-KITF-SSmall KitSmall Foam Dressing1 pc10ˣ7.5ˣ2.5 cm (4ˣ3ˣ1 in)
Transparet Drape1 pc30ˣ30 cm (12ˣ12 in)
Suction Bell1 pc1.5 m (5 feet)
MV-KITF-MMedium KitMedium Foam Dressing1 pc18ˣ12.5ˣ2.5 cm (7.2ˣ5ˣ1 in )
Transparet Drape1 pc30ˣ30 cm (12ˣ12 in)
Suction Bell1 pc1.5 m (5 feet)A6550
MV-KITF-LLarge KitLarge Foam Dressing1 pc26ˣ15ˣ2.5 cm (10ˣ6ˣ1 in)
Transparet Drape2 pcs30ˣ30 cm (12ˣ12 In)
Suction Bell1 pc1.5 m (5 feet)
MV-KITF-XLX Large KiTExtra-Large Foam Dressing1 pc45ˣ30ˣ2.5 cm (18ˣ12ˣ1 in)
Transparet Drape4 pcs30ˣ30 cm (12ˣ12 in)
Suction Bell2 pcs1.5 m (5 feet)

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