Change to DME bandages, dressings, gauze, tape, and preparation solutions

Code

Description

Billing unit

DMAS limit

A4216

Sterile water, saline and/or dextrose, diluent/flush, 10 ml

Each

60/month

A4217

Sterile water/saline 500 ml

Each

60/month

A4244

Alcohol or peroxide, per pint

Per pint

3/month

A4246

Betadine or pHisoHex solution, per pint

Pint

3/month

A4247

Betadine or iodine swabs/wipes, per box

Box of 50

3/month

A4450

Tape, non-waterproof, per 18 sq. in.

1 unit = 18 sq. in

120/month

A4452

Tape, waterproof, per 18 sq. in.

1 unit = 18 sq. in.

120/month

A4461

Surgical dressing holder, non-reusable, each

Each

31/month

A4463

Surgical dressing holder, reusable, each

Each

2/3 months

A6010

Collagen based wound filler, dry form, per gram of collagen

Gram

4 grams/month

A6011

Collagen based wound filler, gel/paste, per gram of collagen

Gram

4 grams/month

A6021

Collagen dressing, sterile, pad size 16 sq. in. or less, each

Each

31/month

A6022

Collagen dressing, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., each

Each

31/month

A6023

Collagen dressing, sterile, pad size more than 48 sq. in., each

Each

31/month

A6024

Collagen dressing wound filler, per 6 inches

Each

31/month

A6025

Gel sheet, for dermal or epidermal applications, (for example, silicone, hydrogel, other), each

Each

31/month

A6154

Wound pouch, each

Each

15/month

A6196

Alginate or other fiber gelling dressing, wound cover, pad size 16 sq. in. or less, each dressing

Each

31/month

A6197

Alginate or other fiber gelling dressing, wound cover, pad size more than 16 sq. in. but less than 48 sq. in., each dressing

Each

31/month

A6198

Alginate or other fiber gelling dressing, wound cover, pad size more than 48 sq. in. each dressing

Each

31/month

A6199

Alginate or other fiber gelling dressing, wound filler, per 6 inches

Each

31/month

A6203

Composite dressing, pad size 16 sq. in. or less, with any size adhesive border, each dressing

Each

15/month

A6204

Composite dressing, pad size more than 16 sq. in. but less than or equal to 48 sq. in., any size with adhesive border, each dressing

Each

15/month

A6205

Composite dressing, pad size more than 48 sq. in., with any size adhesive border, each dressing

Each

15/month

A6206

Contact layer, 16 sq. in. or less, each dressing

Each

15/month

A6207

Contact layer, more than 16 sq. in. but less than or equal to 48 sq. in., each dressing

Each

15/month

A6208

Contact layer, more than 48 sq. in., each dressing

Each

15/month

A6209

Foam dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing

Each

12/month

A6210

Foam dressing, wound cover, pad size more than
16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing

Each

12/month

A6211

Foam dressing, wound cover pad size more than
 48 sq. in., without adhesive border, each dressing

Each

12/month

A6212

Foam dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive border, each dressing

Each

12/month

A6214

Foam dressing, wound cover pad size more than
48 sq. in., with any size adhesive border, each dressing

Each

12/month

A6215

Foam dressing, wound filler, per gram

Gram

4 grams/month

A6216

Gauze, non-impregnated, non-sterile, pad size 16 sq. in. or less, without adhesive border, each dressing

Each

600/month

A6217

Gauze, non-impregnated, non-sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing

Each

600/month

A6218

Gauze, non-impregnated, non-sterile, pad size more than 48 sq. in., without adhesive border, each dressing

Each

600/month

A6219

Gauze, non-impregnated, pad size 16 sq. in. or less, with any size adhesive border, each dressing

Each

180/month

A6220

Gauze, non-impregnated, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing

Each

180/month

A6221

Gauze, non-impregnated, pad size more than 48 sq. in., with any size adhesive border, each dressing

Each

180/month

A6222

Gauze, impregnated with other than water, normal saline, or hydrogel, pad size 16 sq. in. or less, without adhesive border, each dressing

Each

36/month

A6223

Gauze, impregnated with other than water, normal saline, or hydrogel, pad size 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing

Each

36/month

A6224

Gauze, impregnated with other than water, normal saline, or hydrogel, pad size more than 48 sq. in., without adhesive border, each dressing

Each

36/month

A6228

Gauze, impregnated, water or normal saline, pad size
16 sq. in. or less, without adhesive border, each dressing

Each

65/month

A6229

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, each dressing

Each

65/month

A6230

Gauze, impregnated, water or normal saline, pad size more than 48 sq. in., without adhesive border, each dressing

Each

65/month

A6231

Gauze, impregnated, hydrogel, for direct wound contact, pad size 16 sq. in. or less, each dressing

Each

31/month

A6232

Gauze, impregnated, hydrogel, for direct wound contact, pad size greater than 16 sq. in. but less than or equal to
48 sq.in., each dressing

Each

31/month

A6233

Gauze, impregnated, hydrogel, for direct wound contact, pad size more than 48 sq. in., each dressing

Each

31/month

A6234

Hydrocolloid dressing, wound cover, pad size 16 sq. in. or less without adhesive border, each dressing.

Each

12/month

A6235

Hydrocolloid dressing, wound cover, pad size more than 16 sq. in., but less than or equal to 48 sq. in., without adhesive border, each dressing

Each

12/month

A6236

Hydrocolloid dressing, wound cover, pad size more than 48 sq. in., without adhesive border, each dressing

Each

12/month

A6237

Hydrocolloid dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive border, each dressing

Each

12/month

A6238

Hydrocolloid dressing, wound cover, pad size more than 16 sq. in., but less than or equal to 48 sq. in., with any size adhesive border, each dressing

Each

12/month

A6239

Hydrocolloid, dressing, wound cover, pad size more than 48 sq. in., with any size adhesive border, each dressing

Each

12/month

A6240

Hydrocolloid dressing, wound filler, paste, per fluid ounce

Ounce

12/month

A6241

Hydrocolloid dressing, wound filler, dry form, per gram

Gram

12/month

A6242

Hydrogel dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing

Each

31/month

A6243

Hydrogel dressing, wound cover, pad size more than
16 sq. in. but less than or equal to 48 sq. in. without adhesive border, each dressing

Each

31/month

A6244

Hydrogel dressing, wound cover, pad size more than
48 sq. in. without adhesive border, each dressing

Each

31/month

A6245

Hydrogel dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive border, each dressing

Each

15/month

A6246

Hydrogel dressing, wound cover, pad size more than
16 sq. in. but less than 48 sq. in. with any size adhesive border, each dressing

Each

15/month

A6247

Hydrogel dressing, wound cover, pad size more than
48 sq. in. with any size adhesive border, each dressing

Each

15/month

A6248

Hydrogel dressing, wound filler, gel, per fluid ounce

Ounce

4 ounces/month

A6250

Skin sealants, protectants, moisturizers, ointments, any type, any size

Each

2/month

A6251

Specialty absorptive dressing, wound cover, pad size
16 sq. in. or less, without adhesive border, each dressing

Each

180/month

A6252

Specialty absorptive dressing, wound cover, pad size more than 16 sq. in. but less than 48 sq. in. without adhesive border, each dressing

Each

180/month

A6253

Specialty absorptive dressing, wound cover, pad size more than 48 sq. in. without adhesive border, each dressing

Each

180/month

A6254

Specialty absorptive dressing, wound cover, pad size
16 sq. in. or less, with any size adhesive border, each dressing

Each

15/month

A6255

Specialty absorptive dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing

Each

15/month

A6256

Specialty absorptive dressing, wound cover, pad size more than 48 sq. in., with any size adhesive border, each dressing

Each

15/month

A6257

Transparent film, 16 sq. in. or less, each dressing

Each

31/month

A6258

Transparent film, more than 16 sq. in. but less than or equal to 48 sq. in., each dressing

Each

31/month

A6259

Transparent film more than 48 sq. in., each dressing

Each

31/month

A6260

Wound cleansers, any type, any size

IC

4/month

A6261

Wound filler, gel/paste, per fluid ounce, not elsewhere classified

Ounce

4 ounces/month

A6262

Wound filler, dry form, per gram, not elsewhere classified

Gram

4 grams/month

A6266

Gauze, impregnated, other than water, normal saline, or zinc paste, any width, per linear yard

Per linear yard

50 yards/month

A6402

Gauze, non-impregnated, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing

Each

600/month

A6403

Gauze, non-impregnated, sterile, pad size more than
16 sq. in., but less than or equal to 48 sq. in., without adhesive border, each dressing

Each

300/month

A6404

Gauze, non-impregnated, sterile, pad size more than
48 sq. in., without adhesive border, each dressing

Each

300/month

A6407

Packing strips, non-impregnated, up to 2 inches in width, per linear yard

Per linear yard

50 yards/month

A6410

Eye pad, sterile, each

Each

15/month

A6411

Eye pad, non-sterile, each

Each

15/month

A6412

Eye patch, occlusive, each

Each

15/month

A6413

Adhesive bandage, first-aid type, any size, each

Each

15/month

A6441

Padding, bandage, non-elastic, non-woven/non-knitted, width greater than or equal to 3 inches and less than
5 inches, per yard

Per linear yard

144 yards/month

A6442

Conforming bandage, non-elastic, knitted/woven, non-sterile, width less than 3 inches per yard

Per linear yard

144 yards/month

A6443

Conforming bandage, non-elastic, knitted/woven, non-sterile, width greater than or equal to 3 inches and less than 5 inches, per yard

Per linear yard

144 yards/month

A6444

Conforming bandage, non-elastic, knitted/woven, non-sterile, width greater than or equal to 5 inches, per yard

Per linear yard

144 yards/month

A6445

Conforming bandage, non-elastic, knitted/woven, sterile, width less than 3 inches, per yard

Per linear yard

144 yards/month

A6446

Conforming bandage, non-elastic, knitted/woven, sterile, width greater than or equal to 3 inches and less than
5 inches, per yard

Per linear yard

144 yards/month

A6447

Conforming bandage, non-elastic, knitted/woven, sterile, width greater than or equal to 5 inches, per yard

Per linear yard

144 yards/month

A6448

Light compression bandage, elastic, knitted/woven, width less than 3 inches

Per yard

2/3 months

A6449

Light compression bandage, elastic, knitted/woven, width greater than or equal to 3 inches and less than 5 inches, per yard

Per yard

2/3 months

A6450

Light compression bandage, elastic, knitted/woven, width greater than or equal to 5 inches, per yard

Per yard

2/3 months

A6452

High compression bandage, elastic, kitted/woven, load resistance greater than or equal to 1.35 foot pounds at 50 percent maximum stretch, width greater than or equal to
3 inches and less than 5 inches

Per yard

2/3 months

A6453

Self-adherent bandage, elastic, non-knitted/non-woven, width less than 3 inches

Per yard

2/3 months

A6454

Self-adherent bandage, elastic, non-knitted/non-woven, width greater than or equal to 3 inches and less than
5 inches

Per yard

2/3 months

A6455

Self-adherent bandage, elastic, non-knitted/non-woven, width greater than or equal to 5 inches

Per yard

2/3 months

A6456

Zinc paste impregnated bandage, non-elastic, knitted/woven, width greater than or equal to 3 inches and less than 5 inches

Per yard

2/3 months

A6457

Tubular dressing with or without elastic, any width

Per linear yard

2/3 months